An amazing basic surgical

and orthopedic skills

experience!

Perform a number of
reduction and fixation
procedures on a fractured
long bone shaft.

The Apprentice Doctor

ORTHOPEDIC
Course & Simulation Kit
 Introduction

The Future Doctors Academys Orthopedic Surgery Course

An Illustrated Hands-on Basic Surgical Skills

and Orthopedic Course

Developed by Dr. Anton Scheepers for the Future Doctors Academy

Future Doctors
Academy
Your Online Mini Med School!
An Outstanding Introduction to the Fascinating Field of Orthopedic Surgery

Aligned with Next Generation Science Standards (NGSS)

The Future Doctors Academy is a Fully-Accredited Member of the International Asso-

ciation of Distance Learning (IADL)

https://futuredoctorsacademy.com

ii
 Introduction

The Apprentice Doctor Fracture Reduction Kit

Experience Amazing Orthopedic Surgery Simulation Procedures

Designed to be used in Conjunction with the Future Doctors

Academys Orthopedic Surgery Course

Your Simulation Lab in a Box!

A product produced and marketed by: The Apprentice Corporation, using

The Apprentice Doctor as its registered trade name.

Address:
The Apprentice Corporation
1100 Military Road
Kenmore, NY 14217
U.S.A.
Tel (USA toll-free): +1 855-445-7444

www.TheApprenticeDoctor.com

Copyright THE APPRENTICE CORPORATION 2017

All rights reserved
ISBN: 978-0-9815066-8-5

THE APPRENTICE CORPORATION: COPYRIGHT INFORMATION

All material contained in this Apprentice Doctor Orthopedic Surgery Course is protected by international
copyright laws. Copyright of the contents of The Apprentice Doctor Orthopedic Surgery Course including text,
pictures, sketches, logos, animations, photographic material, video material, sound samples and graphic art is the
sole property of The Apprentice Corporation and all the rights of The Apprentice Corporation are reserved. No part
of any of the Apprentice Doctor courses and/or websites, books or e-books may be reproduced or transmitted in any
form or by any means without the express, written consent of The Apprentice Corporation.
We appreciate your integrity in this regard.

Direct all requests for permission to use any of the Apprentice Corporations copyrighted material to:
The Apprentice Corporation: Legal Department. Email the request to: Enquiries@TheApprenticeDoctor.com

iii
Introduction

Warnings
kk The Course is exclusively intended for educational and training purposes and the use of the instruments and items
in this kit on a real human or animal patient is strictly prohibited!
kk The course is intended for students 18 years of age or older. Strict and constant adult supervision and guidance is
required for students ages 15-17. Not suitable for children under the age of 15!
kk The Kit contains sharp instruments and items be extremely careful not to injure yourself or any person assisting!

Important note
kk Before starting this course or any of its associated practical projects, it is imperative that the student and/or teacher
and or supervising person read the Sharps Safety and Medical Waste Management - Informational document (pg 4).

I have read and understood the content

DISCLAIMER
The producer or supplier of this application does not:
kk Offer any warranty regarding the accuracy or correctness of any
information contained in this application.
kk Assume any responsibility for any damage or consequential damage
related in any way to the information, instrumentation, or items con-
tained in this product/application or as a result of their use.
The user takes full and exclusive responsibility for the safe application
of any information contained in this application. The user also takes
full and exclusive responsibility for all safety aspects related in any
way to the use of any instrument, or item supplied with this applica-
tion. This exclusive responsibility applies equally to the user or to any
person being supervised by the user.
No warranties are offered on the functional status or fitness for the
specific application of any information, instrument or item supplied
in this application. The supplier accepts no responsibility for the mal-
function of any instrument or item. (The buyer will be entitled to the
replacement of any defective items within the time limits of the Basic
Terms and Conditions).
The supplier disclaims all liability for any direct or indirect damages
specific or consequentialrelated in any way to the information and
instrumentation or to any items contained in this application.
Regarding correctness of information and potential problems arising
from any misinformation:
Keep in mind that there are differing points of view in medicine and
medical knowledge changes quickly. If you think that any information
is incorrect, contact us at enquiries@theapprenticedoctor.com.
It is solely and exclusively the responsibility of the users of this appli-
cation to ensure that the information offered in this course is correct,
current and in line with their hospital or institutions guidelines and
protocols.
The Apprentice Corporation, its employees, any associates, as well as
the distributors of the product completely absolve themselves of any
liability or potential liability for any misadventure or complications
that may result from using this kit or the information contained in the
course material. We take no responsibility whatsoever for any adverse
outcome, problems, or complications of any nature that might occur
as a direct or indirect consequence of using the kit or applying the
information from the course material. Using this Kitthe instruments,
items, and information suppliedis conditional upon your accept-
ance of this disclaimer and commitment to honor the copyrights
associated with the course material.
For further information on copyright see:

All practical exercises are performed exclusively at the users risk. The Copyright Information
producer or supplier of this application disclaims any responsibility for
any medical emergencies, medical problems, or any other problems Reimbursement Policy:
whatsoever that may arise while using any instrument or item or
Click Here for Information
applying any information supplied with this application.

iv

Contents
Contents.................................................v
PREFACE.....................................................vi
OBJECTIVES...............................................1
THE KIT.......................................................2
SAFETY FIRST! ..........................................3
Sharps Safety in a Healthcare
(Clinical/Hospital) Setting..............4
Discarding Medical and Biological
Waste Safely..........................................7
Skills Required................................ 8
Aseptic Technique................................8
Suturing Skills.....................................17
The Human Skeletal System............. 20
Background Information................20
Anatomy and physiology.................21
Long Bones.............................................22
Fracture fixation methods.............30
Biological considerations..............33
Biomechanical Considerations.....34
Complications of Bone Fractures.. 36
Practical Orthopedic Projects..... 38
CLOSED REDUCTION OF A LONG BONE
FRACTURE..................................................38
Project CR1: The emergency management of
a fracture................................................................. 38
Cast procedures..................................40
Introduction
Project CR2a: Closed reduction of a fracture using
plaster (POP) cast.................................................... 40
REDUCTION AND INTERNAL FIXATION
(ORIF) OF A LONG BONE FRACTURE.......43
Project OR1: Open Reduction and Internal Fixation
(ORIF) of a Long Bone Fracture Using
Monocortical Screws.............................................. 43
Project OR2: Open Reduction and Internal Fixation
(ORIF) of a Long Bone Fracture - Using Bicortical
Screws ..................................................................... 61
Project OR3: Open reduction and internal fixation of
a comminuted long bone fracture........................ 64
Project OR4: Open reduction and internal fixation of
a segmental long bone fracture ........................... 65
Project OR5: Remove plates and screws............... 66
Additional Projects................................................. 66
Research project ideas.....................66
RADIOGRAPHIC CONSIDERATIONS........67
CLINICAL CASE STUDIES........................................ 67
A CAREER IN ORTHOPEDIC SURGERY.....68
What do Orthopedic Surgeons do? ...................... 68
Orthopedic Areas of Expertise.............................. 68
The Career Path of an Orthopedic Surgeon (USA
perspective)............................................................ 68
Career Opportunities............................................. 68
EPILOGUE ..................................................69
CREDITS.....................................................69
GLOSSARY..................................................70
Other products by the Apprentice
Doctor / Future Doctors Academy: ........70
v
Introduction

PREFACE
The Apprentice Corporation, using the trade names
Apprentice Doctor and Future Doctors Academy,
has the mission of assisting medical professionals
globally whether aspiring, in training or practic-
Excellence is an attribute that all medical professionals should
aim for and as far as excellence in surgical skills is concerned
the following are key prerequisites:
kk A good understanding of the foundational medical sub-
jects like anatomy, physiology and pathology.

ing with suitable medical and surgical simulation
training resources, skills workshops and accredited
online training courses.
The Apprentice Doctor Orthopedic Surgery Course and
Kit is useful for teaching students both basic surgical, as well
as basic orthopedic skills. The Course and Kit is recommended
training material for all medical / healthcare profession-
als whether aspiring, in training, or qualified including:
Orthopedic residents/registrars, Medical students, Physician
Assistant (PA) students, Veterinary students, Registered
Nursing students (OR training), refresher surgical skills courses
for a variety of medical professionals, advanced applied Life
Sciences programs in senior High School etc.
Over the past 2-3 decades the emphasis in surgical skills train-
ing has moved from primarily learning in the clinical setting
to acquiring skills in the simulation environment. Gone
forever are the days where it was considered acceptable to
learn e.g. suturing skills on your patients in the emergency
room! Students need to become proficient in their skills and
build confidence in their abilities in the simulation lab and not
in the clinical setting.
kk A thorough knowledge of the basic principles of medicine
and surgery.
kk A sincere respect for your patients as fellow human beings,
for each one of them as a person and unique individual;
for their beliefs, needs, wishes, emotions and for their
bodies, organs and tissue.
kk Practicing surgical skills in a simulation environment up to
a measurable level of proficiency.
kk Learning in the clinical setting is an essential part of the
training of any student in medicine/surgery this part of
the training experience should be a highly controlled men-
toring process with constant supervision and guidance
again up to a certain measurable proficiency level both
in the number of procedures completed as well as the level
of mastery of the technique as judged by experienced con-
sultants in the field.
The Apprentice Doctor realized that a great number of skills
are better learnt with students able to practice their skills at
home or at the dorm rather than merely by a short training
session in the simulation lab thus the Your Simulation Lab
in a Box concept that proved to be exceptionally popular
with both students and mentors.

Lets aim for excellence in surgical skills our patients deserve nothing less!

Dr Anton Scheepers
Director of the Apprentice Doctor and the Future Doctors Academy

vi
 Introduction

OBJECTIVES
Objectives of the Apprentice Doctor Fracture Reduction 2. The student should have the following skills:
Workshop: kk Preparing a sterile surgical field
The objectives of the course are to equip students with an kk Identification of common surgical landmarks
understanding of the basic surgical principles with special kk Sharps safety
reference to orthopedic surgery and to offer students the op-
kk Surgical retraction
portunity to acquire basic surgical and orthopedic skills.
kk Blunt dissection
1. The student, on completion of this course, should be kk Fracture reduction
able to explain the following:
kk Fracture fixation
kk Principles of asepsis
kk Place a bone plate with monocortical screws
kk Surgical sterility
kk Place a bone plate with bicortical screws
kk Basic bone biology and physiology
kk Closing (suturing) a surgical wound
kk Basic anatomy of the human skeleton
kk Placing a dressing
kk Biomechanical considerations in orthopedic surgery
kk Properly discarding medical waste and sharps
kk Radiological considerations
3. The student will have a career perspective regarding:
kk Basic principles and methods of fracture reduction, fixa-
kk A typical operative procedure performed by most ortho-
tion and immobilization
pedic surgeons on a regular basis based on experiential
kk Simple fracture classifications
learning.
kk Healing of the fracture site
kk The various career opportunities available to orthopedic
kk Common complications surgeons.

1
Introduction

THE KIT
The Apprentice Doctor Surgical Skills and Orthopedic Surgery Course and Kit
The fracture reduction kit has been carefully designed, and compiled with great care to offer students a realistic simulation experi-
ence. Kindly take a moment to check the contents using the check-list below.

Items may vary slightly due to availability.

Fracture Reduction Kit Contents

Cotton wool swabs 5
BASIC FRACTURE REDUCTION KIT
Biological waste bag (red) 1
Catspaw retractors 2
Plastic tweezers 1
Kocher forceps (curved) 2
Gloves and paper towel 1 each
Periosteal elevator 1
Sterile work surface cover 1
Tissue forceps 1
Box with all the screws and plates 1
Needle holder 1
A six-hole trans-osseous plate 2
Dissecting scissors 1
Bone screws (Mono- and Bicortical regular and
Cordless surgical drill unit 1 8+2 & 8+2
emergency)
Drill bits (for drill unit) 2 Arm: fracture simulation

Screw driver tips (for drill unit) 2 Fracture simulation arm (linear) 1

Screw driver (Hand) 1 Fracture simulation arm (comminuted)* 1

Fracture simulation arm (segmental)* 1

Fracture Reduction Basic Refill Kit (General items)
Closed reduction items (set)
Simulation radiograph 1
Stockinet 1
Clean gloves 5 pairs
Orthopedic padding (50mm roll) 1
Theater (OR) caps 4
POP bandage (75mm roll) 1
Surgical mask with visor 4
Protective work surface cover 1
Clean work surface cover 1
Fracture reduction: optional extra items
Container for antiseptic solution (empty) fill
1 Malleable flat retractor (for placing bicortical
with e.g. Dettol 1
screws)**
Drape - Surgical 1
Kocher forceps (straight)** 1
A marker pen 1
Bone holding forceps 2
Ruler 2
Acrylic cast set Blue roll & stockinet and ortho-
1
Elastic bands 2 pedic padding
Acrylic cast set Pink roll & stockinet and ortho-
Scalpel with safety sheath and pre-assembled 1
1 pedic padding
blade
Sachets of the appropriate suture materials Surgical cap 1
2
(Chromic catgut or equivalent)
Sterile OR gown 10
Sachets of the appropriate suture materials
2
(Nylon or equivalent) A head lamp 1
Wound dressing 1 Safety glasses (Anti-fog) 1
Small sharps waste container 1 Set of Surgical Scrubs (Apprentice Doctor As per order
branded - XS/S/M/L/XL/XXL) order
Blister pack with disposable items: 1
Sharps waste container (medium size) 1
Gauze squares 5
Other special requests (please specify on a
If available
separate list)

note: When ordering simulation arms marked * - consider ordering instruments marked ** to facilitate the surgery.
Kindly contact us in the unlikely event of any missing instrument or item - after thorough checking please.

2
 Introduction

SAFETY FIRST!
Sharps Safety and Medical Waste Management Informational

The organizers, all instructors at Apprentice Doctor Programs/

Workshops/Practical Projects and all students taking part in any
workshops with a sharps injury risk as well as parents of these
students must read this information carefully. Parents/ legal
guardians are required to sign the form below before the start of
the program/workshop.

Medical/surgical sharps include all items/instruments that

carry a sharps-injury risk. Examples of sharps used in a medical
setting include scalpel blades, suture needles, hypodermic
needles, probes, drills, screws, lancets, scissors, retractors,
and glass items (e.g. glass vials). All Apprentice Doctor work-
shops/projects carrying a sharps injury risk are well marked
with appropriate symbols.
When using any of the Apprentice Doctor Kits containing
sharps e.g. the Suture Wounds Kit, the Venipuncture Kit,
the Fracture Reduction Kit or during any Future Doctors
Workshops where sharps will be used there is a small but
definite risk of sustaining a sharps injury.
Students/participants need to follow strict guidelines as per
this document as well as the guidelines given by the work-
shop instructors/assistants. By following these guidelines and
by applying the instructions of the mentors, the risk of sus-
taining a sharps injury is extremely small. Even if it happens in
a simulation environment injuries are usually quite minor,
and usually heal readily without any problems. Rarely is any-
thing more required than a wipe with an antiseptic swab and
the application of a small strapping. Students will work with
properly sterilized sharp surgical items the same items that
medical professionals use on a daily basis.
In the unlikely case of a more significant injury occurring,
further professional medical assistance will have to be
arranged.
As aspiring medical professionals, it is of utmost importance
that students should learn to handle sharps with great care
and respect.
Students will be instructed and mentored on techniques for
minimizing the risk of sharps injuries like the use of safety
scalpels and safety needles and various sharps handling
safety techniques.
Dr Louise Weimers Story
https://youtu.be/_eCETCXxhAw
WARNINGS:
1. All students taking part in any sharps workshops will
have to wear appropriate PPE like gloves and a visors
or protective glasses as per the instructions of the
workshop mentor/instructors.
2. No students under the age of 15 will be allowed to
participate in a sharps injury risk workshop.
3. Under no circumstances may student use any
medical or surgical sharps either on themselves
or on any other person including fellow participants
(e.g. placing sutures).
4. Students will not be allowed to attach scalpel blades
to the scalpel handles (if applicable) kindly call one
of the mentors/assistants to perform this task.
5. Under no circumstances may student take any used
sharps items home. Always dispose of sharps in the
appropriate way and in a dedicated approved sharps
waste container.
6. Do not hand any sharp item/instrument directly to
another person. If transfer of a sharp item e.g. scalpel
is needed place the sharp item/instrument in a des-
ignated neutral area on the work surface. The second
person will carefully pick it up from that area.
7. Ensure that the necessary first aid equipment and items
for the emergency management of bleeding is avail-
able during any workshops with a risk of sharps injuries.

8. If you are unsure or feel apprehensive, ask for assistance!

3
Introduction

Important notes:

Students will not be exposed to a clinical setting or to real patients during any Apprentice Doctor
simulation workshops.

Students (or parents of students) who do not want (their children) to be exposed to the risk of sharps
injuries should notify the program organizers and/or workshop conductor/assistants. These students
will not be allowed to take part in any workshop with a sharps injury risk like the phlebotomy, sutur-
ing and fracture reduction workshops. They will be allowed to attend these workshops as observers.

Consent to take part in medical/surgical workshops with a sharps injury risk

Sharps Safety in a Healthcare

(Clinical/Hospital) Setting
For the sake of your and your patients safety!
Sharps injuries in a clinical setting carry the risk of the clinician acquiring a cross-infection from exposure to the patients
(and vice versa):

Source of infection Type of organism/infection

Infected wounds Potentially to multi-resistant bacterial strains like MRSA* or **CRE

Bodily secretions e.g. saliva A large variety of organisms living in the oral cavity like Streptococci

Bodily excretions e.g. feces Gram negative enteric bacteria / infection

Body fluids like blood Bloodborne diseases like HIV, Hepatitis B and C

*Multi-resistant Staphylococcus Aureus **Carbapenem-Resistant Enterobacteriaceae

Sharps injuries in a healthcare setting are costing the healthcare
industry enormous amounts and impacts healthcare profes-
sionals in a negative way. In some cases long (even lifelong) and
expensive treatment regimens may be required. In some cases
these infections may result in the demise of healthcare profes-
sionals. So it is no small thing to be brushed aside but rather a
matter of life and death demanding our full attention!
medical professionals at special risk for sharps injuries. At the
same time surgical patients are exposed to the risk of contami-
nation with microbes from healthcare professionals or from the
hospital environment.
Three keys to increasing sharps safety:

The OR is a unique environment. It requires close teamwork, 1. Use Safety-engineered devices

with team members often working under intense emotional Examples of Safety-engineered Devices are safety scalpels
pressure and time constraints. Surgical team members rely (sheathed and retractable), safety hypodermic needles
on limited communicational cues while extensively handling (passive and active) and blunt-tip suture needles (only for
a variety of sharp items and instruments. These factors place soft tissue closure like fascia).

