CFB OT01 Introduction To Orthopaedic Surgery
An introductory overview of orthopaedic surgery covering the fundamental principles of diagnosis, prevention, and treatment of disorders affecting the musculoskeletal system, including bones, joints, ligaments, tendons, and muscles.
This introductory CFB lecture by Professor Peter K Y Chiu provides the conceptual scaffolding for all of orthopaedic surgery. It answers three fundamental questions:
- What is orthopaedic surgery? — Etymology, scope, subspecialties, and defining philosophy.
- What diseases does it deal with? — A systematic disease classification (the "orthopaedic sieve") applied to the musculoskeletal system.
- What are the principles of management? — Aims of treatment, conservative vs operative strategies, and the "5 Rs" framework (Remove, Release, Repair, Reconstruct, Rehabilitate). The last R makes clear that this is a framework for the whole treatment pathway, not a list of operations alone.
Think of this lecture as the table of contents for every subsequent orthopaedic GC lecture. Every topic you encounter later (knee OA, hip arthritis, sports injuries, spine pathology, paediatric orthopaedics, bone tumours, musculoskeletal infection, high-energy trauma) slots into the framework taught here. The exam tests whether you can organise orthopaedic thinking — not just recall isolated facts.
Learning Objectives (Inferred from Slides)
- Define orthopaedic surgery and explain its etymology [1]
- List orthopaedic subspecialties [1]
- Enumerate the components of the musculoskeletal system [1]
- Distinguish form vs function and common deformity terminology [1]
- List the chief complaints in orthopaedics [1]
- Classify musculoskeletal diseases using a systematic sieve [1]
- State the three aims of management [1]
- Differentiate conservative vs operative management [1]
- Explain the "5 Rs" of orthopaedic management with clinical examples [1]
- Understand orthopaedics as a multidisciplinary specialty [1]
1. What Is Orthopaedic Surgery?
"Ortho = straightening; Pedics = child." The term was coined by Nicholas Andry, a French physician, in 1741. The original concept was correcting ("straightening") deformities in children. [1]
- Hippocrates (Greek physician, ~480 BC) is credited as the father of medicine and made early contributions to the treatment of fractures and dislocations. The lecture opens with him to root orthopaedics in its ancient surgical heritage. [1]
- The specialty has since expanded far beyond paediatric deformity correction — it now encompasses the entire musculoskeletal system across all ages.
The historical drawings are visual metaphors, not procedural instruction. The Hippocratic image depicts traction/counter-traction used to address deformity. Andry's famous crooked tree bound to a straight post represents gradual guided correction during growth; the same tree persists in the Hong Kong Orthopaedic Association and College emblems shown in the lecture. The later carpenter/plumber montage is a joke about a misconception: orthopaedics uses tools and engineering, but its object is living tissue with biology, pain and function.
| Context | Usual Name |
|---|---|
| UK / Hong Kong spelling | Orthopaedics; Orthopaedic Surgery |
| US spelling | Orthopedics; Orthopedic Surgery |
| HKU department in this lecture | Orthopaedics & Traumatology |
The HK department name uses "Orthopaedics & Traumatology" — reflecting trauma as a core part of the specialty. [1]
The orthopaedic subspecialties are: General, Trauma, Spine, Joint Replacement, Hand & Foot, Paediatrics, Sports, Oncology, and Rehabilitation. [1]
| Subspecialty | What It Covers (brief) |
|---|---|
| General | Common conditions not fitting neatly into other subspecialties |
| Trauma | Fractures, dislocations, polytrauma |
| Spine | Cervical/thoracic/lumbar pathology including degenerative disease, deformity, infection |
| Joint Replacement | Arthroplasty (hip, knee, shoulder, etc.) for end-stage arthritis |
| Hand & Foot | Peripheral extremity surgery (including microsurgery, nerve repair) |
| Paediatrics | DDH, clubfoot, scoliosis, Perthes disease, SCFE |
| Sports | Ligament injuries (ACL), meniscal tears, cartilage lesions |
| Oncology | Benign/malignant bone tumours, metastatic disease |
| Rehabilitation | Splints, orthotics, prosthetics, exoskeleton technology |
Exam Tip
If asked to "list subspecialties of orthopaedics," remember the mnemonic G-T-S-J-H-P-S-O-R (nine subspecialties). The lecture slide lists exactly these nine — reproducing them earns full marks.
