Clerkship: Orthopedic Surgery

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

Orthopedic Surgery

  • Location: Joseph Brant Hospital
  • Length: 4 weeks

My goals for this rotation was to know the MSK physical exam like it is second nature (#NailedIt) and be familiar with the assessment and management of common orthopedic complaints. I learned more than what I set my goals for.

Read more about what I did during my rotation and my memorable cases!

A typical day

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Back in the OR ❤

My supervising physician is an upper extremity orthopedic surgeon. He also has two PAs in his clinic who are wonderful mentors (both are clinical instructors in the PA programs in Ontario). My rotation was evenly spread out between Clinic, OR, and Fracture clinic. Since I was the only learner and it was a close drive to the hospital, I was able there for all his call shifts.

Clinic: I saw the majority of new consults. I find them VERY fun to do – from taking the history to doing the physical exam. All his patients were very pleasant as well.

OR: Since I was the only learner for the majority of the rotation, I was first-assist as well. The nursing staff were all so wonderful, teaching me The Art of Not-Contaminating-The-Sterile-Field haha! #NailedIt

Fracture Clinic: This clinic is crazy booked – double, triple, and I remember there was one time we were expected to see 5 patients in 10 minutes (5 patients were scheduled for 8AM). I did my best to help by doing all the charting. Sometimes  I can predict what management would be for the chief complaint and will have the script ready for my physician to sign. I also practiced using the oscillating cast saw to remove casts (FUN!).

Common medical conditions I encountered during my rotation

  • Rotator cuff tear (pictured above – the white part is the tear over the humeral head)
  • Distal Radius Fracture
  • Bicep tendon rupture (proximal and distal)
  • Shoulder instability

Some of my most memorable cases

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  • Radial head fracture (start to finish)
    • My first on-call case! This was a young healthy woman who, while running, tripped backward and presented with elbow pain and limited ROM. She guarded her left arm which is resting in pronation. On exam, there was +swelling and +pain, limited ROM. Neurovascularly intact distally. On x-ray, we identified a fractured radial head. She required open reduction with internal fixation (ORIF). In the operating room, I remember this was a very difficult radial head to put back together. On x-ray, it looked like a type II fracture but once we went it, it turned out to be a type III. Eventually, we had to use some expensive bone allograph to fill in the spaces. Alternatively, if this did not work, she would need a prosthetic radial head.

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  • Varus talus deformity secondary to severe osteoarthritis
  • Elbow dislocation and instability, external fixation
    • 52551048a7441f1ebba83b583518a6aa
      Image is taken from google. This is an external fixator for elbow instability.

      Young female came in with a dislocated right elbow after trying to catch her cat. ER staff reduced it by conscious sedation TWICE and when it failed they called my orthopedic surgeon. With that much instability in her elbow, she required an open repair of the ligaments and external fixator to facilitate healing. Man, this surgery was pretty cool. She got something like this (see right).

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  • Septic arthritis in a prosthetic knee
    • Another on-call case. This was very interesting for me, especially because I love infectious disease (I did my final presentation for the rotation based on this case). This was an elderly patient with a septic prosthetic knee and wrist. He required surgical drainage for both joints and this was done simultaneously by two surgeons. My surgeon mostly do upper extremity surgeries so it was exciting for me to join in on a knee case! I was assisting the knee surgeon and learned The Art of Surgical Assisting from him. The washout was crazy, just pouring antiseptics into the joint space to kill all the bacteria and biofilm.

What I learned

Just to clarify, I learned A LOT from this rotation. I have only listed a few here:

  • MSK physical exam
  • Basic MRI readings
  • Approach to x-rays, identifying fractures
  • WSIB forms
  • Importance of physiotherapy
    • Orthopedic surgeons and physiotherapists work hand in hand. Physiotherapy is SO important and it is often the first line management for many orthopedic complaints. I have seen many patients who tell me their shoulder pain is actually getting worse with physiotherapy. However, I think it is important to know what the diagnosis is or the severity of the issue is before going to the physiotherapist so that they can address with the proper exercises.
    • For the post-operative recovery period, we always encourage early range of motion exercises with physiotherapy to decrease the risk of joint stiffness.

Overall

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Last day in clinic, feedback with Anne

100% would do this rotation again. I chose this elective because I knew it would be applicable to wherever I end up working, be it in family medicine or in a surgical specialty. I am very comfortable with my MSK physical exam now. I know there are things I can work on so I want to give a shout out to Anne and Ohood, the PAs working at this clinic, who gave me constructive feedback on how I can improve. They have been such great mentors.

It was also the first time I met Anne in person, two years after I first contacted her when I was still curious about the physician assistant profession! This blog was inspired by her and it was great to be able to finally meet and work with her.

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