4

Figure 1 - A Reflex-Safe passive safety needle (www.reflex-safe.com)
2. Hands-free technique (HFT) or neutral passing zone
Sharp items should not be placed in the hand of another
person. When using HFT, the assistant places a suitably sized,
puncture-resistant container, magnetic pad, or towel on
the operating field between the surgical assistant and the
surgeon and places one sharp item/instrument in the neutral
zone at a time. The surgeon then picks up the sharp instru-
ment/item, uses it and then places it back in the neutral zone.
Research shows HFT reduces sharps injuries by up to 60%.
3. Double-gloving
Wearing double gloves helps protect healthcare workers
from needlestick injuries because punctures are more likely
to breach the outer glove only rather than both gloves. The
inner glove (the indicator glove) should be a different color
(preferably a bright color) as opposed to the outer glove
so that tears and punctures in the outer glove are more
readily visible. Some research shows tears and perforations
occur in up to 12% of surgical procedures. Glove punctures
increase the risk of pathogen transmission during surgery.
Figure 2 (a) - (e) Double gloving
Introduction
The following ten guidelines have been proposed by the
Association of Surgical Technologists for maximizing
the safety of both the medical professional as well as the
patient in a surgical environment.
1. A neutral zone should be utilized during all surgical pro-
cedures to prevent two individuals from simultaneously
handling a contaminated sharp, including but not limited
to scalpel blades, suture needles, hypodermic needles, and
sharp surgical instruments.
2. If the procedure necessitates reuse of a hypodermic needle
multiple times on the same patient, recap the hypodermic
needle between uses utilizing a one-handed approach or a
safety device that enables one-handed recapping.
3. A sterile sharps container should be used on every case to
store used sharps.
4. When organizing the sharps in the work area, e.g. Mayo
stand, back table, the sharps should be pointed away from
the handler and receiving personnel.
5. Visually inspect the field and all waste material for the pres-
ence of sharps before disposal.
6. Utilize mechanical safety devices to remove or attach
blades, needles, or other sharps.
7. The routine use of double gloving by all surgical sterile
team members is recommended for all surgical procedures.
8. A non-sterile sharps container must be used for the dis-
posal of all needles and other sharps to decrease the risk of
injury to HCWs and patients.
9. Reusable sharps should be transported to the central sterile
processing department in a puncture resistant closed
container.
10. Policies and procedures for the safe handling of sharps and
use of hands free techniques should be periodically re-
viewed and when necessary, revised to reflect current safe
practices. Perioperative personnel should complete con-
tinuing education to remain current in their knowledge of
safe practices in the OR.
Full document: http://www.ast.org/uploadedFiles/Main_Site/
Content/About_Us/Standard_Sharps_Safety_Use_of_the_
Neutral_Zone.pdf
Further reading / study material on sharps management
and injuries:
USA perspective: https://www.cdc.gov/sharpssafety/tools.html
https://www.ccohs.ca/oshanswers/diseases/needlestick_inju-
ries.html
5
Introduction

The Emergency Treatment of Sharps Injuries: Sharps Injuries in a Healthcare setting

In a healthcare setting the injured healthcare professional
in addition to the above measures needs to:

kk Report the injury to your unit manager or the Infection

Control Officer of the hospital/healthcare facility and
follow the recommended instructions/protocol.

kk Write a full report on the injury as soon as feasible.

Further management in a clinical setting may be required:

Figure 3 - A needlestick injury
kk PEP (Post Exposure Prophylaxis) In the case of HIV exposure
Step 1: Wash the wound with soap and water, rinse off the soap one needs to start PEP as soon as possible.
(1-2 minutes).
kk Blood tests to assess the patients and the injured healthcare
Step 2: Apply pressure with clean gauze of cotton wool (3-5 professionals HIV and Hepatitis B status (keep legalities re-
minutes) - until bleeding stops. garding the patients informed consent and confidentiality
Step 3: Apply small strapping for protection. in mind).

Step 4: Consider the need for analgesia e.g. Paracetamol (do kk Antimicrobial therapy if indicated.
not use Aspirin as it may promote bleeding). kk Suturing /wound dressing if indicated.
If a small puncture of 2-3mm or less (e.g. needlestick) the above kk Tetanus toxoid injection (if previous injection was more than
steps should suffice. 5 years ago).

Get professional medical help if:

A somewhat modified but similar protocol will apply if the
kk It is a larger wound (4mm or longer) with gaping wound patient has been injured with a medical sharp item/instrument.
margins
kk The bleeding does not stop If the healthcare professionals mucous membranes has

kk Bleeding starts again been exposed to any bodily fluids from a patient:

kk The sharp instrument/item was contaminated

kk Flush splashes to the nose, mouth, or skin with water
kk Throbbing or intense pain develops at a later stage
kk A large area of redness develops around the wound kk Irrigate eyes with clean water or saline
kk You notice a discharge coming from the wound (even days
after the injury)
Comments:

In all cases prevention is the best cure!

Important notes:
Be informed and adhere to your healthcare facilitys sharps
All program organizers must have a contingency plan safety guidelines carefully.
regarding emergency management of sharps injuries
After a sharps injury: Follow your hospital/healthcare facilitys
in place!
recommended protocol/SOPs in this regard.
All injuries (even minor ones) must be to be reported
to the supervisor!
Warning: Respect sharps and handle with great care!
All ocular (eye) injuries MUST be evaluated by medical
professional. For more information visit: http://www.cdc.gov/niosh/topics/
bbp/emergnedl.html
Fill out an INCIDENT REPORT FORM when any injury is
reported with information about the date, time, notes
on what happened and steps taken after the incident.

THE APPRENTICE DOCTOR SHARPS INJURIES REPORT FORM

6
 Introduction

Discarding Medical and

Biological Waste Safely
How to discard used sharps and biological waste safely: the relevant person in charge of waste management or the in-
fection control officer and discuss your needs for disposal of
There are companies specializing in the management of
biological waste in most cases the facilitys normal disposal
medical waste. If you have significant amounts of waste,
routes can be utilized for the disposal of used sharps and small
contact one of these companies. As a rule they are usually not
amounts of biological waste.
interested in assisting with small quantities of waste.
All sharps must be placed in a designated well-marked punc-
For the once off discarding of smaller quantities of waste:
ture resistant closed container for safe disposal.
All hospitals, clinics or healthcare facilities have established
Collect all biological waste (e.g. animal organs used for dissec-
protocols /SOPs (standard operating procedures) in place for
tions) in a leak-proof red plastic bag, and then place it in an
the disposal of sharp medical items and biological waste.
appropriately marked medical waste box for safe disposal.
Establish contact with a suitable healthcare facility e.g. hospi-
Read more about Practice Medicine Safely: https://www.the-
tal or clinic (ask any medical professional for advice). Contact
apprenticedoctor.com/module-2-practice-medicine-safely/

7
 Skills Required

Aseptic Techniques

Suturing Skills

Aseptic Technique
Ginnys story
https://youtu.be/s5x1f3_NJX8
An understanding of the following topics and the associ-
ated healthcare skills are a prerequisite before students can
proceed with the Orthopedic Surgery Course and the associ-
ated practical projects:
1. Sterility and aseptic techniques
2. Surgical knot tying and basic suturing techniques
1
Students who have an understanding of barrier techniques, PPE,
sterility and asepsis and the associated skills of hand hygiene,
donning and doffing of gloves as well as scrub, gown and glove
for surgery may skip this section and go to Suturing Skills
although we recommend that you review this section in any case.
Most of the Aseptic Technique skills that the student will need
before doing the Fracture Reduction Workshop are covered
in the Future Doctors Foundation Course.
An overview of the essential Aseptic Technique skills will be
covered in this section.
It is highly recommended that students get the Apprentice
Doctor Future Doctors Foundation Kit and complete the
associated foundation course before doing the Apprentice
Doctor Orthopedic Surgery Course.

8
1
Skills Required

Lets look at why it so important to acquire the relevant skills related to hygiene, asepsis and sterility
in a healthcare setting.

Next Page
9
 Skills Required

10
 Skills Required

Questions:
kk Would you like to minimize or eliminate the risk of your
patients getting infected and affected by nosocomial
infections?
kk Can you think of novel ways to prevent nosocomial
infections?
kk Do you think developing new stronger antibiotics will
solve the problem?
kk Have you heard about the amazing antibacterial
properties of Copper?
Figure 1 - Microscopic appearance of Carbapenem-resistant
Enterobacteriaceae
Important note: If you have access to the Apprentice Doctor
Foundational Medical Course please review the section on
Hospital acquired infections - and how to Sterility and Asepsis before proceeding.
prevent them

Watch thE video Lets continue onto the practical

projects on the next page...
https://youtu.be/izxdrkJIhQ4

11
 Skills Required
Practical projects:
Project 1A Prepare hands hygienically with
soap and water
Watch thE video
https://youtu.be/3xdPJT1i6ng
Follow the steps in the World Health Organizations (WHO)
guideline diagram
http://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdf
Information
kk The simple act of hand washing is probably the single most
important way to reduce the transfer of harmful microor-
ganisms from one person to another.
kk For hand washing to be effective in avoiding or reducing the
transfer of harmful microorganisms, adherence to a proper
technique is of utmost importance.
kk Hand washing is also important for reasons of personal
hygiene, e.g. the washing of hands after using the bathroom
as well as before meals.
kk Staff working in the food and restaurant industries requires
a high level of hygiene including a protocol regarding hand
washing to avoid the contamination of food with dangerous
microorganisms.
kk It is better to remove all hand jewelry and arm bands. (If you
work in a healthcare setting leave your jewelry at home in
a safe place).
Requirements:
kk A nail clipper or nail care set.
kk Soap (antiseptic or regular soap). Liquid soap is preferable
but a bar of soap will also do.
kk Clean single-use towels e.g. disposable paper towels.
kk Hand washing can be subdivided into the following five im-
portant steps:
kk Wet Soap Wash Rinse Dry
Step 1
Ensure that your nails are neat, short and hygienically clean. No
nail extensions or long nails are allowed in a healthcare setting!
Step 2
Turn on the faucet and adjust to a moderate stream of water.
Wet both hands up to the wrists.
STEP 3
Apply enough soap to the hands until you have a rich foamy
lather. Spread the soap lather over the complete surface of
both hands up the wrist.
12
STEP 4
1. Rub hands palm to palm.
2. Right palm over the back of the left hand with interlaced
fingers then vice versa.
3. Palm to palm with fingers interlaced.
4. Backs of fingers to opposing palms with fingers interlocked.
5. Rotational rubbing of left thumb clasped in right palm and
vice-versa.
6. Rotational rubbing, backwards and forwards with clasped
fingers of right hand and vice versa.
7. Rotational rubbing of wrist by opposing palm and vice versa.
STEP 5
Rinse the hands well. Allow running water to flow over the
hands. If possible let the water run from fingertips to the palms
and then towards the wrists. Ensure that all soap is rinsed off
properly.
STEP 6
Dry the hands thoroughly starting at the fingers then the palms
and back of the hands and lastly the wrist areas with a single
use towel. Then use the same towel to turn off the faucet.
Alternatively use your elbow to close the faucet - do not use
your clean hands.
STEP 7
Your hands are now hygienically prepared. If you intend to
perform a clinical examination, put on a pair of clean gloves
(see: Project 1C).
HINTS:
Hands should be washed for at least 45-60 second to be effective.
Use disposable paper towels. Cloth towels are not suitable in a
healthcare setting as they harbor and retain bacteria and there-
fore get all the more contaminated with use!
Frequent washing of hands will remove the skins natural
surface oils, making it scabby and rough. To reduce this ten-
dency, wash the hands in lukewarm rather than hot water.
From time-to-time use a hospital approved moisturizing hand
lotion. At home use a hand lotion containing lanolin. It will
assist in keeping the hands feeling smooth and comfortable.

Project 1B Prepare hands hygienically
with an antiseptic rub
Watch thE video
https://youtu.be/xFkyYxjh1FU
Follow the steps in the World Health Organizations (WHO)
guideline diagram
http://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdf
Barrier Techniques and Personal Protective Equipment (PPE)
Medical Professionals use barrier techniques and personal
protective equipment (PPE) to prevent injury and to avoid in-
fectious agents like bacteria to:
kk Cross from the medical professional to the patient
kk Cross from the patient to the medical professional
Protective clothing and items commonly used for this
purpose include:
Gloves
Gloves are the most common type of personal protective
equipment (PPE). Gloves are considered a barrier protecting
both you and your patient from the transfer of harmful mi-
croorganisms. Always use gloves when you work on a patient.
Hygienically prepare your hands before gloving and clean your
hands again after removing the gloves and before moving on
to your next patient. Gloves are absolutely essential when you
have an existing cut or small wound on your own hand and
when you are touching any bodily fluid/secretion/excretion.
Over-shoes
Shoe covers are important as they help maintain a sanitary en-
vironment by eliminating tracked-in dirt and microbes and they
protect the wearer from accidental spills and bodily fluids. Always
use shoe covers when entering the operating room or Intensive
Care Unit. Alternatively use dedicated surgical boots or shoes.
Skills Required
OR boots
The operating room can be a messy/bloody/gutsy place.
Surgeons often wear waterproof boots as a protective measure
from contamination with blood, puss, amniotic fluid etc.
Surgical caps
Even clean recently washed hair is contaminated with loads
of bacteria. The surgical cap minimizes the risk of hair falling
into the sterile area during surgery. Ensure that all your hair is
covered by the surgical cap before proceeding with scrubbing
for surgery!
Masks, Visors/glasses
Watch thE video
https://youtu.be/TmpQbh9PbAU
A face mask is worn as a barrier to protect the patient against
the transfer of harmful microorganisms present in the health-
care professionals saliva, nasal discharge and facial hair, and
to protect the healthcare professional from being infected by
microorganisms present in puss, blood, other body fluids, se-
cretions (e.g. saliva) or excretions (e.g. feces) by the patient.
Medical professionals should wear a mask and eye protection
or a visor (face shield) to protect mucous membranes of the
eyes, nose and mouth during procedures and patient-care
activities that are likely to cause splashes or sprays of blood,
body fluids, secretions or excretions. Masks should be worn
at all times in restricted areas of the Operating Room where
sterile supplies are opened and at scrub sinks. Masks with
face shields or masks and protective eyewear are required
whenever splash, spray or droplets of blood or other poten-
tially infectious materials may be generated.
13
 Skills Required

Apron Surgical drapes

Some surgical procedures may become really messy - thus the
surgeon needs to protect him/herself by wearing a waterproof
apron. Surgical procedures where a lot of bleeding or spilling of
bodily fluids like amniotic fluid (e.g. during a Caesarian section)
are examples of where an apron is needed.
Surgical drapes are sterile materials used to isolate the surgi-
calsite from the rest of the body and other possible sources of
contamination.
Surgical draping is the procedure of covering a patient and sur-
rounding areas with a sterile barrier to create and maintain a
sterile field during a surgical procedure. The purpose of draping
is to eliminate the passage of microorganisms between non-
sterile and sterile areas. Draping materials may be disposable
or non-disposable. Disposable drapes are generally paper or
plastic or a combination and may or may not be absorbent. All
drapes must be sterile.

Surgical gowns

Surgical gowns are considered one of the most important

protective items during surgical procedures. Sterile surgical
gowns play an essential role in maintaining aseptic conditions
by blocking the transfer of harmful microorganisms and chem-
icals to and from the patient, and reducing the transfer of
bacteria from the skin of the surgical staff to the air in the op-
erating room.

Wearing surgical gowns and other medical apparel (e.g. surgical

masks, gloves, etc.) is of utmost importance as there will always
be microorganisms present on or in the human skin, even after
conducting strict hygienic and surgical scrubbing procedures.
The purpose of surgical gowns and other protective clothing is
not only to keep bacteria from entering surgical wounds, but
also to protect the surgical staff from bodily fluids, secretions
or excretions like blood, urine, saline, or chemicals used during
surgical procedures.

Figure 2 - (a) Simulation drapes (b) Clinical drapes

(c) Real surgery after draping

See how a professional nurse drapes a patient

before a hip replacement surgical procedure.

Watch thE video

https://youtu.be/47s3M0bXnT8

14

Apply barrier techniques properly
Project 1C Don (put on) clean gloves
Watch thE video
https://youtu.be/DzqmgUfEVoM
Follow the steps in the World Health Organizations (WHO)
guideline diagram
Project 1D Safely remove used gloves
Watch thE video
https://youtu.be/ATU383lIfT8
Follow the steps in the World Health Organizations (WHO)
guideline diagram
PROJECT 1E Change into operating room (OR)
attire
Change from street/work clothes into suitable surgical scrubs
Figure 3 - (a) Entering the change room and (b) ready to enter the OR
Information
The operating room (OR) area of a hospital is a restricted and
highly controlled area. For the safety of the patients and the
operating room staff, the people allowed into operating rooms
are limited to mainly the essential staff as well as the patients
to be operated on.
All people carry legions of microorganisms on their skin, hair,
work clothes and shoes. To limit the entrance, transfer and ex-
change of these microorganisms, hospitals require people who
enter the operating room complex to dress in suitable operat-
ing room attire.
Contaminated linen may be dangerous to the surgical patients,
to the healthcare workers and to the laundry workers if not
properly handled.
Skills Required
Setting
The hospitals/clinics operating room (OR) complex/area
change room
Requirements
Available in the change room:
kk A clean set of scrubs (pants and top)
kk A disposable surgical cap
kk A pair of disposable over-shoes
kk A disposable surgical mask
Step 1 before you enter the change room
If you are physically ill e.g. if you have contracted an infectious/
contagious disease or have a septic wound especially with a
pussy discharge somewhere on your body preferably resched-
ule your visit to the OT for when you have regained your health.
All people entering the OR area must maintain a good level
of personal cleanliness and hygiene. Although not specifically
required by all hospitals anti-static underwear (100% natural
cotton) is recommended.
Preferably leave all valuables at home or in a securely locked-
away place.
Step 2 entering the change room
Commonly the hospitals OR area change rooms require an
access PIN or Password or the entrance door lock may require
an access disk or card to unlock. Arrange the necessary access
arrangements in advance. After entering, ensure that the door
closes shut behind you.
Step 3 in the change room
If you need to use the toilet now is the time.
Wash your hands thoroughly.
Choose a suitable size scrubs pants and top. Undress to your
underwear (do not place surgical scrubs over your outside
clothes). Change into your chosen surgical scrubs. Surgical
scrubs is strictly once-wear only - then it needs to go for
washing/laundering *according to a strict protocol.
Hang your outside clothes on the dedicated hangers/hooks or
in a locker supplied.
Step 4 in the change room
Take a disposable surgical cap and ensure that you cover all
your hair.
If surgical masks are supplied in the change room place the
mask over your mouth and nose.
15
Skills Required

Step 5 entering the inside OR area Follow instructions, honor restrictions and obey directions
given by medical professionals. The RN (registered nursing pro-
Put on your over-shoes. Some hospital OR change rooms
fessional) allocated to the specific operating room is in charge
have a red line between the change room and the inside of
of the operating rooms sterility and asepsis; it is thus of utmost
the operating room-proper area. In this case one is expected
importance that one follows all instructions from this person
to lift your one foot, place the over-shoe on the foot and then
carefully. Sterile areas are often covered by color coded drapes
step over the red line touching the clean inside floor of the
usually green. Dont go anywhere close to any green (sterile)
OR area with your over-shoe for the first time. Then repeat the
draped areas!
process with your other foot/over-shoe as well.
STEP 7 exiting the operating room area via the change room
If so preferred - one is also allowed to use dedicated clean OR
shoes/boots or gum-boots inside the operating room area Remove your used disposable mask, over-shoes and cap and
these shoes/boots should never be used outside of the OR /OR discard in the waste container.
change room area.
Change back into your outside clothes and place your worn
Step 6 entering the OR suite scrubs in the marked dirty/soiled linen container (not on the
floor), and then exit the change room (usually lock-release
Ensure that you have a properly placed and securely tied mask
controlled).
over your mouth and nose before you enter ANY OR suite.

Points of interest need to follow the instructions of the doctors and nurses
Home laundering of scrubs used inside the OR is not recom- closely especially regarding not compromising the sterility
mended. Use accredited laundries for washing your OR scrubs. of instruments, items and of course the sterile area.
See Article kk Dedicated administrative staff, pharmacist etc.

kk Cleaners/workers (assigned to the operating room area) /

The following people are not allowed to enter the operat- maintenance and repair technicians.

ing room area: kk Medical representatives (with permission) from companies

supplying drugs, medical and surgical services/devices.
kk The general public.
kk Students in training - following a career in one of the
kk Any person without specific permission from the relevant
medical/healthcare fields as per arrangement between
person/s in charge.
the various heads of academic departments.
kk Any person not properly dressed in acceptable OR attire
kk Staff from the radiology/radiography, pathology and other
as prescribed by the hospitals/operating rooms rules and
hospital/academic departments as required by the various
regulations /guidelines.
medical professionals working in operating room.