2. The Musculoskeletal System
The musculoskeletal system consists of: Bone, Joint, and Soft Tissues (muscles, tendons, ligaments, nerves, …). [1]
Why does this matter? Because orthopaedic pathology can arise in any of these components. When you see a patient, you must systematically consider which structure is responsible for their complaint.
| Component | Role | Pathology Examples |
|---|---|---|
| Bone | Structural support, mineral reservoir, haematopoiesis | Fractures, tumours, metabolic bone disease, infection (osteomyelitis) |
| Joint | Articulation, movement | OA, RA, septic arthritis, dislocation |
| Muscles | Movement generation, shock absorption | Strains, myopathy, compartment syndrome |
| Tendons | Connect muscle to bone, transmit force | Rupture, tendinopathy, trigger finger |
| Ligaments | Connect bone to bone, joint stability | Sprains, ACL tears |
| Nerves | Sensation, motor control | Carpal tunnel syndrome, nerve injuries |
| Blood vessels | Perfusion (included by the slide's open-ended soft-tissue list and later neurovascular examples) | AVN, diabetic foot, vascular injury |
2.2 Form and Function
The lecture emphasises that the musculoskeletal system serves two purposes: form (structure/appearance) and function (what the body can do). [1]
- Normal form — anatomically correct alignment
- Abnormal form = Deformity [1]
Key deformity terminology decoded from the images:
- Genu valgum = "Knock knee" (knees angle inward)
- Genu varum = "Bow leg" (knees angle outward)
- Scoliosis = a three-dimensional spinal deformity with a coronal curve and vertebral rotation; it is defined radiographically as a Cobb angle of at least 10 degrees [19]
- Hyperkyphosis = sagittal-plane curvature greater than the normal range (the slide abbreviates this to “kyphosis”) [1] [19]
The clinical photographs are teaching alignment, not merely naming diseases. Inspect the patient standing from the front, side and back: compare shoulder and pelvic heights, spinal balance, knee axes and foot position. In the child-leg photographs, valgus brings the knees together while the ankles remain apart; varus brings the ankles together while the knees remain apart. The clubfoot image shows the combined CAVE pattern: cavus, forefoot adductus, hindfoot varus and equinus.
The comparative hand/foot skeleton montage reinforces “form enables function”: the same pentadactyl plan is adapted for grasp and weight-bearing. The clinical hand and whole-body images then show why appearance alone is insufficient—describe tissue loss or deformity, but measure what the person can actually grasp, reach, stand, walk and do independently.
How to Remember Valgum vs Varum
Valgum — the "L" in vaLgum looks like the legs going toward each other (knock knees). Varum — think "V-A-R" → "aRound" → bowing outward. Alternatively: in valgus deformity, the distal part angles AWAY from the midline; in varus, it angles TOWARD the midline.
