CLOSED FRACTURES: THE ROLE OF GENERAL PRACTITIONER (GP) AND FAMILY MEDICINE IN CLOSED FRACTURES MANAGEMENT AT PUSKESMAS

Armis

Professor in Orthopaedic and Traumatologic

UGM, Sardjito Hospital, Yogjakarta

INDONESIA

INTRODUCTION

Fracture is a discontinuity of bone structures. If the soft tissues around the fracture site are intact is called CLOSED FRACTURE, vice versa the soft tissues and skin around the fracture site are not intact, therefore the fracture site is related with external environment is called OPEN FRACTURE.  The fracture is caused by high energy trauma may produce many fracture fragments is called FRACTURE COMMUNITIVE or produce many regions of bone fractures and also bones in different part of the body is called MULTIPLE FRACTURES. The high energy trauma is associated more than one body system is called MULTIPLE TRAUMA. If fracture is caused by low energy trauma is called FRAGILITY FRACTURE.

                                                   A             B                                      C

Fig. 1 A and B. Open fracture type IIIA of the segmental comminuted distal left femur and open intercondylar left femur fracture T type. C. Open comminuted fracture type IIIA of the left tibial plateau Schatacker VI and fracture lines extend to distal of the tibia (OPEN COMMINUTED OF THE DISTAL LEFT FEMUR and OPEN COMMINUTED OF THE PROXIMAL TIBIA/MULTIPLE FRACTURE)  

PRACTICING IN THE OBJECTIVES ASSESSMENT GUIDANCE OF THE ORTHOPAEDICS AND TRAUMATOLOGIC EXAMINATION

PREFACE

 “Is the Candidate mark objective and transparent, valid and reliable in Orthopaedics and Traumatologic examination without prejudices and disparities?”

I always reflect this interesting examination question during ten years’ experience in the Indonesian National Board Orthopaedics and Traumatologic Examiner. Because of the Examiners are able to initiate an interesting topic knowledge or skill question of the scenario independently.  This question stimulates me to solve the problem. Therefore, I think all the Examiners should be able to make a similar perception to evaluate the learning objectives of the examination.

I attempt to design the objectives examination assessment guidance of the Orthopaedics and Traumatologic examination including:

DISLOCATION OF THE KNEE JOINT

SCENARIO

A-20-year male arrived at the emergency with pain and swelling of the left knee joint caused by struck the tree during riding of motorcycle one hour ago (fig. 9). He is conscious and without others region injury.

Fig. 9. Right knee in closed traction

How the candidate solves the scenario problem

OSTEOMYELITIS AND NON-UNION

Case Examination:

A 16-year-old male came to orthopaedic consultation complaining pain during weight bearing, valgus angulation right distal lower leg with shortening. He had open right lower leg fracture and had been operated debridement and internal K-wire fixation of the fibula with external fixation of the tibia 11 months ago. Physical examination revealed valgus angulation and 11 x 7 cm cicatric on antero-medial aspect of the right distal lower leg without sinus. AP and lateral projections radiographs of the right lower leg showed a gap on tibia and fibula and closed of medullary canal of the fragments fracture end with K-wire fixation and bowing to medial. On the tibia showed external fixation without callus formation and a bit medial angulation (Fig.6).

EXAMPLE CASE OF ROTATOR CUFF TEAR ARTHROPATHY (RTA)

Case Examination

 

A 65-year-old male came to orthopaedic consultation with chief complaint of the right shoulder pain especially at night and weakness. He was a right dominant, retired mathematics teacher at favorite high school and NSAID treated without improvement. He had gout arthritis problem since 15 years ago. Inspection of the right shoulder of patient was asymmetric, atrophy of the right side of upper extremity and tenderness in the anterior aspect especially on subacromial of the right shoulder. Active and passive movement (ROM) of the right shoulder was limited

 

Part A: The objectives examination evaluation of the history taking and physical examination data collection for some possibilities or accurate diagnosis determination

 

Learning Objectives Evaluation in Examination

Orthopaedics and Traumatologic Examination : Part A

There are two versionsof the orthopaedic and traumatologic examination:

1.  A real case of exam.

After orthopaedics and traumatologic case selection by the examiners team; the Examiner asks the Candidate to collect the history taking and collect physical examination data of the orthopaedic and traumatologicpatient for analyzing and making the possibilities diagnosis.The Candidate should be able to select the important information and the reasoning of the investigations before presenting the summary

2.        Scenario or clinical signs or investigation findings exam.

The Examiner is able to select the scenario or clinical signs or radiographs of x-ray or laboratory of the patient and then the Candidate is able to ask some key of information in history taking,important data of the physical examinationand investigation findings. These information and key data are able to support the differential diagnosis or possibilities of the illness on the scenario orclinical signs or abnormalities of the investigation finding.

Orthopaedics and Traumatologic Examination : Part B and Part C

Part B: The objectives examination evaluation of the accurate diagnosis determination or possibilities of the abnormalities, patient’s problem, management and complications  

Learning Objectives Evaluation in Examination

The Examiner should be able to evaluate the Candidate ability to:

1.       To decide the problem determination (acute and long-term) of the patient

After the Candidate determines the diagnosis, he/she should be able to consider the impact of the problem on the individual or the severity of the illness process or “how bad” that disease. Example severity of fracture or dislocation must be classified into stable or unstable or other classification system. Unstable fracture of the lower extremity can contribute shortening or malunion and degeneration process of the bearing joint become happened at the long time.The risk factors of 4 parts of the humeral head fracture or femoral neck fracture in elderly condition can lead to avascular necrosis of the head humerus or femur.

THE OBJECTIVES ASSESSMENT GUIDANCE OF THE ORTHOPAEDICS AND TRAUMATOLOGIC EXAMINATION

PREFACE

 “Is the Candidate mark objective and transparent, valid and reliable in orthopaedics and traumatologic examination without prejudices and disparities?”

I always reflect this interesting examination question during ten years’ experience in the Indonesian National Board Orthopaedics and Traumatologic Examiner. Because of the Examiners are able to initiate an interesting topic knowledge or skill question of the scenario independently. This question stimulates me to solve the problem. Therefore, I think all the Examiners should be able to make a similar perception to evaluate the learning objectives of the examination.

I attempt to design the objectives examination assessment guidance of the orthopaedics and traumatologic examination including:

Acknowledgement

ACKNOWLEDGEMENT

To my family: Nyoman Rapiani Armis (my wife), Andrianti (Agung her husband), Ratih Yulianti (Didit her husband). Arief Prasetyo (Susan his wife), Khresna Adi S (Rieke his wife) and my grandchildren: Sekar, Rafid, Safa, Rafa, Nanya and Sofia thank you for permitting our time to support this concept.

To Prof. Bill Cumming, Prof. Joe Ghabrial, from Australia, Prof. Bala Subramanian from Singapore, They are my teachers, mentor and role model and got me started, thank you for inspiration and your support.

Introduction

INTRODUCTION

A Candidate of orthopaedics and traumatologic always makes an effort to have an excellent mark in musculoskeletal system examination. The challenge is still the examiner’s subjectivity of the examination of the candidate’s competence evaluation, according to orthopaedics and traumatologic curriculum. Competency measurement during orthopedics and traumatologic education is expected to become the candidate’s ability for future practice or to be adequate the requirement for higher degree education, and meet knowledge, skill, attitude and professionalism of learning objectives. A successful candidate’s marks in the examination should be correlated with educational institution curriculum in teaching.   Therefore, how does the examiner achieve the objective assessment in orthopaedics and traumatologic examination?