The following people are allowed to enter the operating

room area: Scrub for surgery

kk All healthcare professionals (doctors, nurses and allied Watch thE video
healthcare professionals) who work/perform duties in the
https://www.youtube.com/watch?v=TUwCVvGnk-U
hospital OR area.

kk Patients (awaiting surgery, undergoing surgery and recover-

ing from surgery). Gown for surgery
kk Family members of surgical patients may be allowed into Watch thE video
the OR occasionally and per special arrangement, e.g.:
https://www.youtube.com/watch?v=7KgbxBa2rh8
kk Mothers of babies and children may accompany the anes-
thetist to the OR until the child is comfortably asleep then
leave the OR complex to the family and friends waiting area. Don sterile gloves
kk The daddy (and occasionally other close family members)
Watch thE video
of delivering pregnant mommies. These family members
https://www.youtube.com/watch?v=7KgbxBa2rh8

16

Suturing Skills
Some of the projects in this section
hold a risk of sharps injury!
kk The wearing of protective glasses or a visor is required.
kk Wear gloves (consider double gloving).
kk Wear scrubs
kk Wear closed shoes (no sandals or slops)
Students who have knot tying and suturing skills may skip this
section and go to Background Information.
Students will be performing simulation surgery and will have to
suture the surgical wound after performing the various ortho-
pedic surgical procedures. Basic knot tying and surgical skills is
a definite prerequisite before staring the practical orthopedic
projects in this course.
It is highly recommended that students get the Apprentice
Doctor Suturing Kit and complete the associated Suturing
Course before starting this Orthopedic Surgery Course es-
pecially the practical projects.
Case study: Rhodes ear
Watch thE video
https://youtu.be/bg7pgk3YIRg
Skills Required
Surgical knot tying
Make a square knot and a surgeons knot
Watch thE video
https://youtu.be/BEYWsNYEt78
Information
The majority of square knots that most medical professionals
tie in their careers are done with a tissue forceps and a needle
holder. Master the technique well using imitation skin. It is
never a good idea to practice on real patients. The surgical in-
struments become extensions of the clinicians hands, making
the whole process of suturing more efficient and adding finesse
to the procedure.
Requirements
You will need:
kk A needle holder (supplied in the Apprentice Doctor
Fracture Reduction Kit)
kk A piece of string or shoe lace. Half of it must be colored (red)
and the other half white. This and all the other items that
you will need to do a full course in surgical knot tying and
basic suturing techniques are included in the Apprentice
Doctor Suturing Kit.
kk Construct a small bridge using your ruler, 2 plastic bottle
caps and sticky tape (see photo below).
Follow these steps
Step 1 Color one half of a white string (or shoelace) red
using a red felt tip or permanent marker pen. Leave the remain-
ing half white.
Step 2 Slip the string under the cardboard tube with the
colored section towards you (near side), and the white tip away
from you (far side). The white section should be shorter than
the colored section.
Step 3 Hold the needle holder in your right hand (see photo).
Step 4 Place the needle holder parallel to the cardboard
tube with the tip pointing to the left hand side. The latch mech-
anism of the needle holder must be unengaged at the stage.
Step 5 Hold the colored section on the near side between
the thumb and index finger of the left hand.
17
 Skills Required
Step 6 The colored section of the string is brought from the
near side, over the needle holder, down and back to the near
side thus making the first loop.
Note: to make a surgeons knot loop the string round the
needle holder a second time.
Step 7 Open the jaws of the needle holder and grasp the
white section on the far side, close to the tip of the string. Engage
the ratchet latch mechanism (listen for the first or second click).
Step 8 Pull the white section towards you using the needle
holder and the colored section away from you using your left
hand. Tighten the knot thus completing the first throw.
Step 9 Unclip the latch of the needle holder and release the
white tip.
Step 10 Place the needle holder again parallel to the card-
board tube with the tip pointing to the left hand side. Hold the
colored section on the far side between the thumb and index
finger of the left hand.
Step 11 The colored section of the string is brought from
the far side, over the needle holder, down and back to the far
side thus making the second loop.
Step 12 Open the jaws of the needle holder and grasp the
white section (now on the near side) close to the tip of the
string. Engage the ratchet latch mechanism (listen for the first
or second click).
Step 13 Pull the white section away from you using the
needle holder and the colored section towards you using your
left hand. Tighten the knot thus completing the second throw.
Step 14 Unclip the latch lock of the needle holder and
release the white tip.
Well done! You have just successfully tied an instrument tie
square knot. See Note Step 6 and tie a surgeons knot.
Let the needle penetrate Then on the other side
about 3mm from insert the needle in the
the wound. depth of the tissue.
Diagram 1 - Placing interrupted sutures (a) surface view and (b) cross section
18
Basic suturing techniques
How to place interrupted sutures
Watch thE video
https://youtu.be/8Gjh7XjIEyM
Information
The interrupted suture is by far the most common suture placed
by medical professionals in a wide variety of clinical situations.
In general it is easy to place in an uncompromised wound that
can be closed tension-free. This suturing technique generally
offers good and predictable results.
Requirements
kk *An Apprentice Doctor Suturing Kit (if available).
kk **Tissue forceps
kk **A sachet of suturing material
kk **A needle holder
kk **A pair of scissors
kk Imitation skin (or substitute with a suitable fruit like a banana).
*All items and instruments for practicing suturing are available
in the Apprentice Doctor Suturing Kit /
**Available in the Apprentice Doctor Fracture Reduction Kit
Step 1 Create a 12cm (5 inch) fake laceration in the fake
skin. The 12 cm (5 inch) cut in the imitation skin represents a
surgical incision or a laceration.
Step 2 Clip a needle with suture material attached to a
needle holder.
Step 3 Take the tissue forceps in your left hand and the
needle holder in your right hand. Ensure that the needle tip is
facing downwards and towards you.
Step 4 Use the tissue forceps to gently lift and open (evert)
the imitation skin on the far side of the incision/laceration.
Tie a instrument square
knot and cut the
loose ends.
 Skills Required

Place the Interrupted suture in a single step: Step 6 Tie an instrument square knot or a surgeons knot (see
the previous project). Cut the loose ends; leave at least 3 mm
Step 5 (in two sub-steps):
( inch) of suture material beyond the knots ensuring a long
Step 5a Let the needle penetrate the surface of the imita- enough piece of suture to facilitate the removal of the sutures
tion skin on the far side, approximately 3 mm ( inch) from the at a later stage. On completion, pull the knot to one side of the
margin of the incision at an angle of 90 degrees to the surface incision line (pull away from sensitive structures like the eyes or
(or slightly more). Let the needle penetrate both the epithe- lips and ala of the nose).
lium and the dermis (including 1 or 2 mm of the subcutaneous
Step 7 Place some more interrupted sutures by repeating
tissue would be quite acceptable). Assist the emerging needle
steps 5 to 7, placing a suture approximately every 5mm (inch)
through the tissues with your tissue forceps then deliver 3-5
over the width of the entire incision. Pull all the knots to the
cm / 1-2 inches of suture thread. Re-clip the needle holder
same side- ensuring that the knots are situated on intact skin
needle tip facing downwards and towards you.
and not over the laceration. Place additional sutures if you see
Step 5b With the Tissue Forceps evert (outwardly turn / lift any gaping areas.
and open) the imitation skin on the near side of the incision/
laceration. Insert the needle in the depth of the tissue (on the
side closer to you) exactly opposite the spot where the needle Placing a subcutaneous suture
emerged previously. Try to mirror the course of the needle on
Subcutaneous Sutures are placed upside-down with the
the two sides, ensuring the deep part is slightly wider than the
knots tied in the depth of the tissue.
surface part (see Diagram x (b))Deliver the needle completely
out of the tissue including most of the suture thread (leave See diagram below.
3-5 cm / 1-2 inches of suture undelivered on the far side.

Step 5 (in a single step) Let the needle penetrate the surface
of the imitation skin on the far side, approximately 3 mm ( inch)
from the margin of the incision, at an angle of 90 degrees to the
surface (or slightly more). Let the needle penetrate both the epi-
thelium and the dermis. Do not unclip the needle holder. With
the Tissue Forceps, evert (lift and open / outwardly turn) the im-
itation skin on the near side of the incision/laceration. Insert the
needle in the depth of the tissue on the near side - exactly op-
posite the spot where the needle emerged from the far side. The
course of the needle on the near side should mirror the course of
the needle on the far side. Deliver the needle completely out of
the tissue including most of the suture thread (leave 3-5 cm / Figure 4 - Tie the knot in the depth of the tissue
1-2 inches of suture thread free).

Insert the needle in the deep
side of the laceration. Penetrating
the tissue in an upwards direction
letting the needle emerge
somewhere below the epithelium.
Insert the needle in the opposite Allow a reasonable section
spot where the needle emerged of the free end of suture thread
previously, directing the to remain on the surface.
needle downwards.

Make a square knot and cut the ends.

Diagram 2 - Placing subcutaneous sutures (a) Surface view and (b) cross section

19
 The Human
Skeletal System

Anatomy and physiology

Long bones

Fracture fixation methods

Background Information
2
Bio-mechanical considerations

Biological considerations

Complications of bone fractures

Have you ever wondered why some animals, like crabs or

certain bugs, have a hard shell on the outside instead of soft
skin like us? Its because they have exoskeletons. Anexoskele-
tonis an outer (external) skeletal system. This means that their
bones are basically outside of their body. Humans have en-
doskeletons, which mean our bones are inside of our body.

See more: Click here

Imagine humans with exoskeletons like big insects just

think how much easier orthopedic surgery will be! Orthopods
would probably just need lots of jars of glue to fix all the broken
arms and legs.

20
2
The Human Skeletal System

Anatomy and physiology

Figure 1 The human skeleton

The adult human skeleton consists of 206 bones. Bones can be

classified into four types: long, short, flat and irregular bones.
Articular cartilage
Epiphyseal
artery and vein
Flat Bone (Frontal) Sutural Bone Epiphyseal
artery and vein

Short Bone (Carpal) Irregular Bone Periosteum

(Vertebra)

Compact bone

Nutrient
Long Bone (Femur) artery and
Sesamold Bone vein
(Patella) Medullary cavity
Nutrient
foramen

Metaphyseal
artery and vein
Figure 2 - Classification of Bones by Shape

Composition Metaphysis Epiphyseal line

Bone consists of both an organic (cells and matrix) and an in-

organic (mineralized) component. It is important to note that
bone is a vibrantly living and metabolically active type of tissue,
with living cells requiring a blood supply. Figure 3 - The blood supply of a long bone

21
 The Human Skeletal System

Bone tissue (osseous tissue) differs greatly from other tissues in the
body. The primary difference is the fact that bone is hard in order to
enable it to fulfil its structural, protective and locomotor functions.
Functions of bone
Bone has five main functions:
1. Structure.
The prime qualities of bones are strength and rigidity and
thus they are exceptionally suitable for providing shape to
our bodies.
3. Locomotion.
The skeletal system in conjunction with the muscular system
enables movement to the body. The muscles control bone
positions and orientations and the various bones transmit
loads and act as levers. Joints are the fulcrums facilitating
the movement of 2 (or more) adjacent bones.
4. Blood cell formation.
The red bone marrow consists of trabecular bone contain-
ing large numbers of hemocytoblasts (blood cell precursor
cells) producing red and white blood cells as well as blood
platelets for fulfilling the bodys physiological requirements.

2. Protection. 5. Storage.

The vital organs like the brain, spinal cord, the heart and Storage of inorganic salts including: Calcium, Phosphate,
lungs are protected by the surrounding bones. Sodium and Potassium as well as organic components
mainly fat in the yellow bone marrow spaces.

Long Bones
With the exception of the clavicles, all the long bones in the human Microscopic structure
skeleton are situated in either the upper or the lower extremities.
There are two types of bone tissue: cancellous or spongy bone
and compact (cortical) or dense bone. Spongy bone makes up
Articular cartilage most of the tissue of epiphyses. It consists of lamellae arranged
Proximal
epiphysis in an irregular lattice pattern of thin plates of bone called tra-
beculae. The spaces between trabeculae are filled with red bone
Metaphysis Spongy bone marrow. Compact bone structure is based on Haversian systems
Epiphyseal line (Figure 5). Haversian systems are located in the diaphysis. They
Red bone marrow
also cover spongy bone in the epiphyses. The Haversian design
Endosteum
of bone is to optimize the strength of lamellar bone for pro-
Compact bone
tection, support, and resisting stress, while maintaining a viable
environment including blood supply for the bone cells.

Medullary cavity
Osteon
Diaphysis Yellow bone marrow (Haversian system)
Periosteum Circumferential Blood vessel continues
lamellae into medullary cavity
containing marrow
lamellae
Nutrient artery
Perforating
(Sharpeys)
fibers Spongy bone
Compact
Metaphysis bone
Central (haversian)
Periosteal canal
blood vessel
Blood vessel
Distal Periosieum endosteum lining
bony canals and Perforating (Volkmanns)
epiphysis canal
Articular cartilage covering trabeculae

Figure 5 - The microscopic structure of bone: Compact Bone

Figure 4 - The structure of a typical long bone.

22
 The Human Skeletal System

Periosteum Endosteum
Endosteum
Periosteum Osteoclast
(Fibrous layer)
Periosteum
Bone matrix
(Cellular layer)
Osteocyte
Osteocyte
Osteogenic cell
in lacuna
Osteoblast

Figure 6 - The periosteum and endosteum

Cortical bone contains a relatively small number of osteocytes Parts of a typical long bone
embedded in a matrix of mineralized collagen fibers. The inor-
The two end regions of bone are called the epiphysis and the
ganic component of bone forms when calcium phosphate and
middle region is called the diaphysis or bone shaft, Figure 4
calcium carbonate combine to create hydroxyapatite, in com-
(on the previous page). The region in between the epiphysis
bination with other inorganic compounds like small amounts
and the diaphysis is called the metaphysis. Between the met-
of magnesium, sodium, and bicarbonate. The hydroxyapatite
aphysis and epiphysis is the epiphyseal cartilage disk or plate
crystals (about 65% of adult bone mass) give bones their hard-
(during growth age), which is responsible for bone growth in
ness and strength, while the collagen fibers offers bone an
length. A joint is where the epiphysis of a bone makes contact
element of elasticity (flexibility).
with another bone. Joints allow for movement. Each epiphysis
Although bone cells compose a small amount of the bone is covered by a layer of articular cartilage. The articular cartilage
volume, they are crucial to the function of bones. Four types of reduces friction and functions as a shock absorber.
cells are found within bone tissue: osteogenic cells, osteoblasts,
All bones are covered by a thin membrane called a periosteum.
osteocytes, and osteoclasts (Figure 7). Osteogenic cells are os-
The periosteum consists of two layers. The outer dense fibrous
teoblast precursor cells. Osteoblasts lay down new bone, while
layer consists of collagen fibers and fibroblasts. The inside layer
osteocytes are responsible for maintenance of the bone matrix.
contains osteogenic (osteo-progenitor) cells and osteoblasts.
They live in small hollow areas (lacunae) within the mineralized
Long bones are hollow inside. This hollow area in the middle
bone. Osteoclasts assist in the resorption and breaking down
of the diaphysis is called the medullary cavity. It is filled with
of bone for various reasons. Bone is constantly being resorbed
yellow bone marrow and consists mainly of fat. Can you think
while new bone is constantly being laid down.
of any reason why the inside of long bones is hollow? The med-
ullary cavity is lined with a thin layer of endosteum.

Red bone marrow is found mainly in the epiphyseal ends of long

bones within the small spaces inside the cancellous (spongy)
bone. Red bone marrow is functionally classified under the
lymphatic system and is responsible for the formation of white
and red blood cells as well as blood platelets.

Bone fractures
One of the most remarkable properties of bone is that of healing
and reconstruction after injury. Bone has the ability to heal after
Osteocyte Osteoblast Osteogenic cell Osteoclast damage - usually caused by mechanical forces exceeding its phys-
(maintains (forms bone (stem cell) (resorbs bone) ical strength. A break of bone is called a fracture. Bone healing
bone tissue) matrix)
is an amazing process and if healing is uncomplicated and well
managed there may be no bone scar (evidence of a previous frac-
Figure 7 - Types of bone cells ture) visible on a radiograph a year or more after the injury!

23
 The Human Skeletal System

Location Pattern

(a) (b) (c) (d) (e) (f ) (g) (h)

Figure 8 - Types of long bone fractures based on fracture location and pattern. (a) Mid-shaft (b) Peri-articular (c) Transverse (d) Oblique (e) Spiral
(f) Comminuted (g) Segmental (h) Green-stick

Figure 9 - Different types of fractures

24
 The Human Skeletal System

Case study - Just kids playing

25
 The Human Skeletal System

26
The Human Skeletal System

27
 The Human Skeletal System

Types of long bone fractures
Phenomenon: Demonstrate a fracture by using a dry wood
twig/stick and a green twig/stick.
2. The induction stage starts almost immediately after the
injury with the formation of a hematoma at the fracture
site, and ends with the appearance of inflammatory cells
approximately 48 hours after the injury.

Green Broken Stick 3. The inflammatory stage begins with the inflammatory
response and ends with the appearance of the bone (and
occasionally cartilage) production.
4. The soft callus stage is characterized by the deposition
of bone and cartilage tissue - creating a number of newly
formed bone bridges over the fracture line - and is com-
pleted with the cessation of noticeable fracture motion.
DRY Broken Stick 5. The hard callus stage involves the conversion of the
soft callus (immature bone and cartilage) into hard callus
(woven bone). At the completion of this stage, the fracture
Questions: is considered healed both clinically and radiographically.
The fracture strength is regarded as directly proportional to
kk Do you notice the difference?
kk Do you know why the twigs fractured in different ways? the amount and hardness of the new bone produced.
kk Have you ever wondered why bones fracture in 6. Bone remodeling is the conversion of woven bone to lamel-
different ways?
lar bone. Unwanted bone including the callus is removed
and replaced by normal bone as to restore the normal bone
morphology both microscopically and macroscopically.
Research opportunity:
Get your mind in destruction mode! Design a model to
produce various types of fractures in the lab?
Stage 1: Incident
Impact
Bone fractures are empirically classified as simple, comminuted
Dead Bone
and compound. Periosteum Marrow
Stage 2: 48 hours
kk Simple: one linear fracture with or without displacement.
Induction
The overlying tissue is intact.
Haematoma/Inflammatory Cells
kk Comminuted: the bone has broken in several pieces.
kk Compound: a simple or comminuted fracture where the Stage 3: Week 1
Inflammation
bone has pierced the overlying skin exposing the fracture
Cartilage
to the outside environment causing a significantly higher Subperiosteal Bone
risk of infection. Stage 4: Week 2-3
Long bone fractures can also be classified based on the loca- Soft Callus

tion and the pattern. Each type of fracture has its own unique Chordroid Matrix
challenges for reduction and fixation. The fracture on the sim- Stage 5: Week 4-16
ulation arm in this Apprentice Doctor Fracture Reduction Ossification

Kit is a simple transverse mid-shaft (diaphyseal) fracture. Other Woven Bone

Lamelair Bone
fracture patterns are available online: Click Here. Stage 6: Week 17
Remodelling and beyond

Stages of long bone healing Restored medulary Cavity

1. The impact is when the bone absorbs enough energy for

mechanical failure to occur. The energy level required to Figure 10 - Stages of long bone healing
induce the bone failure is related to the hardness of the
Bone healing following a fracture is a complex process and pre-
bone, the volume of the bone and the magnitude and vector
dictably starts with stages one and two. A variety of factors will
of the force/s exerted on the bone. Mechanical failure implies
influence the progression from stages three to six. Four sub-
that the normal continuity of the bone has been disturbed
types of fracture healing processes have been described:
and the medical term used is fracture of the bone.