- Activities of Daily Living (ADL) — the functional benchmark in orthopaedics [1]
- ADLs include: dressing, eating, bathing, toileting, transferring, walking
- A patient may have normal anatomy but poor function (e.g., stiff knee after fracture), or abnormal anatomy but preserved function (e.g., mild scoliosis without symptoms)
- Why this matters: Management decisions hinge on whether the problem is primarily one of form (cosmesis, deformity correction) or function (restoring independence)
Chief complaints include: Pain, Deformity, Stiffness, Instability, Weakness, Numbness, … [1]
| Complaint | Think About… | Why |
|---|---|---|
| Pain | Characterise site, onset, mechanical or rest pattern, severity, progression and associated systemic/neurological features | Persistent, progressive or unexplained pain is more concerning when combined with swelling, fever, weight loss, neurological deficit or cancer/infection risk; night pain alone is not diagnostic |
| Deformity | Congenital or acquired? Progressive? | Determines urgency and intervention |
| Stiffness | Ask when it occurs and how long it lasts; prolonged morning stiffness supports inflammation, whereas OA in people aged 45 or over commonly has no morning stiffness or lasts no longer than 30 minutes [21] | A useful pattern, not a stand-alone diagnostic cut-off |
| Instability | Joint giving way? Recurrent dislocation? | Suggests ligamentous insufficiency |
| Weakness | Myopathic? Neurogenic? Tendon rupture? | Level of pathology changes management entirely |
| Numbness | Peripheral nerve? Radiculopathy? Myelopathy? | Distribution tells you the lesion level |
3. Classification of Musculoskeletal Diseases (The Orthopaedic Sieve)
Diseases of the musculoskeletal system can be classified as:
- Congenital / Developmental
- Trauma
- Infection
- Neoplasm
- Inflammation
- Metabolic
- Neurovascular
- Degeneration
- Idiopathic [1]
This is the surgical sieve adapted for orthopaedics. It is a prompt for a broad differential, not a set of mutually exclusive boxes: a diabetic foot problem, for example, can be metabolic, neurovascular, infective and mechanical at the same time. The lecture illustrates each heading with a memorable example:
| Category | Lecture Example | Key Points |
|---|---|---|
| Congenital/Developmental | Congenital Talipes Equinovarus (CTEV / "Club foot") | Foot is in equinus (plantarflexion), varus (inversion), adductus, and cavus. Treated with Ponseti method (serial casting → tenotomy → bracing) [1] |
| Congenital/Developmental | Congenital Dislocation of Hip (CDH) / Developmental Dysplasia of Hip (DDH) | DDH is the preferred term because the disorder is a dynamic spectrum from instability/dysplasia to dislocation. Barlow and Ortolani manoeuvres are age-limited infant tests; imaging and treatment depend on age and stability. [1] |
| Trauma | Fractures of radius and ulna; Shoulder dislocation | Immediate priorities include skin/soft tissues, neurovascular status, associated injury, analgesia, reduction when indicated, stable retention and rehabilitation [1] |
| Infection | Tuberculosis of the spine | Professor Arthur Hodgson (HKU, 1915–1993) pioneered the "Hong Kong Operation" — anterior radical debridement and bone grafting for spinal TB [1] |
| Infection | Necrotising fasciitis | Life-threatening deep soft tissue infection. Emergency surgical debridement is mandatory [1] |
| Neoplasm (Benign) | Osteochondroma ("Exostosis") | Most common benign bone tumour. Cartilage-capped bony outgrowth. [1] |
| Neoplasm (Malignant) | Osteosarcoma | Most common primary malignant bone tumour in adolescents. Treated by neoadjuvant chemo + wide excision + adjuvant chemo [1] [4] |
| Inflammation | Rheumatoid arthritis (RA) | Autoimmune synovitis → joint destruction. Symmetrical small joint involvement [1] |
| Inflammation | Ankylosing spondylitis (AS) | HLA-B27 associated. Bamboo spine. Axial skeleton predominant [1] |
| Metabolic | Gouty arthritis | Monosodium urate crystal deposition. Negatively birefringent under polarised microscopy [1] |
| Metabolic | Diabetic foot | Neuropathy + vasculopathy → ulceration, infection, Charcot arthropathy [1] |
| Neurovascular | Carpal tunnel syndrome | Median-nerve compression in the carpal tunnel. Symptoms usually involve the thumb, index, middle and radial ring finger; the central palm is often spared because the palmar cutaneous branch travels superficial to the flexor retinaculum [1] |
| Neurovascular | Avascular necrosis (AVN) of the femoral head | Disruption of blood supply → bone cell death → collapse. Risk factors: steroids, alcohol, SLE, trauma (femoral neck fracture) [1] |
| Degeneration | Osteoarthritis of the knee | A symptomatic whole-joint disorder with cartilage loss, subchondral bone change, osteophytes and variable synovitis—not simply passive “wear and tear” [1] [21] |