28
 The Human Skeletal System

1. Primary callus (medullary bridging callus) is initiated in

External Bridging Callus Medullary Bridging Callus
the majority of fractures and is the fastest type of healing.
Callus is produced beneath the periosteum bridging the
two fracture ends. This type of healing is quite tolerant of
movement in the fracture area in fact micro-movement
to some extent stimulates callus formation. If the bone gap
is not bridged by callus within a reasonable period of two
weeks, bone healing by primary callus formation is likely to Intercortical Uniting Callus
fail resulting in a mal-union or a non-union of the fracture. Figure 11 - Types of callus

2. External bridging callus formation occurs concurrently with

primary callus formation. Callus is formed on the external
surface of the bone and helps to join and immobilize the
moving fragments of the bone. External bridging callus is
also tolerant of slight fracture motion. In fact, complete ri-
gidity at the fracture will suppress the formation of callus.
Successful bone healing is highly dependent on a good
blood supply from surrounding tissues. Once satisfactory
bridging is achieved, remodeling of the bone starts.
3. Medullary callus formation is often noted under conditions
of higher stability. It is a slow process with bridging callus
noted on the medullary (marrow cavity) side of the fracture.
4. Direct bone healing (primary cortical healing) takes place
at the fracture site in cases of complete mechanical rigidity.
It is a slow healing process and bone union is achieved by
direct remodeling of lamellar bone, the Haversian canals
and the associated blood vessels.
It is important to note that more than one of these types of
healing may occur simultaneously or in sequence.
Soft tissue healing
Many a perfectly reduced and well-fixated fracture ended up
in non-union or mal-union due to infection of the covering
soft tissue. Coverage of the treated fracture site by viable and
healthy soft tissue is an absolute integral part of the healing
and rehabilitation process. Clinicians should pay as much at-
tention to the health of the soft tissue as to the health of the
healing fracture. A wound properly closed within 24 hours
normally heals by primary intention. Complicated wounds,
wounds closed after a period of 24 hours and/or large wounds
with tissue defects will heal by secondary intention (Figure 12).
Fracture Reduction
Reduction is the action of restoring a fracture or dislocation by
returning the affected part of the body to its normal position.
There are two reduction methods:
kk Direct reduction is where the fragments are restored under
direct vision.
kk Indirect reduction is restoring the normal position of the
fragments without direct view on the fracture.

More Info from AO Trauma Foundation

Healing by primary intention

Dermis Fibrin Epidermis

Wound edges Regrowth of basel Lysis of fibrin and Restoration to

joined by fibrin plug layer of epidermis re-epithelialisation intact skin

Healing by secondary intention

Dermis Fibrin Epidermis

Large defect filled New blood vessels and Collagen laid down by Maturation of collagen
by fibrin clot fibroblasts (granulation granulation tissue achieves structural integrity
tissue) grow from the fibroblasts to and allows regrowth
dermis into fibrin restore integrity of epidermis

Figure 12 - Steps of soft tissue healing

29
The Human Skeletal System

Fracture fixation methods

Current non-invasive stabilization methods include splints,
straps and casts. A number of splints are available in the emer-
Fixator gency setting (Figure 15 ).

Non-invasive Invasive

Plaster Splint Strap Site of Fracture

Internal External

Figure 13 - Types of fracture fixation methods Board

Fracture fixation: Padding

Fixation methods can be classified into two main
categories: invasive and non-invasive. Figure 15 - Types splints

Non-invasive fixation methods

Non-invasive stabilization methods are suitable for treating

relatively simple and undisplaced fractures. They provide
very little mechanical control over the reduction fracture,
because they have no direct contact with the underlying bone.
Positional control of the broken bone segments is attained via
the surrounding soft tissues and is therefore fairly inaccurate.
The advantages of non-invasive fixation methods are the rel-
atively ease of application and the atraumatic nature of the
application procedure thus minimizing the risk of infection.
Fractures stabilized by non-invasive fixation methods most Figure 16 - Types splints
commonly heal by (mainly) external bridging callus.
Casts

A cast (previously POP/plaster of Paris but now more commonly

Slings and splints made from fiberglass) are shaped as close as possible to the
original anatomical shape of the limb thus keeping the under-
As a first option always consider the possibility of treating a
lying bone in an anatomically acceptable position. It offers very
fracture conservatively. In some instances a hairline fracture
limited control over the position of the fractured bone segments.
will heal perfectly well on its own if the affected limb is taken
out of function with a sling/strap and the necessary care is
taken to avoid trauma to the limb.

Figure 14 - A arm sling Figure 17 - A fiberglass cast on a simulation arm

30
 The Human Skeletal System

Practical projects: Wire fixation

Reduction of fractures through manipulation and The placement of stainless steel bone wires (circumferential
immobilization or trans-bony wires) is currently reserved in most instances
kk Project CR1: The emergency management of a fracture for temporary reduction purposes to facilitate the placement
kk Project CR2a: Closed reduction of a fracture using plaster of more rigid techniques e.g. plating. In non-weight bearing
of Paris (POP) cast bones wires may suffice as a definitive fixation method e.g. the
zygoma. Socioeconomic factors may also dictate the use of
kk Project CR2b: Closed reduction of a fracture using a fiber-
these wires in certain circumstances.
glass cast

Workshops:
kk Workshop 1: Cast workshop (Available during Future
Doctor Programs)
kk Workshop 2: Removal of cast (Available during Future
Doctor Programs)

Invasive fixation methods

Invasive fixators require a surgical intervention/procedure for
placement. They can be grouped into: internal and external fix-
ators Figure 18.

Internal Fixation External Fixation

(a) (b) (c) (d) (e)
Figure 19 - Wire fixation of the mandible

Bone plates

Figure 18 - Examples of invasive fracture fixation methods: (a) plate
and monocortical screws (b) plate and bicortical screws, (c) intramed-
ullary nail/rod (d) unilateral bar (e) Ring fixator
One or more bone plates may be secured over the fracture using
either monocortical or bicortical screws see figure 21 (a) and
(b). The placement of rigid bone plates can result in stress shield-
ing the reduction in bone density (osteopenia) as a result of
the reduction of the normal stress forces exerted on the bone.
Stress shielding may cause a delay in the bone union, due to
the formation of poor quality bone. Premature removal of bone
plates may result in the re-fracture of a healed fracture.

Internal fixators

Internal fixators can be divided into wire fixation, bone plates

and screws and intramedullary rods/nails. Internal fixators
are surgically placed and fixed on or into a bone and act as a
splint that shares the load with the healing bone. The main
advantages of internal fixators are: excellent control over the
position of the bone segments, early stability/rigidity, and early
resumption of the functionality of the relevant limb.

Figure 20 - Surgery Plates

31
 The Human Skeletal System
Figure 21 - A bone plate with (a) monocortical screws and (b)
bicortical screws
Intramedullary nails (IMN)
Intramedullary nails (IMN) (Figure 22) are especially effective in
treating certain types of long bone shaft fractures, like the femur
and the tibia. Fractures treated with intramedullary nails/rods
commonly heal by external bridging callus and later by medul-
lary callus formation.
Figure 22 - Intramedullary nailing of the tibia
External fixators
External fixators are grouped into two main groups rods and
ring fixators. External fixators require minimally invasive surgi-
cal procedures for placement. The structure of external fixators
(also called exoskeleton) is located outside of the affected limb
(externally). Since the exoskeleton of the fixator is located
some distance away from the skin, access to the skin allows for
post-operative care, and hygienic maintenance. External fix-
ators can be applied with minimal soft tissue damage due to
small diameters of the pins and wires, and so providing for a
reduction in pain experienced and allowing for early mobility
and functional rehabilitation.
32
External rods/bars
Unilateral or bilateral rods (or bars) are structurally simple and
fairly easy to place. One or more rods/bars are connected to
the bone segments via a number of pins and wires. External
rods/bars have low bending stiffness. It essentially only offers
2 dimensional control over the bone segments thus making
deformity correction difficult/impossible. The axial fixators are
suitable mainly for stabilizing fractured bone segments where
low load forces are expected during treatment. This type of
fixator allows for micro-motion, so the typical bone healing is
by formation of external bridging callus.
Ring fixators
(a) (b) (c) (d)
Figure 23 - Ring fixator diagram of increasing the bones length and
photo during placement
Figure 24 - Photo during placement of ring fixator
Ring fixators are highly versatile, allow for post-operative adjust-
ments and offers 3-dimesional control of the bone segments
allowing for deformity correction during the healing phase.
They also enable the orthopedic surgeon to perform novel pro-
cedures like lengthening bones by the process of distraction
osteogenesis. The vertical axis of the ring fixator is aligned with
the bone load axis, minimizing unwanted bending forces.
The disadvantages of the ring fixators include their size, weight,
form, pin tract infections, and their high cost.

Biological considerations
The orthopedic surgeon wanting to excel, needs an in depth
understanding of both the basic biological principles as well
as the mechanical and biomechanical principles forming the
scientific foundation of orthopedics. Lets focus in on some of
these basic principles.
Anatomy and physiology
In orthopedics the clinician needs to excel in his/her knowledge
of the basic medical sciences. A detailed working knowledge of
anatomy with special emphasis on osteology, the muscular
and joint anatomy as well as the course of all the various arter-
ies, veins and nerves in the human body are key to success.
Basic surgical principles
Orthopedic surgeons apply their surgical knowledge in a dis-
cipline where there just is very little tolerance for mistakes if
any! So details like:
1. Taking a thorough medical history
2. Good treatment planning
3. Sterility and aseptic technique. Orthopedic surgeons do
not have the luxury of compromising in this department.
Long surgical scrub times, extensive draping and barrier
techniques, and laminar flow ORs are all part of minimizing
the chances of post-operative wound infection. During the
simulation projects the student will do well to pay a lot of
attention to all the instructions in this regard.
4. Good vision / lighting
5. Minimum surgical invasion within limits of (4) above
6. Optimize the surgical areas oxygen tension and thus blood
supply
7. Respect both the hard and the soft tissue
The Human Skeletal System
Short notes on hemostasis
Orthopedic surgeons often work almost completely blood-
less! Do you know why?
kk Taking a good medical history and then taking care of all
risk factors that may increase the chances of bleeding like
hemophilia, hypertension, and anticoagulation medication
for instance.
kk Hypotensive anesthesia. The anesthetist uses vaso-regulating
pharmacological agents to reduce the blood pressure signifi-
cantly while ensuring that the brain still gets enough Oxygen.
kk Diathermy. This is the use of electric current to burn close
smaller blood vessels.
kk Avoiding arteries and veins in the surgical field due to their
knowledge of anatomy.
kk Tying off arteries and veins in the surgical field. All larger
arteries and veins should be tied off with tie sutures or clips
not only for the surgery, but to avoid post-operative bleeding.
kk Using hemostatic agents. Hemostatic agents like bone wax
can limit bone bleeds significantly.
kk Tourniquets. Arterial tourniquets, inflated way above the
systolic blood pressure stops the inflow of arterial blood.
The surgeon needs to record the tourniquet time accurately
as to avoid tissue damage to the specific limb due to depriv-
ing the limb from its arterial blood supply for too long.
Also see page 50
Question
kk Which one of the above techniques makes it possible
for orthopedic surgeons to work in an essentially
bloodless operative field?
kk The answer is simple orthopedic surgeons use all of the
above techniques in one way or the other but placing
an arterial tourniquet adds the most significant part to
bloodless surgery in orthopedics.
kk See this YouTube video (ORIF Distal Radius Fracture
Surgery by Dr. Thomas Trumble) as proof:
https://www.youtube.com/watch?v=GX7Lz-kh2j0
33
 The Human Skeletal System
Biomechanical Considerations
Questions:
kk What is the strongest a solid or a hollow tube (identical
material composition) of the same dimensions?
kk What is the strongest a solid or a hollow tube
(identical material composition) of the same weight?
Research opportunity:
Design an experiment to test the strength of various
tube designs with form and dimensional variations.
The primary responsibility of the skeleton is to withstand
loadbearing. Bone is strong, it is stiff, and it is tough. Bone can
withstand extremely high loads, and will remain strong even
following several million cycles of load. Understanding a few
basic elements of mechanics allows the scientist, physician,
engineer, and even architect, to appreciate how nature has
achieved a solution to a demanding task, such as holding up a
one ton animal that runs at very high speeds.
If you, as a scientist, engineer, architect or physician, were to
design the ultimate material, bone could teach you a lot about
the mechanics and design of a structure. Below are some me-
chanical criteria essential to any structure. The terms as used by
scientists have very specific meanings:
Compression Tension Shear (Torsion)
Figure 25 - Different types of forces
34
Strain
When a force is applied to any material, such as bone, it deforms.
The amount of deformation in the material relative to its orig-
inal length is the strain. When a material is pushed together,
the material shortens (compressive strain). When pulled, it
gets longer (tensile strain). Shear strain arises when layers of
a material slide against another, as might occur with torsion or
bending. The strain can be expressed as a percentage (100 x
change in length/original length). When your muscle contracts,
the tendon can strain as much as 5% in tension during intense
activities. Compressive strains in bone during peak activities
only rise to about 0.3% strain, and bone begins to fail at 0.7%
strain (7000 micro-strain).
Stress
To have stretched or compressed the bone, a force had to be
applied to it. The force per unit area is the stress, and is reported
in Newtons per square meter, or Pascals. A Pascal is essentially
the stress caused by the weight of one apple (0.1Kg) acting on
a square meter tabletop. One million Pascals (1 MPa) is 10kg per
cm of bone. Imagine the stress on your knee as you are stand-
ing. The force applied to your knee is your weight, acting upon
the top of your tibia. The stress caused in the third metacarpal
of a thoroughbred racehorse during a gallop is on the order
of 63 000 000 Pascals. Now imagine 63 million apples on that
same kitchen table.
Areal properties
The properties of bone described above are material proper-
ties, which can be measured from any small segment of bone.
The structural properties, which define the overall pattern of
the bone, are also important to the ultimate success of the skel-
eton. Consider a pencil, for example. Axial loading (pressing
straight down on the long axis of the pencil) results in very little
strain. But consider how easily the pencil is snapped when it is
subject to bending. Bone must resist complex forces, and must
also remain light enough to allow speed and dexterity.
Figure 26 - A pencil

The cross-sectional areas of these 3 cylinders are identical, and
they have the same elastic modulus. For an axial force (i.e.,
pushing or pulling the ends of the bar) the stress is also iden-
tical. BUT, the ability to resist bending is strongly dependent
on the distance of the material relative to the center of the
cylinder. Notice how much stronger the larger cylinder is. The
mid-sections of the long bones in the arms and legs are shaped
like cylinder B. They gradually become wider and thinner as
adults reach old age.
100% 400% 700%
Figure 27 - Resistance to bending forces various tubes
Credits:
Educational resource materials:
American Society for Bone and Mineral Research
Link (complete article):
https://depts.washington.edu/bonebio/ASBMRed/mechanics.html
University of Washington: http://www.washington.edu/
With kind permission (webmaster): smott@u.washington.edu
The Human Skeletal System
Biomaterials
Note: Time and space does not allow for a detailed section on bio-
materials, but a short summary follows. The students with a keen
interest in these subjects should research these topics in more detail.
Becoming a successful orthopedic surgeon requires an in-
depth understanding of all the materials used in the orthopedic
field. Some of the material, for instance bone plates and screws
may remain embedded in the patients body for an indefinite
period of time, possibly for life! It follows that bio-compatibility
of the materials are of utmost importance!
Common materials used for the Hardware (bone plates
and screws, intramedullary nails/rods) are:
kk Stainless steel
kk Titanium and Titanium alloys
kk Cobalt-Based Alloys
kk Tantalum
kk Composites materials
kk Carbon-Fiber-Reinforced Composite
(see: https://tinyurl.com/yaxlr7dh )
kk Absorbable material used for bone plates and screws:
poly-l-lactic acid (PLLA)
Other biological materials used for bone grafting are:
kk Autogenous grafts (from the patient)
kk Allografts (processed human bone)
kk Xenografts (processed animal bone)
kk Synthetic variants (made in a laboratory)
All of the above materials have a list of specific indications, a list
of advantages and a list of disadvantages. The most ideal mate-
rials for some reason are usually the most unaffordable option
for the average patient.
35
The Human Skeletal System

Complications of Bone
Fractures
Bone fracture healing is dependent on optimal biological con- Early local complications
ditions as well as a stable mechanical environment. A long list
of complications may occur if any of these 2 factors are com- kk Damage to important structures e.g.:

promised complications like: delayed healing, non-healing,
mal-union, various bony deformities, bone loss, bone death
and sequestration (pieces of dead bone being expelled by the
body), bone infection (osteitis) and wound infections resulting
in increased hospitalization periods, hospital expenses, loss of
kk Vascular injury injury to veins and arteries
kk Various organs e.g. damage to the brain, lungs or bladder.
kk Damage to nerves or skin.
kk Bleeding into joints (hemarthrosis)

limbs and even death. It is important that one optimizes the kk Compartment syndrome*
biological environment and chooses the appropriate treatment
kk Infection of the wound
method. As a general rule, choose the simplest and least inva-
sive treatment modality that will achieve good and predictable kk Fracture blisters: these are a relatively uncommon complica-
results, and keep to basic surgical principles. tion and occur in areas where skin adheres tightly to bone
with little intervening soft tissue e.g. the ankle, wrist, elbow
and foot.
Early life-threatening complications
*Compartment syndrome

Compartment syndrome is increased pressure within one

of the bodys compartments which contains muscles and
nerves. Compartment syndrome most commonly occurs in
compartments in the leg or arm. There are two main types of
compartment syndrome: acute and chronic.

Acute compartment syndrome occurs after a traumatic injury

such as a car crash. The trauma causes a severe high pres-
sure in the compartment which results in insufficient blood

Figure 28 - Complications may be life-threatening

kk Fat embolism: a fat embolism is a type of embolism in which
the embolus consists of fatty material. They are often caused
by physical trauma such as fracture of one of the long bones.
supply to muscles and nerves. Acute compartment syndrome
is a medical emergency that requires surgery to correct. If un-
treated, the lack of blood supply leads to permanent muscle
and nerve damage and can result in the loss of function of the
limb or in severe cases loss of the limb.

kk Severe hemorrhage and the development of surgical shock:

an example of severe hemorrhage is severance of the
femoral artery due to a femoral fracture.

kk Pneumothorax: pneumothorax is when air enters the chest

cavity and this may lead to respiratory distress. It may be a
result of rib fracture/s.

kk Medical emergencies e.g. pneumonia, deep venous throm-

bosis (DVT) and emboli: elderly patients are especially are risk
e.g. after hip fractures. Medical compromised patients are es-

pecially vulnerable to develop these types of complications.

36
 The Human Skeletal System

Normal Anatomy
Anterior
Deep posterior compartment
compartment

Lateral
compartment

Superficial
posterior
compartment
L R
Cross-section through calf of right leg

Compartment Syndrome

The fascia is cut

A longitudinal
over the lateral
incision is made
compartment
over the fibula
reducing the
pressure of
lateral leg
muscles

Swelling of muscles causing compression

of nerves and blood vessels

Chronic exertional compartment syndrome is an exercise-in- kk Myositis ossificans: myositis ossificans is the formation of
duced condition in which the pressure in the muscles increases bone tissue inside muscle tissue after a traumatic injury to
to extreme levels during exercise. the area.

kk Avascular necrosis: avascular necrosis is the loss of blood

supply to part of a bone resulting in death of bone cells and
Late local complications of fractures:
consequently the slow absorption of this part of the bone.
kk Delayed union (the fracture takes longer than the typically
kk Growth disturbance resulting in deformity
expected time period to heal)

kk Malunion (fracture heal in a malaligned position)

Late systemic complications
kk Non-union (fracture does not unite at all)
kk Septicemia
kk Re-fracture of the bone: a subsequent fracture at the orig-
kk Gangrene
inal fracture site or a new fracture adjacent to the fixation
appliance/s e.g. a trans-osseous bone plate. kk Tetanus (contaminated wounds)

kk Breakage/fracture of plates, nails/rods, screws and/or other

fixator appliances. Psychological complications

kk Joint stiffness (ankylosis) kk Fear of mobilizing

kk Osteitis and osteomyelitis: is infection of the bone / bone kk Post-traumatic stress syndrome
and marrow spaces.

kk Contractures: a contracture is a condition of shortening

and hardening of muscles, tendons, or other tissue, often
leading to deformity.

37
 3
Practical
Orthopedic
Projects

RECOMMENDED SAFETY MEASURES during practical projects. Look out for these icons!

Wear surgical scrubs Wear gloves Wear protective apron Wear protective Sharps injury risk No open shoes/
(optional) eyewear take great care! sandals

CLOSED REDUCTION OF A LONG BONE FRACTURE

Project CR1: The emergency management of Fractures may result from:
a fracture
kk Direct trauma for instance a blunt force applied to an extremity.
kk Indirect trauma for instance a vertical fall that produces a
How to temporarily set a fractured long bone in an
spinal fracture distant from the site of impact.
emergency setting
kk Pathologic conditions e.g. a fracture as a consequence of
osteitis or a malignant tumor weakening a specific bone.
Watch thE video
Associated complications of a bone fracture:
https://youtu.be/qX4i72H9zpI
kk Excessive hemorrhage

BACKGROUND: kk Instability of the affected limb / body part

Emergency Management of a Broken Bone
A broken bone, or fracture, may vary from a hairline undisplaced
crack fracture to a severely comminuted and/or compound
type of injury.
kk Loss of soft tissue and / or hard tissue
kk Contamination and subsequent infection
kk Interruption of the affected limbs blood supply
kk Nerve damage
kk Long-term disability

38
3
Although definitive orthopedic management will be required to
care for a broken bone, one should be familiar with the basic prin-
ciples of first aid and emergency care for a fractured long bone.
The person assisting the injured patient should:
cc Assess the injury
Briefly assess the seriousness of the injury. Be careful when
assessing the injury not to cause any significant movement.
Suspect the possibility of a fracture after any serious trauma
to a person. Some fractures are difficult to diagnose without
access to radiography. Fractured long bones for instance bones
in the arms, legs, fingers, and toes will typically look crooked, or
misaligned. A badly broken bone might stick through the skin
(compound fracture).
Common symptoms of broken bones include:
kk Reduced mobility or an inability to put any weight on the
affected limb
kk Swelling and bruising
kk Numbness or tingling in part of the injured extremity/hand/foot
kk A loss of the distal pulse (towards the finger/toe tips). This is
a sign that requires urgent orthopedic surgical intervention!
Moving a person with an injured spine, neck or pelvis is very
risky and should be avoided unless properly trained.
cc Call for help!
All suspected fractures should be assessed by a suitably trained
medical professional. If the injury is serious call for emer-
gency medical assistance. If the injury is less serious get the
injured person to the emergency department of a hospital as
soon as feasible.
Urgent emergency medical assistance is required if the person:
kk Isnt breathing
kk Is unresponsive
kk There is serious bleeding
kk You suspect a broken neck, spine or pelvis
kk The bone has pierced the skin
kk The toes or fingers are numb or bluish in color
cc Resuscitation measures
Provide cardiopulmonary resuscitation if necessary. If the for hydration purposes.
injured person is not breathing or you do not feel a pulse
(carotid in adults, brachial artery in babies), then start CPR (if
properly trained in BLS/ALS). A lack of oxygen for much more
than five minutes may cause brain damage. For possible spine
injuries especially cervical spine do not use the head-tilt-
chin-lift method.
Performing CPR on an injured patient who is actively and pro-
fusely bleeding will only accelerate the onset of surgical shock.
In this instance, attend to the bleeding fist.
Practical Orthopedic Projects
cc Stop excessive bleeding
Stop any significant bleeding by applying firm pressure to
the wound with a clean bandage, a clean towel or piece of
clothing. Maintain the pressure for a few minutes and inspect
briefly. If bleeding persists, reapply the pressure. One can
maintain the pressure by wrapping an elastic bandage tightly
around the bandage/towel/cloth used for applying pressure.
The use of a tourniquet to stop bleeding has place in the
hands of an experienced emergency medical professional.
cc Emergency immobilization
(optional - some judgment is required)
Temporarily immobilize the broken bone while waiting for
emergency medical personnel. Immobilizing the fracture will
help reduce the pain and protect the broken bone from further
injury. Do NOT attempt to reduce the fracture by aligning it.
Immobilize the fracture using a simple splint. The following
are examples of improvised temporary splints: stiff cardboard,
plastic, wood, a metal rod, or rolled up newspaper/magazine.
One can also use the adjacent limb (e.g. leg or finger) as a
splint. Place the splint on either side of the injury to support
the bone and tie these supports together firmly with e.g. tape,
string, rope, cord, leather belt, tie, or scarf. Do not tie it too
tightly and allow for some moment of the adjacent joints.
cc Apply ice to the area (optional)
Apply ice to the injury for about 20 minutes (use ice in a bag
or wrap in a moist cloth do not put ice directly on the injured
area). Benefits of cold therapy include: numbing the pain, re-
ducing swelling and bleeding.
cc Elevation (optional - some judgment is required)
Ensure (if possible) that the broken bone is somewhat elevated
in order to reduce swelling and slow down bleeding.
cc Stay calm and reassure
Keep calm and reassure the patient that help is on the way
and the situation is under control. While waiting for help,
keep the patient warm by covering him/her. Do not offer the
patient any food to eat, but small sips of water are permissible
Watch for signs of shock by checking the vitals every 5-10
minutes. Signs of shock include: feeling faint / dizzy, pale com-
plexion, cold sweats, rapid breathing, increased heart rate,
confusion, irrational speech and a drop in the blood pressure.
cc Analgesia
Consider pain medication, like paracetamol, if available.Avoid
medication containing aspirin as this may increase the ten-
dency towards excessive bleeding.
39
 Practical Orthopedic Projects

Perform Project CR1

Emergency splint procedure Cast procedures
Safety Guidelines: Safety Guidelines:

kk Use a *volunteer patient for this purpose or use the

fake simulation fractured arm supplied in the kit.
*Choose any extremity (arm or leg) to perform this project.
You will need: a magazine, pieces of string or shoe laces, and a
clean bandage or cloth.
Follow these steps:
Step 1 Assess the injury and the patients responsiveness
Step 2 Call for help!
Step 3 (In a real emergency setting CPR and/or stop exces-
sive bleeding if applicable.)
Step 4 Check the patients vitals or at least the heart rate and
the respiratory rate.
Step 5 Check the patients peripheral pulse on the injured limb.
Assess the color of the fingers/toes.
Step 6 Use a clean bandage/cloth and place it around the arm
as a buffer.
Step 7 Gently roll the magazine around the fractured arm.
Step 8 Secure the splint with pieces of string/shoe laces.
Step 9 Position the fractured limb slightly higher than the rest
of the body if possible.
Step 10 Apply cold (a bag of ice) over the injured area for 20 min.
Step 11 Reassure your volunteer patient.
Step 12 Stay with your patient until professional medical assis-
tance is available!
Project CR2a: Closed reduction of a fracture
using plaster (POP) cast
Watch thE video
https://youtu.be/XQPC2uYrMFU
Project CR2B: Closed reduction of a fracture
using a fiberglass cast
Watch thE video
https://youtu.be/wea9L_7IYrA
All invasive surgical procedures may result in the occurrence
of a number of negative sequelae or complications that would
have been avoided by the surgeon opting for a non-invasive
treatment modality like a split or a cast. It follows that if one
can attain the same end result by using either an invasive or
a non-invasive treatment method, the non-invasive method
should be the method of choice in the majority of cases.
POP (Plaster of Paris) had been around for donkeys years and has
withstood the test of time. It is still used for producing a custom
cast when the surgeon opts for a closed reduction, although the
use of fiberglass casts has grown significantly in popularity.

Note: There are a variety of emergency temporary splints Qualities of materials:

on the market. Click here for more information.
Plaster Fiberglass

Heavier Lighter
(Difficult for patients to tolerate) (Easier for patients to tolerate)

More malleable Less malleable

Do not tolerate water well after Water resistant - Waterproof cast

setting liner makes it waterproof

Color: usually just white Comes in a number of appealing

colors

Sets slower (temperature Sets faster (temperature

dependent) dependent)

Cheaper More expensive

40
 Practical Orthopedic Projects

Perform Project CR2a and CR2b Step 5 Cover the arm (intended area for receiving plaster splint)
(Simulation project) with stockinet.

You will need:

kk The fracture simulation mini-arm

kk Stockinet
kk Cotton wool
kk Plaster of Paris (POP) or Fiberglass cast
kk Sufficiently large bowl filed with water at room temperature
kk A pair of scissors
kk An assistant

Note: Fiberglass casts are not included in the kit these

items are available from the Apprentice Doctor website.

Warning: Do not practice this project on a volun- Step 6 Gently roll 2 layers of protective orthopedic padding over

teer person - as the kit does NOT contain the required the stockinet for protection. Do not apply the padding too tightly!

equipment for removing casts!

Follow the steps as in the video clip.

Step 1 Clean the arm and dry properly.

Step 2 Put on the protective apron and don clean gloves.

Step 3 Remove the outer paper of the plaster rolls.

Step 4 Ask the assistant to stabilize the arm in a reduced position.

41
 Practical Orthopedic Projects

Step 7 Soak the roll of plaster in lukewarm water allow most Step 9 Mold the plaster splint. (Use water to assist in the
of the air bubbles to escape. Give it a gentle squeeze to remove molding process).
excess water.

Step 10 Roll back the edge of the stockinet to ensure that the
casts side edges are covered by something soft to avoid abra-
sive action of the cast on the adjacent skin.

Step 8 Unroll the plaster over the protective layer as demon-

strated in the illustration below.

Step 11 Allow to plaster to set (about 10-15 minutes for

Fiberglass and 20-30 minutes for POP). Setting time depends
on the temperature of the water used.

Step 12 *Give instructions to the patient.

*In a clinical setting, give written instructions covering things like:

follow-up dates, anticipated time for removal of the cast, instruc-
tions regarding restriction of activity and mobility, care for the
extremity, care for the cast and avoiding water contamination.

42

REDUCTION AND INTERNAL FIXATION (ORIF) OF A LONG
BONE FRACTURE
The projects in this section hold a risk
of sharps injury!
kk The wearing of protective glasses or a visor is required.
kk Wear gloves (consider double gloving)
kk Wear scrubs
kk Wear closed shoes (no sandals or slops)
Project OR1: Open Reduction and Internal
Fixation (ORIF) of a Long Bone Fracture Using
Monocortical Screws
Watch thE video
https://youtu.be/f-XR3vVH6Sg
Foundational information
Have you ever wondered what differentiates the average
surgeon from the excellent surgeon?
Surgery stands on three important legs:
1. A correct diagnosis
One can perform the most impressive surgery, but if the
diagnosis is wrong the surgery is futile and may lead to
serious medicolegal consequences!
2. Thorough treatment planning
This is the distinguishing factor between average and excel-
lent surgeons and surgeries. Thorough treatment planning
is the foundation of excellence in surgery.
3. The surgical procedure
Most medical and surgery students just want to go straight
to the OR and do surgery. Without steps (1) and (2) above,
one is doomed to failure! Excellence in surgery requires
thorough knowledge of the surgical procedure one per-
forms as well as a proficiency of ones surgical skills born out
of repetition firstly in the simulation environment an later
on in the clinical setting. Good surgeons freshen up on their
knowledge of the relevant surgical anatomy and the proce-
dure if they havent performed a specific surgical operation
in the recent past. They also often ask an experienced
surgeon to assist them (or vice versa) with a procedure that
they are not perfectly familiar with performing.
Practical Orthopedic Projects
Clinical perspective
Pre-op consultation
It is beyond the scope of this course material to cover the
details of a complete clinical examination see the Future
Doctors Foundation Course for more information on this
subject. But here follows a number of brief thoughts
The first consultation will revolve around establishing a pro-
fessional relationship and initiating the first steps towards
making a diagnosis. Follow-up visits may be requires until
the surgeon makes a final diagnosis after reviewing all the
clinical and reports from the various special investigations
like blood results, X-ray and CR/MRI scan reports.
There should be a dedicated discussion during the pre-op-
erative consultation appointment between the patient
and the orthopedic surgeon who will be responsible for
the proposed surgical procedure.
The surgeon should ensure that the full clinical records like
the medical history, detailed notes on the clinical examina-
tion as well as relevant special investigations are in place.
The patient should receive detailed information about the
proposed surgery, benefits, possible complications as well
as the incidence and management of these complications.
The patient should receive information about alternative
treatment options with the advantages and disadvan-
tages of these treatment modalities and get ample of
opportunity and time to ask questions.
Once the surgeon and patient have decided on the appro-
priate surgical intervention, and the patient has received
all the relevant information including financial consid-
erations the patient or relevant legal entity should sign
a written consent (permission) for the surgical procedure.
The patient should also receive detailed instructions re-
garding the date, time, length of hospital stay special
arrangements, fasting guidelines etc.
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 Practical Orthopedic Projects

Prepare for the Surgical Procedure The team also needs a facilitator preferably a teacher or
Arrange your surgical team! medical professional who supervises the procedure and of
course the safety aspects of the project. The facilitator can also
open the non-sterile packets containing the sterile packets of
Clinical perspective suturing material.

The surgeon and his/her staff is responsible for ensur-
ing that a competent surgical team including specialist
surgical assistant (if required) and all the relevant anes-
thetic, nursing and medical staff has been arranged for
the date and time of the procedure, and that all parties
have been duly informed regarding routine and special
requirement (surgical sets, plating sets, blood on standby
etc.) for the procedure.
Simulation project
The Open Reduction (ORIF) Projects can be performed in a for-
malized group setting, but individuals can do the simulation
surgery at home within the guidelines spelled out previously,
and in the section.
In a group setting
All members of the surgical team must dress and prepare ap-
propriately for the surgery.
For individuals
This is not a solo-workshop. You will need at least (in addition
to you acting as the surgeon):
kk One suitable surgical assistant
kk One suitable facilitator
Read the suggestions for performing the procedure in a group
setting - mentioned previously.
The surgical assistant will function as assistant surgeon and
could be a friend, family member or a fellow student who shares
your passion for medicine. The person needs to be responsible
and will need to have read the sharps safety instructions and
disclaimers. The limitations as per the warnings on the box and
in the course material apply equally to you and to the assistant
surgeon. In addition to the assistant surgeon you may opt to
add another one or two co-assistants.

The facilitator should be a responsible adult (e.g. teacher or

parent) who can assist with supervision and other peripheral
functions (like introducing sterile items into the surgical field)
during the procedure.

All the limitations as explained in the various warnings and dis-

claimers are applicable to each member of the surgical team.
Figure 1 - Groups/teams of 4-5 students
To offer all team members maximum opportunity to performs
All the limitations as explained in the various warnings and simulation surgery we recommend that the simulation mi-
disclaimers are applicable to each member of the group/ ni-arm be used more than once.
team. Groups of 2-4 team members are ideal, but up to 6 team
members can work together at a work station/simulation op-
erating table. Performing a successful surgical procedure/
operation calls for a well-oiled functioning team of medical
professionals. This simulation procedure is no different as it
calls for working together as a team. Each team must have a
team leader responsible for guiding the other team members
and for the final result. All team members must get a turn to do
something worthwhile. If the first person makes the incision
through skin the second can dissect into the deeper tissue
and so forth. The plate has six holes so each team member
should get an opportunity to prepare and place at least one
bone screw. The assisting members of the team help with re-
traction and facilitate the surgery and thus contribute to the
success of the surgery.

44
 Practical Orthopedic Projects

Find a suitable work surface to perform the procedure on. The

How to re-use the fracture simulation mini-arm in
Project OR1 and OR2:
At the end of the first ORIF procedure cut all the sutures
and remove all the screws and the bone plate. Close the
used surgical site with 3 or 4 hold sutures. Turn the arm
45 - 60 degrees and do the second ORIF procedure using
monocortical (short) screws.
To perform an ORIF using bicortical screws perform
the same routine at the second operative site (remove
sutures, screws and plates then place 3 of 4 hold
sutures). Turn the simulation mini-arm again by about 45
-60 degrees and proceed with Project 1b.
Watch thE video
surface must be hard, stable and in a well-lit area/room (very
important). Consider using a head-lamp (available as an op-
tional extra for the kit).
For your convenience all the items that you will require to
perform the procedure are available in The Apprentice
Doctors Fracture Reduction Kit. Remove all the items from
the kit and place it next to the bench/table/work-surface where
the procedure will be performed.
Open one work surface cover corresponding with the operat-
ing table sheet on which your patient will be lying. Stabilize
the fracture simulation mini-arm as shown in the photo/video,
and place the stabilized arm on the opened work surface (this
corresponds with your patient being moved onto the OR table).

https://youtu.be/Y7ivIX-y_mU Recommended aseptic preparation of the surgical team

Additional fracture simulation mini-arms are available
from our website HERE
Gather all items and prepare for surgery.
including personal protective equipment (PPE)
Choose either the complete scrubbed for surgery experience
or the minimum requirements experience. Wearing surgi-
cal scrubs is highly recommended irrespective of the aseptic
preparation experience chosen!

The complete scrubbed for surgery experience:

Clinical perspective

All OR complexes at hospitals have a sterilization section/

department. The staff in the central sterilization depart-
ment ensures the sterility of all surgical instruments and
surgical devices to be used during surgery. They use large
steam autoclaves to sterilize all the metal surgical instru-
ments and other autoclavable items. Most autoclaves
sterilize instruments and other items by subjecting them
to high-pressure saturated steam at 121 C (249 F) for
around 1520 minutes (depending on the size of the
load and the contents).

The perioperative Registered Nursing staff in the specific

surgical team needs to ensure that all the instruments,
surgical devices, and other items required for the specific
surgical procedure are available, ready and sterile at the
time of the booked surgery.

Simulation project

Ensure that all the surgical instruments and items are ready and Figure 2 - (a) Scrubbing (b) Gowning and (c) Ready for surgery!
available for the simulation surgery.

Check the instruments and items using your check-list.

Prepare for surgery like a real surgeon. If all the facilities for
Ensure that the electric drill is fully charged and functional. scrubbing for surgery and all the relevant items like surgical
Check the forward and reverse drill buttons. Ensure that the gowns and sterile gloves are available the students should
LED light lights up when the drill rotates. prepare by changing into surgical scrubs, putting on a mop or

45
 Practical Orthopedic Projects

surgical cap followed by a mask-visor combo. Now the students The Surgical Pause
should scrub and glove for surgery see the Foundational The surgical pause is an absolute essential part of the procedure.
Medical Course for more information on how to scrub and
gown for surgery and don sterile gloves. All the rules associated
with a sterile environment will now apply. Clinical perspective

Pause on purpose to ask a number of essential questions:

Watch thE video
Is the patient correctly identified? Is it the correct limb
https://youtu.be/xDLcoYAAids
e.g. left or right knee?
Minimum requirements
Is it the correct procedure?
Participants wearing:
Is there a legally signed informed consent (written per-
kk Surgical scrubs mission for surgery) form on file?

kk Mop cap Are the relevant special investigations like radiographs,

Cover all hair with a mop cap (supplied in the kit) and wear
either a mask with a visor or safety glasses.
kk Mask
Put on the mask-visor. Fold (ply) the metal strip over the
nose and tie both straps at the back. The mask must be
tight enough to limit air/breath being directed towards
the sterile surgical field. If one needs to sneeze or cough
face towards the operative site and dont attempt to cover
the nose/mouth with the hand/s.
CT/MRI-scans available?
Are all the surgical sets, instruments and items available
and ready?
Are all the members of the various surgical, anesthetic
teams as well as any other medical and healthcare pro-
fessionals required for the procedure present?
Use a checklist to ensure that you have not omitted any
essential checks before commencing surgery.
Many a surgical pause have avoided serious medicolegal
malpractice claims!