| Degeneration | Lumbar spondylosis | Degenerative disc disease and facet arthropathy → back pain, possible radiculopathy/stenosis [1] |
| Idiopathic | Adolescent idiopathic scoliosis (AIS) | A rotational spinal curve of at least 10 degrees Cobb with no identified cause. Adam's forward-bend test detects truncal rotation; management depends on curve magnitude, progression risk, skeletal maturity and patient factors—not Cobb angle alone [1] [19] |
The slides deliberately teach recognition by juxtaposing normal anatomy with pathology. For an introductory viva, describe the image before naming the diagnosis:
| Slide Example | What the Image Is Showing | Safe Description |
|---|---|---|
| DDH pelvis radiograph | The femoral heads are not concentrically located in well-formed acetabula | In infants the femoral heads may be incompletely ossified, so diagnosis and screening are age-dependent; do not infer treatment from this single historic image |
| Displaced radius/ulna fractures | Loss of cortical continuity, displacement and angulation on two views | Always state bone, side, level, displacement/angulation, open/closed status and neurovascular findings |
| Anterior shoulder dislocation | The humeral head is displaced anteroinferiorly relative to the glenoid, contrasted with a centred normal shoulder | Confirm direction and associated fracture on orthogonal views; document axillary-nerve and vascular status before and after reduction |
| Spinal tuberculosis | Vertebral-body/endplate destruction, disc-space loss and angular kyphosis | A plain film suggests destructive spondylodiscitis; MRI defines marrow, canal and abscess involvement |
| Necrotising fasciitis | Rapidly progressive swelling and dusky/necrotic skin with bullae | This is a surgical emergency; severe pain, toxicity or rapid progression can precede dramatic skin changes |
| Osteochondroma | A metaphyseal exophytic lesion whose cortex and medullary cavity are continuous with the parent bone | Continuity is the key radiographic clue; a new painful/enlarging lesion after skeletal maturity requires specialist assessment |
| Osteosarcoma | An aggressive metaphyseal lesion with mixed destruction/ossification and periosteal reaction around the distal femur | Describe an aggressive bone lesion and stage it; never perform an unplanned excision before tumour-centre imaging and biopsy planning |
| Rheumatoid hand | Chronic MCP-predominant deformity with ulnar drift | The photograph represents established disease, not an early diagnostic sign |
| Ankylosing spondylitis | A “bamboo spine” appearance from bridging syndesmophytes | A late radiographic phenotype; early axial spondyloarthritis may have no such finding |
| Gout | Podagra/tophi around the first MTP region | Confirm uncertain acute monoarthritis with aspiration when feasible, especially to exclude infection |
| Diabetic foot | A plantar pressure ulcer beneath callus | Assess neuropathy, perfusion, depth, infection and bone involvement; the metabolic label does not capture the condition's combined neuropathic, vascular and infectious mechanisms |
| Femoral-head osteonecrosis | Sclerosis, contour irregularity and collapse of the femoral head | Early osteonecrosis may be radiographically occult; MRI is more sensitive when suspicion remains high |
| Knee OA / lumbar spondylosis | Varus knee deformity and degenerative spinal changes on imaging | Radiographic severity can correlate poorly with symptoms; treat the patient and functional impact, not the image alone [21] |
| AIS Cobb diagram | Lines are drawn along the end vertebral endplates; the intersecting perpendiculars give the Cobb angle | The displayed 55-degree curve illustrates measurement and a severe deformity, not a universal operative threshold [19] |
High Yield: The Hong Kong Operation
Professor Arthur Hodgson (HKU, 1915–1993) pioneered the "Hong Kong Operation" for tuberculosis of the spine — anterior radical debridement and bone grafting. This is a classic HKU orthopaedic history fact and has appeared in local exam settings. It is the lecture's way of highlighting that spinal TB is a significant orthopaedic condition, especially in endemic areas. [1]
Historical slide context: the lecture reproduces a 20 August 2018 SCMP article quoting life expectancy of 81.7 years for males and 87.7 years for females, with projections to 2066. These are not current surveillance figures and should not be repeated as present-day statistics. [1]
Why include this? Because degenerative conditions (OA, spondylosis, osteoporotic fractures) are becoming the largest burden in orthopaedics as the population ages. This underpins why joint replacement, osteoporosis management, and geriatric hip fracture pathways are high-yield exam topics.