Simulation project

Your patient is Mr. John Doe. He is a 50 year-old gentleman who

fractured his right humerus after a recent fall from his bicycle.

Do you have Mr. Does radiograph? Place it in a spot where you

Figure 3 - The correct way to tie and wear a surgical mask with visor
can examine it if necessary during the procedure.

kk Protective glasses (or mask with visor) Do you have all the relevant instrument and items required for
the procedure?
kk Clean surgical gloves
Are all the members of the surgical team present, ready and
informed regarding the procedure?

Figure 4 - (a) Students ready for the workshop wearing mop caps,
protective glasses and masks (b) Student gloved with head lamp

With the above PPE in place all the rules associated with a
sterile environment are applicable as if fully scrubbed and
gowned for surgery!

46
 Practical Orthopedic Projects

Prepare for Surgery

At this stage the surgeon and the assistant/s will be dressed
in surgical scrubs. Before aseptically preparing for the surgery,
stabilize the simulation arm for the surgical procedure, using a
ruler and elastic band see photos below:

(Alternatively, one or two small pieces of double-side tape will

also serve the purpose of stabilizing the arm well).

Figure 5 (a) Stabilize the arm Figure 6 (a) Receiving alcohol hand rub (b) Preparing hands hygieni-
cally (c) Donning clean gloves

Wash hands or Alcohol hand-rub then Don gloves

Prepare hands hygienically by washing with soap and water

or by using alcohol based hand rub according to the correct
healthcare protocol and glove with surgically clean gloves. All
the rules associated with a sterile environment will apply from
now until the end of the operation. Do not to touch anything
unsterile after donning clean gloves and keep the hands on
or near the surgical field at all times. For instance: do not adjust

Figure 5 (b) The simulation arm on works surface cover

glasses or scratch any body part if itching etc.

The facilitator now introduces the following items into the

sterile field:
Turn the simulation arm so that the seam faces to the bottom
or sideways. kk The blister pack with the various disposable items. The fa-
cilitator peels of the top paper cover from the blister pack
Open a work surface cover in the middle of the simulation OR-
and places it next to the surgical area.
table. Use sticky tape to secure the work surface cover to the
table, to minimize movement during the surgery.

Place the prepared arm in the center of the work surface cover.
This represents the patient on a clean sheet on the OR-table.

Prepare hands aseptically:

Figure 7 (a) - Blister pack with disposable items

Figure 7 (b) - Peel off blister paper cover to open

47
 Practical Orthopedic Projects

kk Unfold the sterile paper cover and place it on one side kk The facilitator now introduces the surgical instruments, ortho-
next to the simulation arm to create a sterile field for pedic drill and accessories, plates and screws into the sterile
placing all the surgical instruments, items and devices. field students neatly pack these items on the sterile cover.

Figure 9 - (a) Introduce surgical items into sterile field & (b) add the drape

kk Introduce the surgical drape into the sterile field (keep it

Figure 8 - Create a sterile field for placing sterile instruments and items
folded for now).

NOTE: An extra pair of gloves and a paper towel are

supplied should the aseptic status of any member
of the surgical team become compromised.

kk Remove all the items except the cotton wool swabs and
plastic forceps from the blister pack and place these
items in the sterile field.

Figure 10 - Remove the Surgical drape from the sterilizing pouch

Prepare the surgical site aseptically

Clinical perspective

There are many antiseptic solutions for preparing the

surgical site in a medical/surgical setting. Orthopedic
surgeons are especially meticulous about proper clean-
ing of the surgical site with strong antiseptic solutions
e.g. Betadine/povidone Iodine as well as using a proper
technique. Have a look at this video to see antiseptic
preparation of the skin before an orthopedic procedure.

Watch thE video

https://youtu.be/47s3M0bXnT8

48
 Practical Orthopedic Projects

Simulation project Technique:

Cleaning the operative site
Use any of the common commercially over-the-counter availa-
ble antiseptic solutions e.g. Dettol (diluted), or simply use saline
(commonly used to prepare non-septic surgical areas in anatom-
ically sensitive areas like the face especially close to the eyes).
Ask the facilitator to open the antiseptic solution container and
pour the contents onto the cotton wool swabs in the blister
pack. Use the plastic forceps supplied in the blister pack to pick
up one antiseptically soaked cotton wool swab, and apply the
antiseptic solution to the intended operative site. Always start
in the middle and work your way linearly or in a circular way
outwards. Never go from outside back inwards. Once used, the
swab must be discarded. NEVER return a used swab into the
blister container. Follow the same routine with the other swabs.

Figure 11 - (a - d) (a) Pour antiseptic solution (b) Take soaked swab with forceps (c) Clean the
operative site (d) Discard the used swab (e) Gently dry the area

Anatomical landmarks and marking the incision line

Clinical perspective

These are typical surgical areas just before the surgeon makes the incision:

Figure 12 - Examples of surgeons marking the inteded surgical site (a) the ankle,
(b) the knee and (c) the shoulder

49
 Practical Orthopedic Projects

Frons / forehead (Frontal) Oculus / eye (orbital / ocular)

Cranium / skull (Cranial) Bucca / cheek (buccal)
Cephalan / head
Facies / face (Facial) Aurtis / ear (otic) Shoulder (cephalic)
Nasus / nose (nasal) (acromial) Cervicis / neck
Oris / mouth (oral) Cervicis / neck (cervical) Dorsum / back (cervical)
Mentis / chin (mental) (dorsal)
Thorcis / thorax /
chest (thoracic) Brachium /
Axilla / armpit (axillary) arm (brachial)
Brachium / arm Mamma , breast Olecranon /
(brachial) (mammary) back of elbow
Antecubitis / Abdomen (olecranal)
front of elbow (abdominal) Lumbas / Upper
(antecubital) loin (lumbar) limb
Umbilicus / navel
Antebrachium / (umbilical) (sacral)
forearm (antebrachial)
hip (coxal) Antebrachium /
Carpus / wrist
(carpal) forearm
(antebrachial)
Pollex / thumb
Pelvis (pelvic)
Palma / palm Manus /
(palmar) hand (manual)
Inguen / groin Gluteus / buttock
Digits (phalanges) / fingers (inguinal) (gluteal)
(digital / phalangeal)
Pubis (pubic) Femur / thigh
Patella / kneecap Femur / thigh (femeral) Lower
(patellar) (femoral) Popliteus / limb
Crus / leg (crural) back of knee
Tarsus / ankle (tarsal) (popliteal)
Sura / calf (sural)
/ toes Calcaneus /
(digital / phalangeal) heel of foot
Pes / foot (calacaneal)
(pedal)
Planta /
Hallux / great toe sole of foot (plantar)
(a) Anterior view (b) Posterior view

Master Process of Temporal Bone

Zygomatic Bone C7 Spinous Process
Clavicle Acromion Process of Scapula
Spine of Scapula
Sternal Notch
Axillary Border of Scapula
Coracoid Process of Scapula
Vertebral Border of Scapula
Sternum Inferior Angle of Scapula
Xiphoid Process Superior Angle of Scapula
Ribs Lateral Epicondyle of Humerus
Lateral Epicondyle of Humerus Ocecranon Process of Ulna
Medial Epicondyle of Humerus
Medial Epicondyle of Humerus
Posterior Border of Ulna
Head of Radius Styloid Process of Radius
Pisiform Styloid Process of Ulna
Iliac Crest Carpals
Anterior Superior Iliac Spine Metacarpals
Phalanges
Pubis Symphysis
Iliac Crest
Greater Trochanter of Femur
Sacrum
Medial Epicondyle of Femur Coccyx
Lateral Epicondyle of Femur Posterior Superior Iliac Spine (PSIS)
Patella Ischial Tuberosity
Head of Fibula Greater Trachanter of Femur
Medial Epicondyle of Femur
Tuberosity of Tibia
Lateral Epicondyle of Femur
Anterior Shaft of Tibia
Head of Fibula
Medial Malleolus Lateral Malleolus
Lateral Malleolus Medial Malleolus
Calcaneus

Figure 13 - (a) Various anatomical reference terms and (b) skeletal bony landmarks

50
 Practical Orthopedic Projects

Draping the operative site

Questions: (Opening a drape and draping the site)
kk Have you ever thought how a surgeon knows where to
make an incision?
kk Have you ever thought why most surgeons mark the Clinical perspective
incision line before incising?
Draping is the procedure of covering a patient and sur-
kk How do surgeons know how to avoid important nerves
and blood vessels when they perform a surgical rounding areas with a sterile barrier for creating and
procedure? maintaining a sterile field during surgical procedures. The
purpose of draping is to eliminate the passage of microor-
Surgeons use their knowledge of the surface anatomy combined
ganisms from nonsterile to sterile areas. Draping materials
with bony landmarks to plan their surgical incisions.
may be disposable or non-disposable. All drapes must be
sterile. Draping must be done correctly and the entire sur-
Surgeons mark the incisions for precision and for accurate gical team should be familiar with the draping procedure.
re-approximation of the opposing wound margins on closing
Have a look at this registered nursing professional
the incision. They avoid important structures by their knowl-
preparing and draping the surgical site before a hip re-
edge of anatomy and by careful surgical technique. They will
placement procedure: https://youtu.be/47s3M0bXnT8
use blunt dissection instead of sharp cutting when in anatom-
ical sensitive areas.

Simulation project
Use the skin marker pen and the second ruler in the kit and draw
a 13 cm line over the fracture area thus marking the intended
incision. Make a number of cross marking as reference point
when closing the surgical incision at the end of the procedure.
Simulation project
Open and unfold the drape. Peel off the cover over the sticky
part of the under-side of the drape.
Now carefully position the drape over the surgical area ensuring
that you allow enough space (length) for the imminent incision.

Figure 15 - (a) Peel off the wax paper, (b) center the drape over the
arm and (c) secure the drape over the arm by positioning the sticky
transparent part of the drape over the mid-arm area.
13cm

Figure 14 - Marking the incision line (a) Use a marker pen and ruler
Important note: Do NOT peel of the sticky
(b) Draw the lines on the simulation arm and (c) Diagram of markings
transparent plastic off the drape!
(fracture line at arrow)

51
 Practical Orthopedic Projects

Introducing items into the sterile field
Open items with a non-sterile outer wrapper by peeling it open
over the sterile field, neither touching the inner sterile item
nor the sterile area. It is the facilitators task to introduce sterile
items safely into the surgical field.
Watch thE video
https://youtu.be/xDLcoYAAids
Take extreme caution when doing this. It is recommended
that the facilitator places and removes scalpel blades
during this practical project.
Safety scalpels
The Future Doctors Fracture Reductions Kit is issued with a
safety scalpel with a preassembled blade and a plastic blade
cover. The scalpel is disposable and thus recommended for one
surgical procedure only.

The Incision
Handling instruments (regular and sharps)
How to hold a scalpel various hand positions
This course will demonstrate the classical way of holding various
Here are 3 common scalpel grips. For this project use the pencil grip.
surgical instruments, but there are a number of different holds
and grips that may work well for one person and not so well for
another. Take extreme care when working with sharp instru- Pencil Grip
ments like scalpels for you and your teams safety! Ensure that
all participants are familiar with the sharps section in the course.

Important rule: Never hand a sharp instrument to

another team member! This is how to hand a sharp instru-
ment to a second person: Identify a neutral zone on the
sterile field and place the sharp instrument in this zone.
The second person should pick it up from this neutral zone.

Assemble a scalpel blade Fingertip Grip

The scalpel in your kit comes with a pre-assembled blade. If for
any reason one needs to place a regular scalpel blade onto a
scalpel handle use an instrument like an artery forceps to do
this. NEVER use your hand!

Watch thE video

https://youtu.be/YrJQpAbwZf0

Palm Grip

Figure 17 - Various scalpel hand grips/holds (a) Pencil grip

Figure 16 - Assemble and remove scalpel blade: (a) correct and
(b) Fingertip grip (c) Palm grip
(b) incorrect

52
 Practical Orthopedic Projects

Make the incision

Important:

Take caution to avoid any sharps injuries.

Report all injuries to the workshop supervisor.
Do not recap the scalpel!

At the end of the procedure all sharps including the scalpel

should be collected by the supervisor and then discarded
safely (see section on Sharps Safety).

Visualization of the Operative Field

Clinical perspective

The surgical field must be well-lit. Choose a suitable area

with good illumination for the simulation procedure.
Consider using a head-lamp (available as an optional
extra with the kit). Modern operating rooms are designed
to optimize the amount and quality of the light available
to the surgeon. There have been amazing advances in
OR-table lights. With LED lights surgeons can control the
frequency of the light shining on the operative wound.

Figure 18 (a) Make the incision along the marked line

(b) Deepening the incision

If not already opened ask the facilitator to peel open the scalpel
outside wrapping and introduce it into the sterile field. Remove
the blade cover. Hold the scalpel using the pencil grip. The
scalpel handle should be between 30 and 45 degrees to the
skin surface when making the incision.

Figure 20 - (a) and (b) Good light (a) Overhead OR lights (b) Headlamp

Vision is not only one of the basic principles of surgery; it

is the primary and most important basic principle of suc-
cessful surgery. So the surgeons ability to visualize the
surgical area is of utmost importance. It is the surgical
assistant/s primary task to assist the surgeon firstly with
good visualization of the surgical area by retraction.

Simulation project
Figure 19 - The various layers in the simulation arm
Ensure that the simulation procedure is performed in a room
Make the incision in a definitive way. Incise cutting the epider- with very good overhead lighting.
mis and the dermis along the marked line, from the one to the
Ensure that the drills LED light is in working order.
other side. Do not cut hesitantly, like a painter, using repetitive
short strokes! Apprentice orthopedic surgeons may opt to order a headlight
as an optional extra item.
When not in use place the scalpel in the neutral zone with the
blade pointing away from you.

53
 Practical Orthopedic Projects

Retraction

Figure 21 - The assistant surgeon/s assist with visualization by retracting the surgical wound margins

The assistant uses retractors to help the surgeon to see what he/she is doing. Retraction should be positive enough to maximize
visualization of the surgical area and gentle enough to avoid damage and tearing of the tissue and wound margins.

Control hemostasis (Clinical perspective)

Bleeding especially excessive bleeding will obscure the
surgeons vision of the surgical area. Surgeons avoid exces-
sive bleeding by a number of measures:
1. Avoidance
1) By taking a good medical history and making
modifications if necessary. The patient may be a
hemophiliac who will need clotting factors sup-
plementation before, during and after the surgery.
The patient may take blood-thinning drugs like
aspirin and this will need to be modified/stopped or
managed by other measures.
2) Surgeons can avoid cutting larger veins and arter-
ies due to their detailed knowledge of the surgical
anatomy of the operative area.
3) By their surgical approach and technique for in-
stance the surgeon may opt to blunt dissect into the
deeper tissue instead of cutting into anatomical sen-
sitive areas that may contain large blood vessels or
important nerves.
Blunt dissection is when a surgeon instead of using a
sharp blade to cut into the deeper tissue uses a dissection
scissors to open the tissue and thereby safely dissecting his/
her way into the deeper tissue.
2. Hemostatic measures during the operation:
1) Special hemostatic scalpels e.g. the Colorado needle
scalpel
2) Dabbing with swabs
3) Suctioning
4) Surgical diathermy (electro-coagulation). A surgical
diathermy unit generates electrical current to heat
up the tissue at a focus point for burning close small
blood vessels and so to stop the bleeding. Surgeons
can use one of 2 modes when using the surgical
diathermy:
a. Cutting with a surgical diathermy tip
b. Coagulate small blood vessels with a surgical
diathermy tip
5) Tying off larger blood vessels with a suitable surgical tie
6) Asking the anesthesiologist to lower the patients
blood pressure (hypotensive anesthesia)
7) By applying arterial tourniquet on a limb - proximal
to the operative area
3. By hemostatic measures after the procedure
1) Positioning the patient with the operated area being
elevated
2) Pressure packs/bandages
3) Ice packs (cold packs promote vasoconstriction and
limits excessive swelling)
4) By placing negative pressure drains
5) By giving hemostatic medication
An average adult has about 5 liters of circulating blood and
losing more than 20% of this volume will need aggressive
compensatory measures to avoid surgical shock.

Simulation project

Use the dissection scissors and the tissue forceps and practice blunt bleeding will not be a factor during the surgery but in a real opera-
dissection towards the fractured bone. In the simulation setting tive procedure bleeding adds a whole new dimension to the surgery.

54

Strip Periosteum
Identify the periosteal elevator in the kit.
Clinical perspective
The periosteum is a tough fibrous membrane covering all
bones in the body. It consists of a fibrous outer layer and
a cell-rich (osteoblast-rich) inner layer. The periosteum
acts as a natural splint, offers attachment to muscles,
conveys the nutrient blood vessels to the bone and is ac-
tively involved in bone repair. Therefore it is important to
strip just enough periosteum for placing the plates and
screws. In some instances orthopedic surgeons place
bone plates on top of the periosteum (supra-periosteal)
to minimize interfering with the periosteal blood supply
of the bone.
Simulation project
Use the periosteal elevator to strip enough periosteum from
the bone on both sides of the fracture. Ensure that you will have
enough room for placing the bone plate over the fracture line.
Control the Fracture
Clinical perspective
A variety of design of bone manipulating and bone
holding forceps have been designed to assist orthope-
dic surgeons with attaining acceptable reductions of the
facture and to maintain this reduction during the fixation
process. Figure 22 are examples of bone holding forceps.
Simulation project
The Future Doctors Fracture Reduction Kit has 2 curved
Kocher forceps (Figure 23) to be used as bone holding forceps
for this project. Ensure that you understand the latch lock
mechanism and can engage and disengage the latch. Identify
the 2 curved Kocher Forceps to be used in the next step.
Figure 22 (a)-(c) Various bone holding forceps, (d) Curved Kocher forceps
Practical Orthopedic Projects
Reduce the fracture
The assistant retracts using the flat part of the cats paw re-
tractors, and the surgeon or one of the team members place
one Kocher forceps over the bone on both sides of the fracture
line, ensuring that both forceps curve away from the fracture to
maximize visibility and access to the operative area. Ensure that
the teeth at the tip of both Kocher forceps pass the convexity
of the bone at a distance of about 2 cm (1) away from the
fracture line.
Important: Place the Kocher forceps so it curves AWAY from
the fracture/middle of the bone. Do NOT try to engage the
lock mechanism of the Kocher forceps.
Figure 23 - Kochers curve away from midline
The assistant surgeon should hold both Kocher forceps by
placing the index finger and thumb in the eyes of the forceps
handles (Figure 23). He/she now manipulates the bone in an
effort to reduce the fracture. Try to attain a straight line (first
objective) with no gap (second objective) and no step (third
objective) at the fracture line (Figure 24). The purposes of these
3 reduction objectives are to:
kk Get maximum bone-on-bone surface interphase/contact
for optimal healing,
kk Maximize anatomical restoration and to
kk Attain the best functional rehabilitation and the most pleas-
ing esthetic result.
Once the team is satisfied with reaching all 3 reduction objec-
tives, it is time to start the plating process.
Figure 24 - Reduction objectives
55
 Practical Orthopedic Projects
Fixation procedure: place the bone plate using mono-
cortical screws
Clinical perspective
A large variety of fixation techniques and materials are
available to the modern orthopedic surgeon. Bone pates
vary in design, mechanical and biological characteristics,
non-absorbable e.g. Titanium, absorbable (e.g. polylac-
tic acid) etc. There are also a large variety of screw types,
makes, sizes etc. (lag screws, self-tapping, tapering, ab-
sorbable/non-absorbable and so forth) - all with their
own indications and specific characteristics.
Figure 25 - Various types of absorbable polylactic acid bone
plates and screws
Simulation procedure
Identify the following items in the kit: The surgical drill unit with
accessories (screw driver bit and drill bit), the hand screw driver,
the six-hole plate, the regular monocortical screws and the
emergency monocortical screws.
Ensure that the drill unit is in working order and identify the
forward and reverse rotation buttons. The drill unit has an LED
light which will switch on when the drill is rotating.
Opportunity - Research Project:
Design a scientific laboratory study to compare the mechani-
cal stability of a long bone fracture fixed with a six-hole plate
using 6 monocortical screws versus long bone fracture fixed
with a six-hole plate using 6 bicortical screws.
56
Clinical perspective
Monocortical screws are shorter screws for penetrating
only through the cortical bone adjacent to the bone
plate thus leaving the cortical bone across the marrow
space intact. Orthopedic surgeons will take into account
a number of mechanical, bio-mechanical, anatomical and
physiological considerations when choosing a specific
fixation method, including the choice between placing
mono- and/or bicortical screws.
For instance:
kk Mechanical considerations
kk Will the plate/s and screws be strong enough to
withstand the new mechanical stress forces that will
apply during the healing phase? Plate or screw/s
fracture is not too uncommon an occurrence.
kk Will the bone be strong enough to withstand the
new mechanical stress forces that will apply during
the healing phase after placing the relevant plates
and screws? (Re-fracture of the bone is a possibility.)
kk Will bicortical screws add to the stability of the
reduced fracture?
kk Anatomical considerations
There could be important structures (nerves arteries or
large deep veins) on the far side of the fracture that may
be at risk when going through the second cortex.
kk Bone quality and bone quantity
The bone of one of the cortices may be thin, weakened by
the injury or just poor quality of bone necessitating going
through the second bone cortex for reasons of stability.
Simulation project
Identify the monocortical regular and emergency screws.
Figure 26 - The box containing the various screws and the plates