4. Principles of Management
The three aims are:
- Relieve pain
- Improve function
- Correct deformity [1]
These are not mutually exclusive — a total knee replacement relieves pain (aim 1), improves walking ability (aim 2), and corrects valgus/varus malalignment (aim 3) simultaneously. But in exam answers, explicitly state all three.
Choose conservative or operative care according to diagnosis, urgency, stability, tissue viability, neurological/vascular status, likely natural history, functional goals and the patient's informed preferences. Many conditions start with non-operative care, but “conservative first” is not a universal safety rule: open fractures, threatened limbs, necrotising infection, compartment syndrome, cauda equina syndrome and some unstable injuries require urgent surgery.
| Conservative | Operative | |
|---|---|---|
| Examples from slides | Plaster of Paris (closed reduction + cast), bracing for scoliosis [1] | Open reduction & internal fixation (ORIF), instrumentation & spinal fusion [1] |
| Philosophy | Appropriate first-line care for many stable conditions; still requires a defined diagnosis, follow-up and safety-netting | Used when expected benefit outweighs harm, either urgently or electively; “displaced fracture” alone is not a sufficient indication because pattern, stability, soft tissues and patient factors matter |
4.3 The "5 Rs" of Orthopaedic Management
The lecture frames orthopaedic management around five memorable actions. Many examples are operations, but rehabilitation spans non-operative and peri-operative care, so the framework should not be mistaken for five surgical indications.
The lecture's five treatment actions are: Remove, Release, Repair, Reconstruct, Rehabilitate. [1]
Lecture examples of removal include:
- Selected torn meniscal tissue, loose bodies or pathological synovium — often via arthroscopy
- Prolapsed intervertebral-disc material — selected decompression/discectomy for concordant nerve-root compression
- Symptomatic benign tumours or tumour-like lesions — e.g., dorsal wrist ganglion
- A limb (amputation) — for malignancy, severe infection, severe trauma — "To save life!" [1]
Why remove? The pathological tissue may cause a mechanical block, compression, infection, local tumour risk or a threat to life. The slide's arthroscopy photographs show a shaver/instrument working inside the knee, but modern meniscal surgery aims to preserve as much functional meniscus as possible when surgery is indicated [17]. A disc protrusion on MRI is not itself an indication for discectomy: for sciatica, decompression is considered when non-surgical treatment has not improved pain or function and imaging matches the symptoms [18]. A dorsal wrist ganglion can be observed if asymptomatic; excision is selective because many are harmless and recurrence remains possible [22].
Amputation: When and Why
Students often forget that amputation is a legitimate orthopaedic procedure. It is not a failure: it may save life in overwhelming infection or uncontrolled haemorrhage, achieve tumour control, or provide a more functional and less painful limb than repeated futile salvage. The lecture's emphatic phrase is "To save life!", but real decisions are multidisciplinary and patient-specific. [1]
Lecture examples of release include:
- Trigger finger — release of the A1 pulley
- Carpal tunnel syndrome — release of the transverse carpal ligament (flexor retinaculum)
- Contracted soft tissues — e.g., equinus deformity of ankle (Achilles tendon lengthening) [1]
Why release? A tight structure (tendon sheath, ligament, contracted tissue) is causing mechanical restriction or nerve compression. Dividing it restores excursion or decompresses the nerve. The diagrams explain the anatomy: trigger-finger surgery opens the stenotic A1 pulley so the flexor tendon can glide; carpal-tunnel release divides the transverse carpal ligament to increase tunnel volume around the median nerve. These are not automatic first-line operations for every case; severity, duration, motor deficit and response to non-operative care matter. Current AAOS guidance recognises both mini-open and endoscopic carpal-tunnel release as having similar long-term outcomes [20].