The surgeon will get the drill unit ready by placing the drill-bit
on the drill, keeping the screw-driver tip and the hand screw-
driver ready and close-by. Give a final check on the forwards
and backwards buttons.
Figure 27 - The operative procedure: (a) placing the trans-osseous
plate (b) drilling the holes
The assistant surgeon holds the reduced fracture carefully in
position. The surgeon places the bone plate over the fracture
line so that an equal number of screw holes are on both sides
of the fracture.
Ensure that the plate holes are not too close to the fracture
line! The plate will have to be stabilized at this point in time
(a second assistant will perform this task if available). Use the
periosteal elevator for this purpose.
The surgeon now drills the first hole (usually closest to the
fracture on one of the sides). Drill in the center of the hole. The
surgeon will feel a give as the bur goes through the near bone
cortex. Stop DO NOT drill through the far bone cortex.
Gently remove the drill while rotating the drill in reverse.
Place the first monocortical screw using either the electric drill
(in forward rotation) with the star screw-driver tip or one may
use the hand screw driver.
Practical Orthopedic Projects
Figures 28 (a) - (c): Various fracture patterns and the placement of the
bone plates and screws. The numbers represents the recommended
order of screw placement (it is only a suggestion and may be changed
for a variety of reasons or due to personal preference).
Proceed by drilling the equivalent hole on the opposite side,
and place the second screw. Prepare and place the second and
third screws and finally the screws on the holes furthest away
from the fracture line (Figure 27). As a last step the surgeon
tightens all the screws using a hand screw driver. The assis-
tant surgeon can now finally relax, but retain the bone-holding
forceps in position to facilitate inspection.
Important note: If the surgeon over-prepared the hole for
the screw it may start rotating instead of engaging. If this is the
case remove the regular size screw and replace with an emer-
gency screw (slightly wider diameter). Do not over tighten the
emergency screw.
Critically inspect the reduced fixated fracture. Evaluate the 3
reduction objectives in the order of importance:
1. Straight line (no significant angulation)
2. No significant fracture line gap (more than 1 to 1 mm)
3. No significant step (more than 1 to 1 mm)
If you and your team are satisfied, proceed to the next step
(closure of the operative wound). If not, now is the time to
correct a poorly reduced fracture. Undo the screws and plate,
move the plate to solid bone and repeat the procedure. Take
great care to get a good reduction and fixation this time!
57
 Practical Orthopedic Projects

Close the Surgical Wound

Clinical perspective

The surgeon will remove excess bone fragments created

by the drilling process by rinsing with water, while suc-
tioning, and followed by a gentle wipe with a gauze swab.

The team will do a count of all instruments and items

to ensure that and all used instruments and items are
accounted and that NOTHING remains in the wound or
inside the patient.

This is a good time to inform the anesthetist about the im-

minent conclusion of the surgery and to offer an estimate
on the remaining surgical time required for wound closure.

After a final check for bleeders it is time to suture the

wound closed in anatomical layers periosteum to
periosteum, muscle to muscle, fascia to fascia, then the
Figure 29 - (a) Suturing the wound and (b) the final closed wound
subcutaneous tissue and lastly the skin. As a general rule
absorbable sutures should be used in the depth of the Place a Dressing
tissue and non/absorbable sutures on the skin surface.
Keep to minimum suturing material buried in the wound
Clinical perspective
while ensuring a secure closure.
The placement of a dressing is not always mandatory but
it does serve the following purposes:
Simulation project
kk It absorbs residual blood and tissue fluid emanating
Students should have reasonable suturing skills before at- from the wound.
tempting to close the surgical wound on the simulation arm.
For those who do not have suturing skills, the Apprentice kk It prevents staining of clothes and bed linen by blood

Doctor Suturing Course is a highly recommended resource and tissue fluid.

for learning how to suture wounds. As a bare minimum, ensure
that you cover the section on suturing in this course material:
Click Here.
Use the subcutaneous suturing technique in the depth of the
wound. For skin closure you may use interrupted sutures but
feel free to practice your mattress and continuous sutures for
closing the skin.
kk It limits bacterial contamination and thus wound
infection.
kk It protects the wound during the delicate first couple
of days of wound healing.
kk If watertight, it will prevent water from entering the
wound during washing/bathing/showering.
kk Special dressings like Steristrips may assist with the
wound closure by keeping the wound margins together.
Dont cover the wound for too long with a dressing. After
a couple days of uncomplicated wound healing, if the
wound is not draining any blood, exudate or puss, one
can leave the wound open to dry and to heal without
applying further dressings.

Simulation project

Clean the wound by wiping it with the antiseptic solution and

then dry it with gauze square.

If the dressing is not already in the surgical area ask the facili-
tator to introduce the dressing into the sterile field.

58

Remove the back part of the dressing and place the absorbent
strip in the middle of the sticky side.
Place the dressing over the closed surgical wound, and apply
with gentle pressure.
At the end of the surgery:
Clinical perspective
The surgeon will do a final check regarding the complete-
ness of the surgical procedure. Occasionally the patient
may have requested an additional minor procedure to be
done during the anesthetic like the removal of a mole,
a small biopsy or cautery of a wart for instance. Once the
surgeon is satisfied that everything is complete he/she will
inform the anesthetist regarding the completion of the
surgery, then thank the members of the team, assist with
minor remaining tasks and then un-gown and de-glove.
Simulation project
At the end of the session:
Collect all the surgical drills, surgical instruments and usable
excess items like unused bone screw. Participants leave sharps
in a designated sharps area in the sterile field. Supervisors / fa-
cilitators collect all surgical sharps in an appropriate puncture
resistant container. Scholars should NOT pass any sharps to any
other individual or to the person collecting the sharps. Discard
according to guidelines in the relevant document.
All participants now doff their used gloves. See more on how
to doff gloves.
All used disposable medical waste items like gauze, cotton
wool, paper towels etc. should be placed in the red bags
supplied. Collect all the red bags and discard according to
guidelines in the relevant document.
Students may keep the fractured arm as a souvenir but decid-
ing which one is often problematic!
If the workshop was run as a competition the winning group
should be announced (or keep it as a surprise and announce at
the prize-giving ceremony).
Veterinary Orthopedic Procedure
Watch thE video
https://youtu.be/MUje0_FfB0A
Practical Orthopedic Projects
Post-Operative Care (Clinical perspective)
In addition to the internal fixation method used, the
surgeon may opt for additional stability measures like the
placement of a temporary cast, splint or sling for protec-
tions and immobilization. The limitation of function and
stress on the healing limb by e.g. crutches is of utmost
importance. Most patients will require the assistance of a
specialized physical therapist (physiotherapist) to help with
the post-op mobilization and rehabilitation of the patient.
Post-op ward round
No matter how busy the surgeon should always do a
post-operative ward round. Remember there are anxious
patients, family members and friends waiting to get
feedback on information about success, possible compli-
cations etc.
Medication
Post-operative take home medication may include:
kk Suitable analgesics (pain killers)
kk Anti-inflammatory medication
kk Antibiotics (only if clinically indicated and NOT as a
routine)
kk Topical antiseptic ointment/solution
kk Topical antibiotic cram/ointment (only if clinically in-
dicated and NOT as a routine)
kk Dressing/strappings for home care
Patients should receive clear instructions from both the
surgeon and the pharmacist on how and when to take
the medication as well as related information.
Instructions
The patient and anyone that may be assisting with the
home-care should receive written and verbal instructions
regarding the wound-care at home, and a demonstration
on how to change dressings at home (if applicable).
Follow-up appointments
The surgeon needs to make arrangements and give clear
instructions regarding post-operative visits for moni-
toring the healing progress and for further minor office
procedures like the changing of dressings and removal
of sutures See Apprentice Doctor Suturing Course for
more information.
Further surgery
Some procedures require multiple surgical interventions
and certain fixation methods may need the routine or the
occasional removal of the hardware like external fixators,
rods, pins, nails, plates and screws. If complications occur,
the management of the complications may require surgical
management. Discuss these operative procedures includ-
ing possible complications in detail with your patient.
59
Practical Orthopedic Projects
Instructions on how to perform the
complete fracture reduction simula-
tion procedure
Watch thE video
https://www.youtube.com/watch?v=f-XR3vVH6Sg&t=19s
Note: the Fracture Reduction and Basic Surgical Skills
Workshop is best performed in a group setting, thus teaching
students the value of working in a team, just like real surgery in
a hospital OR. At very least the student will need a suitable sur-
gical assistant to assist with the procedure. Do not perform this
simulation procedure on your own as a single operator.
It is recommended that all participants wear surgical scrubs for
the workshop. Order Scrubs Here
Open a work surface cover on a suitable work surface (represent-
ing the patient on a clean sheet on the operating table in the O.R.).
Don the relevant PPE (Personal Protective Equipment).
kk Surgical cap
kk Mask with visor
Open a pair of clean/sterile gloves (consider double gloving for
extra protection).
The operator and the assistant prepare their hands hygienically
and then gown and glove according to protocol. The Apprentice
Doctor For Future Doctors Course thoroughly covers all the
basics on sterility and asepsis and related protocols.
The operative site is aseptically prepared with a suitable anti-
septic solution. Mark your incision over the fracture line with
a surgical marker pen, while considering adjacent bony land-
marks and the underlying anatomy. Ensure that it is a suitable
length for unrestrained access. Make a number of cross mark-
ings to help you re-align the opposing tissue margins during
closure at the end of the procedure.
Isolate the surgical site using a sterile surgical drape.
Incise the skin holding the scalpel upright and between 30 and
45 degrees to the skin surface.
Figure 30 - The recommended scalpel hold
60
Figure 29 shows the correct way to hold a scalpel. Make the
incision decisively - cut through the epithelium as well as the
dermis. In a real patient one would inspect the wound margins
at this point in time for bleeding, followed by taking appropri-
ate hemostatic measures if necessary.
Warning! Take great care when working with
sharp instruments. The scalpel is very sharp and
can cause serious injuries if it slips.
Proceed with deepening the incision. Ask your surgical as-
sistant to help you by retracting the wound margins. The
retractors should be placed on the opposing sides of the sur-
gical wound and the assistant should retract with the intention
of opening the wound for proper visualization of the operative
site. Retract within reasonable limits do not retract so hard as
to tear the tissue. Use the paw-side of the catspaw retractor ini-
tially. As one goes deeper down into the wound, the flat side of
the retractors will be better for retraction and thus maximizing
the surgeons view of the surgical site. Respect the tissue and
therefore handle the tissue gently.
Use a pair of dissection scissors to perform blunt dissection into
the depth of the operative wound. When the operator is close
to the bone, he / she makes the final cut through the perios-
teum, with a scalpel, onto the bone.
Use a periosteal elevator to expose bone over the fracture and
adjacent areas for visualizing the bone properly. Try not to strip
the periosteum too extensively. Visualize the fracture prop-
erly and expose sufficient bone on either side of the fracture
for accommodating the repositioning forceps as well as the
trans-osseous plate. Remove any excess hematoma or tissue
that is noted in the fracture between the 2 bone segments.
Place repositioning (or bone-holding) forceps on both sides of
the fracture some distance away from the fracture-line.
Perform a test reduction. If you are confident that you can attain
a good reduction, place the plate over the fracture line. Position
the plate such as to ensure that there are the same numbers of
holes on either sides of the fracture.
Hold the plate in position and stabilize it with a suitable in-
strument e.g. the periosteal elevator. The assistant aids by
stabilizing the bone segments and keeps them in position with
the repositioning forceps.
Drill monocortical holes and place the bone screws one by one.
Ensure that the drill is rotating forwards (or clockwise) when
drilling. Put the drill in reverse (or anti-clockwise) to facilitate
withdrawal of the drill. Drill at a 90 degree angle to the bone
surface. Aim for the middle of the hole in the plate or slightly
away from the fracture line to ensure a bit of compression
when the bone screws are tightened. Keep one eye on the

fracture while drilling to ensure that the bone segments do not
get displaced during the drilling procedure or while fixing the
trans-osseous plate.
Once all the screws are placed, inspect the fracture line again
as well as the alignment of the bone. If you are unhappy now
is the time to correct a poorly reduced fracture. To redo the
plating procedure move the plate over onto healthy bone and
repeat the process while taking care to maintain a good reduc-
tion of the fracture and proper alignment of the bone.
Once satisfied with the reduction and fixation, clean the wound
and remove all bony fragments.
The reduction procedure is now complete and the operator
can now proceed with closing the wound using sutures. Use
absorbable sutures to suture the deeper parts of the wound in
the various anatomical layers (it is - periosteum to periosteum,
muscle to muscle, fascia to fascia, and subcutaneous tissue to
subcutaneous tissue). The suture needle is clipped onto the
needle holder and adjusted with the tissue forceps. The subcu-
taneous sutures are usually placed with the knots placed in the
depth of the tissue away from the skin side. The assistant re-
tracts to facilitate vision during the suturing procedure. When
the surgeon ties the knots the assistant first eases, and then
completely releases the retraction to allow the opposing wound
surfaces to approximate. Once the suture knot is securely tied
the assistant cuts the ends of the suture about 1-2 mm away
from the knot. If the suture is cut to close the knot, spontaneous
Project OR2: Open Reduction and Internal
Fixation (ORIF) of a Long Bone Fracture - Using
Bicortical Screws
Note: Only perform Project OR2 once you have
completed Project OR1
Watch thE video
https://youtu.be/DHc47p4owH8
Follow the same steps as with Project OR1, but with the fol-
lowing modifications:
Since the surgeon will intentionally drill through both the near
and the far bone cortices, protections of the anatomically im-
portant structures like nerves and blood vessels situated at the
far side of the bone will be required.
Use a flat pliable retractor for this purpose. Bend the tip of the
retractor to follow the curvature of the bone. Strip the perios-
teum minimally for allowing the placement of the retractor at
Practical Orthopedic Projects
unraveling may occur and if cut too long, one will leave an un-
necessary amount of foreign material inside the wound.
Close the skin with non-absorbable sutures. Start closing the
skin at the cross marks made before making the incision to
facilitate undistorted closure of the skin. Observe the meticu-
lous placement of each individual interrupted suture. A Nylon
3-zero suture will be used for the closure. The surgeon starts
at the far side and enters the skin at about a 90 degree angle;
the needle penetrates both the epithelium and the dermis and
emerges in the wound. The course of the needle is mirrored on
the near side of the wound and then eased through the skin
using the needle holder and toothed forceps.
Do not touch the sharp needle with your hands
use the forceps to adjust the position of the needle.
The surgeon now ties the suture with a surgeons knot and
ensures that the knot is lying on skin and not on the incision.
The assistant cuts the tied suture with a suture scissors, leaving
4-5 mm free ends to facilitate removal at a later stage.
Once neatly and securely closed the operator or assistant
follows with cleaning the wound nicely and then allows time
for drying. The final step is the application of a suitable dressing
by the assistant.
Congratulations! You have just completed your
first successful open reduction of a fracture long bone.
the far side of the bone. Gently place the retractor at the far
side of the bone for protection during drilling through the far
bone cortex. Be gentle using excessive force when placing
the retractor may damage the soft tissue structures instead of
protecting them!
Follow these steps once the fracture is properly visualized:
Identify the regular and emergency bicortical screws in the
Fracture Reduction Kit.
The surgeon will get the drill unit ready by placing the drill-bit
on the drill, keeping the screw-driver tip and the hand screw-
driver ready and close-by. Give a final check on the forwards
and backwards buttons.
61
 Practical Orthopedic Projects

Figure 31 (a) and (b) Cross-section to show the course of the drill bit.

B
(These photos are for demonstration purposes only).

The assistant surgeon holds the reduced fracture carefully in

position. The surgeon places the bone plate over the fracture
line so that an equal number of screw holes are on both sides
of the fracture. Ensure that the plate holes are not too close to
the fracture line! The plate will have to be stabilized at this point

C
in time (a second assistant will perform this task if available)
use the periosteal elevator for this purpose. The surgeon now
drills the first hole (usually closest to the fracture on one of the
sides). Drill in the center of the hole, and penetrate both the
near and the far bone cortexes. The surgeon will feel a give as
the bur goes through the near bone cortex and a second give
as it penetrates the far bone cortex.

Figure 32 (c) and (d) Cross-section to show the course of the drill bit.
(These photos are for demonstration purposes only).
E
Ideally one needs to place a malleable retractor (optional extra
order) behind the bone as to protect the soft tissue where one
anticipates the bur to emerge through the far bone cortex. Gently
remove the drill while rotating the drill in reverse. Place the

F
first bicortical screw using either the electric drill with the star
screw-driver tip or the hand screw driver. Ensure that the tip of
the screw finds the hole at the far-side bone cortex by chang-
ing the angulation slightly if necessary. Place the first bicortical
screw using either the electric drill (in forward rotation) with
Figures 34 (a) - (c): Various fracture patterns and the placement of the
the star screw-driver tip or one may use the hand screw driver. bone plates and screws. The numbers represents the recommended
While fastening the bicortical screw, ensure that the screw goes order of screw placement (it is only a suggestion and may be changed
in the correct direction, with the screw-tip going into the hole for a variety of reasons or due to personal preference).
drilled in the far bone cortex. Figures 34 (d) - (f): Consider placing a second plate for extra stability
(use monocortical screws to secure the second plate).

Figure 33 (e) to (h) Cross-section to show the course of the bi-cortical

screws. (These photos are for demonstration purposes only).

62
 Practical Orthopedic Projects

Proceed by preparing (bicortical drilling) and placing the mess up a second time the bone should not look like Swiss
second, third and subsequent screws - thus securing the plate cheese on the post-operative radiograph!
over the fracture line (the recommended sequence of drilling
holes and placing the screws as demonstrated in Figure 33). As
a last step the surgeon tightens all the screws using a hand
screw driver. The assistant surgeon can now finally relax. Retain
the bone-holding forceps in position to facilitate inspection.