Repair targets:
Professor SP Chow performed the first successful thumb replantation in Hong Kong in 1977. [1]
Why repair? The structure is disrupted but still has potential for healing if continuity, alignment, stability and biology are restored. The fracture radiographs contrast plates (surface implants fixed with screws) with an intramedullary nail (a load-sharing implant placed in the medullary canal). Implant choice follows the fracture pattern, soft tissues, patient and mechanical goal—not a simple “plate versus nail” rule.
| Repair Method | When Used | Mechanism |
|---|---|---|
| Plating | Can be used for articular, metaphyseal or diaphyseal fractures depending on technique | Compression plating can provide absolute stability for selected simple patterns; bridge plating provides relative stability for multifragmentary patterns [23] |
| Nailing | Common for selected long-bone shaft and some metaphyseal fractures | Usually load-sharing fixation with relative stability and callus, although construct mechanics vary |
| Tendon repair | Acute tendon lacerations/ruptures | Suture maintains continuity while collagen healing occurs |
| Nerve repair | Selected sharp nerve transections, or graft/reconstruction when a tension-free primary repair is impossible | Axonal regeneration is often taught as roughly 1 mm/day after an initial delay, but recovery also depends on age, level, gap, delay, target-muscle viability and rehabilitation |
| Vascular repair | Arterial injury threatening limb viability | Direct repair or vein graft to restore perfusion |
Reconstruction targets:
Why reconstruct? The original structure is damaged beyond repair. A new construct (prosthesis, graft, transferred tissue) must be created to restore form and function.
The images make the distinction concrete:
- Total knee replacement: diseased joint surfaces are replaced and limb alignment is restored; the long-leg before/after radiographs show correction of coronal deformity as well as the prosthesis.
- ACL reconstruction: a tendon graft is routed through femoral and tibial tunnels and fixed with cortical/screw devices; this substitutes for the torn ligament rather than simply suturing it.
- Toe-to-hand transfer: a vascularised toe is transferred with bone, tendon, nerve and vessel reconstruction to restore a missing digit. This is functional microsurgical reconstruction, not merely cosmetic transplantation.
Repair vs Reconstruct — Know the Difference
Repair = restoring the original structure (e.g., suturing a torn tendon back together). Reconstruct = building a new structure to replace something that cannot be repaired (e.g., ACL reconstruction using a hamstring or patellar tendon graft, or total joint replacement). This distinction is a common exam discriminator. [1]
Rehabilitation aims to:
- Preserve function — prevent deterioration
- Restore function — using splints, orthotics, prosthetics
- Enhance function — through training
- Advanced rehabilitation — e.g., paraplegic walking with exoskeleton [1]
Why rehabilitate? Healing and surgery do not automatically restore participation. Rehabilitation begins early and can be the main treatment: prevent contracture and deconditioning, protect a repair, retrain movement, and adapt the environment so gains translate into real-world function.
Visual sequence from the slides:
- A dynamic hand splint protects tissues while applying controlled force.
- An ankle-foot orthosis, lower-limb prosthesis and walking frame restore safe mobility at different levels of impairment.
- Wheelchair sport and bathroom grab rails illustrate two equally important endpoints: community participation and independent ADLs.
- A powered exoskeleton illustrates emerging assistive technology; it is an adjunct for selected users, not a substitute for comprehensive spinal-cord-injury rehabilitation.
5. The Nature of Orthopaedics — Defining Characteristics
The lecture concludes with a philosophical summary of what makes orthopaedics unique:
Orthopaedics is:
- Not limited to one organ or one anatomical region — it spans the entire body (spine to toes)
- Not limited by age or sex — from neonates (DDH, clubfoot) to the elderly (hip fractures, OA)
- Quality of life rather than life & death — the slide's deliberately provocative wording highlights orthopaedics' focus on mobility, independence and participation. It is not literal: trauma, spinal cord compression, sarcoma, sepsis and necrotising infection can threaten life or limb.
- Based on biological AND engineering principles — unique among surgical specialties in applying biomechanics, material science, and implant design
- An art and a science — the lecture invokes Michelangelo's David to illustrate the aesthetic dimension of restoring human form
- One of the fastest advancing specialties — highlighted by 3D printing, robotic-assisted surgery, artificial intelligence/machine learning [1]
The two small engineering diagrams near the end of the deck are easy to miss but carry a central message: bones and joints obey force and moment principles.
- Contralateral cane at the hip: in single-leg stance, body weight creates an adduction moment about the hip and the abductors must generate a counter-moment. Holding a cane in the hand opposite the painful hip adds an external counter-moment, reducing the abductor force—and therefore hip joint reaction force—required for equilibrium.