Important note: If the surgeon over-prepared the hole for

the screw it may start rotating instead of engaging. If this is the
case remove the regular size screw and replace with an emer-
gency screw (slightly wider diameter). Do not over tighten the
emergency screw.

Critically inspect the reduced fixated fracture. Evaluate the 3

reduction objectives in the order of importance: (1) straight
line (no significant angulation), (2) no significant fracture line
gap (more than 1 to 1 mm) and (3) no significant step (more Figure 35 - Swiss cheese
than 1 to 1 mm).

If you and your team are satisfied, proceed to the next step
Complete the project in the same fashion as Project OR1 by
(closure of the operative wound). If not, now is the time to
judging the result (redo if the reduction is not acceptable).
correct a poorly reduced fracture. Undo the screws and plate,
Close the surgical wound in layers and place a dressing.
move the plate to solid bone and repeat the procedure. Do not

63
 Practical Orthopedic Projects

Project OR3: Open reduction and internal fixa-
tion of a comminuted long bone fracture
Study the diagram - indication the sequence of preparing the
holes and placing the 6 screws in this comminuted simulation
fracture. Drill through the near cortex if placing monocortical
screws and through both the near and far cortices if placing
bicortical screws.

Safety guidelines
kk Wearing surgical scrubs is optional but recommended
kk Don gloves
kk Sharps injury risk take great care!
kk Wear protective eyewear
kk No open shoes/sandals allowed Proceed by drilling and placing the second and third screws
and so on as per the sequence on the diagram. For addi-
Watch thE video tional stability, consider placing a second plate and screws - as
demonstrated in the diagram.
https://youtu.be/Kfh9TxoMkls

You will need all the instruments and items as supplied in the
Apprentice Doctor Orthopedic Kit. In addition to these items a
malleable flat retractor and a straight Kocher forceps will be re-
quired (these items are available from the Apprentice Doctor
Online Shop).

The suggested surgical team consists of a primary surgeon, an

assistant surgeon and possibly one or two additional surgical
assistants.
Plan the proposed surgery beforehand. Use one or two plates
with mono- and / or bicortical screws.
Follow the same steps to access the fracture site as described in
Project OR1 then follow these steps once the fracture is prop-
erly visualized. Keep periosteal stripping to a minimum as to
maintain the bones periosteal blood supply:
Identify the regular and emergency bicortical screws in the
Fracture Reduction Kit. Attach the 1.5mm drill-bit on the drill-
unit and give a final check to ensure that the drill is functioning
well. Keep the hand screw-driver and screw-driver tip near-by.
Use a flat malleable retractor to protect important anatomical
structures, like nerves and blood vessels at the far-side of the
bone when placing bicortical screws.
If any of the regular screws do not engage into the bone,
remove the regular screw and replace it with an emergency
screw. Do not over tighten the emergency screw.
Once all the screws are placed, tighten them with a hand screw
driver taking care not to use excessive torque force.
Critically inspect the reduced fixated fracture. Evaluate the 3
reduction objectives in the order of importance:
kk Firstly any malalignment should not exceed 5 degrees as
compared to the original anatomical alignment,
kk Secondly the fracture gap should be less than 1 mm and
kk Thirdly -the fracture step should be less than 1mm
If you judge the result as unacceptable -now is the time to
correct the poorly reduced fracture. Undo the screws on one
or both sides of the fracture, maintain the fracture in an prop-
erly reduced position and repeat the procedure. If you and your
team are satisfied, proceed to the next step by closing of the
surgical wound in layers. Complete the procedure using the
same steps as in project OR1.

Consider immobilizing the reduced fracture using a sling, a

splint or a cast.

64
 Practical Orthopedic Projects

Project OR4: Open reduction and internal fixa-

tion of a segmental long bone fracture

Safety guidelines
kk Wearing surgical scrubs is optional but recommended
Proceed by drilling and placing the second and third screws
kk Don gloves and so on as per the sequence on the diagram. For additional
kk Sharps injury risk take great care! stability, consider placing a second plate as demonstrated in
the diagram.
kk Wear protective eyewear

kk No open shoes/sandals allowed

Watch thE video

https://youtu.be/T87Lx80YPKc

You will need all the instruments and items as supplied in the
Apprentice Doctor Orthopedic Kit. In addition to these items
a malleable flat retractor and a straight Kocher forceps is rec-
ommended (these items are available from the Apprentice If any of the regular screws do not engage into the bone,
Doctor Online Shop). remove the regular screw and replace it with an emergency
screw. Do not over tighten the emergency screw.
The suggested surgical team should consist of a primary
surgeon, an assistant surgeon and possibly one or two addi- Once all the screws are placed, tighten them with a hand screw
tional surgical assistants. driver taking care not to use excessive torque force.

Plan the proposed surgery beforehand. Use one or two plates Critically inspect the reduced fixated fracture. Evaluate the 3
with mono- and / or bicortical screws. reduction objectives in the order of importance:

Follow the same steps to access the fracture site as described in
Project OR1 then follow these steps once the fracture is prop-
erly visualized. Keep periosteal stripping to a minimum as to
maintain the bones periosteal blood supply:
Identify the regular and emergency bicortical screws in the
Fracture Reduction Kit. Attach the 1.5mm drill-bit on the
drill-unit and give a final check to ensure that the drill rotates
forwards and backwards. Place the hand screw-driver and
screw-driver tip near-by in the sterile field.
Use a flat malleable retractor to protect important anatomical
structures, like nerves and blood vessels at the far-side of the
bone when placing bicortical screws.
Study the diagram - indication the sequence of preparing the
holes and placing the 6 screws in this comminuted simulation
fracture. Drill through the near cortex if placing monocortical
screws and through both the near and far cortices if placing
bicortical screws.
kk Firstly any malalignment should not exceed 5 degrees as
compared to the original anatomical alignment,
kk Secondly the fracture gap should be less than 1 mm and
kk Thirdly -the fracture step should be less than 1mm
If you judge the result as unacceptable -now is the time to
correct the poorly reduced fracture. Undo the screws on one
or both sides of the fracture, maintain the fracture in a prop-
erly reduced position and repeat the procedure. If you and your
team are satisfied, proceed to the next step by closing of the
surgical wound in layers. Complete the procedure using the
same steps as in project OR1.
Consider immobilizing the reduced fracture using a sling, a
splint or a cast.

65
Practical Orthopedic Projects

Project OR5: Remove plates and screws Additional Projects

The Future Doctors Academy is developing many other
Watch thE video
orthopedic projects and will add these with associated
https://youtu.be/Y7ivIX-y_mU add-on Apprentice Doctor Kits as they become available.

Project OR6: Fixation of a longitudinal fracture using lag screws

Should one like to remove the plate/s and screws for using in a
subsequent ORIF procedure follow these steps: Project OR7: Fixation of a fracture using stainless steel wires

Project OR8: Fixation of a fracture using intra-medullary rods

1. Cut all the skin Sutures by lifting the knot and cutting the
suture just below the knot. Remove all the skin sutures in Project OR9: Fixation of an animal cadaver fracture
the way. Project OR10: Fixation of fractures using Sawbones
2. Remove all the subcutaneous sutures by cutting the suture
Project OR11: Fixation of a fracture using external fixators
and removing it - using a forceps holding the suture at the
knot area. Project OR12: Repair a fracture using a bone graft

3. Open the surgical site asking the assistant to assist with Project OR13: Repair a fractured mandible
the Catspaw retractors.
4. Remove all the screws using the hand screw-driver. If one uses
the cordless screw-driver, ensure that it is running in reverse.
5. Remove the plate/s
Research project ideas
5. Replace the screws and plates in the Orthopedic Kit
6. Place 4-6 hold sutures, to close the surgical incision. This #Project RI1 A Comparative study of the post-op-
helps to minimize distortion of the arm during subsequent erative bone strength of a fixated long bone
procedures. fracture.
Devise a research project to compare the post-operative
Note: In a clinical setting one will need to incise the pre- strength of a fracture fixed with a bone plate and 6 monocorti-
vious healed incision. This is often a good opportunity to
cal screws and bone plate and 6 bicortical screws.
excise a scar that may have formed. The surgeon will now
dissect down to the bone.

If Titanium plates and screws were used for fixation they

may have integrated into the bone, and removal may be
#Project RI2 Design a research project using
excessively difficult (much more difficult than placing Sawbones
them in the first instance!)
This is an open project the student must use his/her creativity
Orthopedic surgeons do not routinely remove plates and and resourcefulness to create a research project. Keep in mind
screws as a general rule but may opt to do so due to com-
plications like infection, constant symptoms in the area or
that Sawbones have very similar biomechanical properties
to minimize stress shieling (a reduction of bone density comparable to real human bone.
and thus bone strength in the previous fracture site).
Most orthopedic plates and screws will not trigger the https://www.sawbones.com/products/orthopaedic-models.html
metal detectors at the airports low dosage X-ray scans
may be required to verify the presence of these orthope-
dic hardware. #Project RI3 Compare the wound strength using
a variety of suturing techniques

The Future Doctors Academy can connect you

with a bio-medical researcher who will be able
to mentor and guide you during the research
project (at a fee).

CLICK HERE TO CONNECT WITH A BIOMEDICAL

RESEARCH MENTOR

66
 Practical Orthopedic Projects

Answers:

RADIOGRAPHIC 1. Yes there is a complete fracture of the right angle of the

CONSIDERATIONS mandible and a greenstick fracture in the midline and

towards the left-hand side resulting in a mal-occlusion (the
upper and lower teeth mismatch when biting).
Have a look (case study)
2. Without a medical history possible causes will include:
Study this CT-scan image with 3D reconstruction:
assault, motorcar accident, sport injury, a fall, etc.

X-rays are part of the electromagnetic spectrum. Can you

explain (or build a model) to demonstrate why X-rays can pen-
etrate where light waves wont?

Radiologists use a number of modalities to see inside the

human body like radiographs or X-rays (plain X-rays, tomo-
grams, computerized tomography or CT-scans), ultrasound,
and magnetic resonance imaging (MRI).

Orthopods rely on their skills of clinical examination (history

and physical examination) as well as special examinations like
radiographs and CT-scans to diagnose fractures of the human
skeleton. Radiographic assessment of fractured bones by
X-rays is an integral part of the way orthopedic surgeons make
a diagnosis, do their treatment planning, guide the surgery
(e.g. using a C-arm in the OR) and evaluate their surgical results
as well as monitor the progression of the bone healing.

For those who want to learn more: http://learningradiology.

Figure 36 - A CT-scan of the skull with 3D reconstruction
1. Do you see anything abnormal?
2. What do you think happened to this patient?
com/medstudents/recognizingseries/recognizingfx2012/
Recognizing%20Fractures/Recognizing%20Fractures.html
CLINICAL CASE STUDIES
Follow this link to some interesting orthopedic trauma case studies:

https://www.orthogate.org/cases/trauma

es ys
wa
v d
o- s raretion ible let a -ra
r io
di
o ic ve nf ia s t av ys m
M a I ad Vi igh ltr r- a m
Ra w r l U X Ga

10 3 1 10 -3 10 -5 10 -7 10 -9 10 -11 10 -13
Figure 37 - The electromagnetic spectrum

67
 Practical Orthopedic Projects
A CAREER IN ORTHOPEDIC SURGERY
Orthopedics is the medical specialty that focuses on the di-
agnosis and treatment of the musculoskeletal system. An
Orthopedic Surgeon treats patients who suffer from disorders
of the bones, joints, muscles and associated structures like lig-
aments, tendons, nerves, bones and skin. They diagnose and
treat a wide range of bone and skeletal problems, from per-
forming minor surgery like treating minor injuries e.g. a broken
toe and the repair of a lacerated tendon to major surgery e.g.
performing a knee replacement procedure and lumbar spine
surgical procedures. Thanks to doctors specialized in this area
of medicine, patients suffering from injuries and diseases of
the musculo-skeletal system can be rehabilitated so they can
move, work and lead an active life.
What do Orthopedic Surgeons do?
Orthopedic Surgeons endeavors to improve the mobility and
motility of their patients by:
kk Examining, evaluating and diagnosing injuries or disorders
of the musculoskeletal system;
kk Restoring patients strength and movement;
kk Developing and recommending treatment plans (including
medication, exercise, and/or surgery);
kk Tailoring physical therapy to each patients condition;
kk Informing people about the prevention of bone and joint
injuries;
kk Contributing to patients rehabilitation;
kk Halting or slowing disease progression and taking steps to
prevent/minimize complications;
kk Discussing treatment options with patients and helping
them choose the best treatment plan to regain health, mo-
bility, function and maximize independence.
Orthopedic Areas of Expertise
Orthopods can choose general orthopedics or may specialize
in one or several areas, such as:
kk Spine care: treatment of back and neck pain, as well as all
types of spine disorders;
kk Hand and upper extremity: focuses on treating conditions
affecting the hands, arms, elbows, wrists and shoulders due
to injuries, trauma, arthritis or congenital malformations;
kk Toe, foot and ankle: injuries or conditions including cartilage
injuries, fractures, tendon ruptures, arthritis, osteoarthritis;
68
kk Joint care and replacement: addresses patients suffering
from degenerative joint diseases. These Orthopods deal
with hip or knee replacement and arthroscopy among other
areas of interest;
kk Trauma or sports medicine: concerns the prevention,
treatment and rehabilitation of sports injuries;
kk Pediatric orthopedics: provides diagnosis, nonsurgical and
surgical care for newborns, toddlers and teenagers;
kk Physical medicine and rehabilitation: restores the health
and lost body functions following sports injuries, amputa-
tion, joint replacement or spinal disorders;
kk Orthopedic oncology: treats benign and malignant bone
or soft-tissue tumors.
The Career Path of an Orthopedic Surgeon (USA
perspective)
Orthopedic surgeons have to keep up with the development of
noninvasive diagnostic methods as well as with the advances in
the treatment of musculoskeletal diseases and injuries. Mastery
in this field is accomplished through extensive training, re-
search and continuous improvement of orthopedic skills and
knowledge. In general, Orthopods complete up to 14 years of
formal medical education. According to the American Academy
of Orthopedic Surgeons (AAOS), this includes:
kk 4 years of college or university;
kk 4 years of medical school;
kk 5 years of orthopedic residency at an approved academic
training hospital;
kk 1- 3 year of specialized education (optional).
Certified Orthopedic Surgeons are also required to pass oral
and written exams as well as practical and clinical evaluation
organized by the Board of Orthopedic Surgery.
Career Opportunities
Orthopods have the opportunity to work alongside other
health care professionals by joining multidisciplinary teams
and treat complex cases for instance multi-system trauma
(poly-trauma) patients. They can serve as team physicians and
orthopedic consultants or provide highly specialized ortho-
pedic care for professional or high school sports teams and
Olympic athletes. Orthopedic doctors also play a crucial role in
managing and delivering emergency care.
 Practical Orthopedic Projects

EPILOGUE
Bone is forgiving and unforgiving at the same time.
Bone is forgiving, and will often heal despite the biological con-
straints of limited blood supply and the challenges of restoring
a very specialized type of tissue while there may be some dis-
crepancies and some imperfections regarding the position and
alignment of the fragments. Bone will smooth off little promi-
nences and bumps and fill up small defects making difficult for
the medical professional to see any evidence of a fracture after
a period of time.
CREDITS
Alex Westoby: Videographer Videography and video editing
of multiple videos in the Apprentice Doctor Orthopedic Course.
Annette Klut RPN: Assistance with various aspects of the
Apprentice Doctor Orthopedic Course development and
Fracture Reduction Kit production.
Chantel Keppie: Design of the Kit Box Cover
Gareth Norman: All the illustrations in the Apprentice Doctor
Orthopedic Course

Bone is unforgiving in the sense that if the surgeon makes any Kevin Berry: Gifted illustrator, founder and owner of Drawing
mistakes on the biomechanical side, like fixing a bone in a ma- Concussions - comic strip illustrations of all the case studies.
ligned position, the bone healing will indelibly ingrain the error Maryke Van Wyk: Final compilation of all the graphic and text
and make it permanent. The only solution to a mal-aligned elements, layout for the final course material.
healed fracture is an osteotomy and then resetting and re-fix-
Thank you to 123RF.com for the use of their images for this publi-
ing the break.
cation. All videos, illustrations, graphics and images are copyright
A good orthopedic result equals: the proper and appropriate of The Apprentice Doctor except where attributed below:
surgical technique, using high quality engineered orthopedic
PAGE CREDIT
appliances, an in depth understanding of the underlying sci-
i wavebreakmediamicro/123RF.COM
entific principles, the biological foundations, and the guiding
i decade3d/123RF.COM
anatomical and physiological principles while always main-
i joloei/123RF.COM
taining good clinical judgement and excelling in patient and
i andreypopov/123RF.COM
inter-professional communication skills.
i franckito/123RF.COM
Always maintain a high level of respect for bone as a living met- i plepraisaeng/123RF.COM
abolically active type of tissue. i wavebreakmediamicro/123RF.COM
Always consider the mechanical and biomechanical constraints 11 sciencerf/123RF.COM
of an orthopedic appliance or prosthesis. 11 subbotina/123RF.COM
13 leonidp/123RF.COM
Always respect the biology and do not try to twist biologys
13 luissantos84/123RF.COM
arm. Bone metabolism is slow and teaches the patient and the
13 hriana/123RF.COM
clinician patience!
13 yolanda387/123RF.COM
14 wavebreakmediamicro/123RF.COM
20 suljo/123RF.COM
21 elenabsl/123RF.COM
30 halfpoint/123RF.COM
30 olovedog/123RF.COM
34 picsfive/123RF.COM
35 albln/123RF.COM
36 leaf/123RF.COM
Enter here to access your Future Doctors 37 imagedb/123RF.COM
Orthopedic Course Assessment Module and 40 alexandrmoroz/123RF.COM
41 kmiragaya/123RF.COM
get an IADL backed certificate for 60 extra-
43 nexusplexus/123RF.COM
curricular hours of Orthopedic skills training! 44 vgstudio/123RF.COM
46 nito500/123RF.COM
https://www.theapprenticedoctor.com/ortho_exam/
48 luissantos84/123RF.COM
63 draghicich/123RF.COM
64 albln/123RF.COM

69
Practical Orthopedic Projects

GLOSSARY Other products by the

Online Medical Glossary/Dictionary Apprentice Doctor /
1. US National Library of Medicine
Future Doctors Academy:
https://medlineplus.gov/mplusdictionary.html The For Future Doctors Academy specializes in innovative re-
sources and services to assist you towards a fulfilling career in
medicine!

The Apprentice Doctor Future

Doctors Foundational Course and
Medical Kit

2. The Johns Hopkins Health Library

http://www.hopkinsmedicine.org/healthlibrary/

Your introduction to the amazing

world of clinical medicine!

The Apprentice Doctor Basic

Suturing Course and Kit
3. Orthopedic terminology - pronunciation, flash cards etc.

https://quizlet.com/79329750/
medical-terminology-chapter-6-orthopedics-flash-cards/

Acquire basic surgical knot tying and

suturing skills
The Apprentice Doctor How to Suture Wounds
Course and Kit teaches students all the basics
regarding surgical knot tying and suturing skills. The
various techniques are clearly explained, and you will
have the opportunity to practice your suturing skill up
to perfection!

70
 Practical Orthopedic Projects

The Apprentice Doctor The Apprentice Doctor Behavioral

Venipuncture Course and Medical Kit Science Online Course

Acquire basic injection, phlebotomy, The peoples skills that ALL medical
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An great way to practice a wide variety of

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Join us on our dynamic Future Doctors Facebook page!

Visit our website www.TheApprenticeDoctor.com for more

information about our courses, kits, resources and programs.

71