- Elbow flexion: the biceps inserts close to the elbow's axis, so its internal moment arm is short compared with the load in the hand. To hold the forearm static,
muscle force × internal moment arm = external load × external moment arm; the muscle force can therefore greatly exceed the hand load.
This is why orthopaedic treatment is both biological and mechanical: healing tissue needs an appropriate strain environment, implants alter load transfer, and assistive devices work by changing lever arms.
- 3D printing can create anatomical models, patient-specific guides and selected implants.
- Robotic-assisted surgery helps execute a pre-operative plan and position instruments/components; it does not replace surgeon judgement.
- AI/machine learning can assist image analysis, prediction and workflow. The slide shows these as directions of travel, not proof that every application improves patient outcomes.
Orthopaedics is multidisciplinary, involving:
- Doctors — anaesthesiologist, radiologist, physician, rheumatologist, pathologist, oncologist
- Nurses — wards, outpatient department, operating theatre
- Allied health — physiotherapist, occupational therapist, prosthetist & orthotist, podiatrist
- Others — clinical psychologist, medico-social worker, engineers, material scientists
- Patient family members [1]
High Yield: Multidisciplinary Team
Exams often ask you to "describe the multidisciplinary team involved in managing [condition X]." The lecture slide gives you a comprehensive list. For orthopaedic conditions, always mention: surgeon, anaesthetist, physiotherapist, occupational therapist, and if relevant, oncologist (bone tumour), rheumatologist (inflammatory arthritis), or prosthetist/orthotist (amputee). [1]
While the primary lecture is introductory, the supporting orthopaedic history-taking material [2] provides the clinical approach that complements this lecture:
| History Component | Orthopaedic Specifics |
|---|---|
| Presenting complaint | Pain, deformity, stiffness, instability, weakness, numbness, loss of function |
| Pain characterisation | SOCRATES: Site, Onset, Character, Radiation, Associated features, Timing, Exacerbating/relieving, Severity |
| Functional assessment | ADLs: can you walk? How far? Stairs? Dress independently? Need walking aids? |
| Red flags | Progressive/unremitting pain plus cancer or infection risk, fever/systemic illness, unexplained weight loss, destructive swelling, acute neurological deficit, bladder/bowel or saddle symptoms, threatened limb, or high-energy trauma. Night pain is contextual evidence, not a diagnosis. |
| Past medical history | DM (diabetic foot, poor healing), RA (inflammatory joint disease), malignancy (metastases), osteoporosis |
| Drug history | Steroids (AVN, osteoporosis), anticoagulants (surgical risk), NSAIDs (current analgesia) |
| Social history | Occupation (functional demands), sporting activities (mechanism, return-to-sport goals), smoking (impaired healing) |
| Related GC Lecture | How It Connects |
|---|---|
| GC 228: Knee OA [3] | Degeneration category → core non-surgical care; consider TKR (reconstruct) when symptoms substantially impair quality of life and non-surgical care is ineffective or unsuitable [21] |
| GC 229: Hip Arthritis [5] | Degeneration + neurovascular (AVN) → THR (reconstruct) |
| GC 230: Knee Sports Injuries [6] | Trauma → meniscal tear (remove), ACL tear (reconstruct) |
| GC 227: Cervical Spine Pathology [7] | Degeneration + neurovascular → myelopathy → decompression (release/remove) |
| GC 231: High Energy Trauma [8] | Trauma → fracture fixation (repair), amputation (remove) |
| GC 237: MSK Infection [9] | Infection → osteomyelitis, septic arthritis, necrotising fasciitis (remove/debride) |
| CFB OT02: Children's Ortho [10] | Congenital/developmental → DDH, CTEV, scoliosis (correct deformity) |
| Bone Tumour lecture [11] | Neoplasm → osteosarcoma (remove via wide excision) |
9. Exam Intelligence
| Question Format | What They Test | Example Stem |
|---|---|---|
| MCQ | Terminology (valgus vs varus), disease classification, management principle | "A goniometer is most useful for examining which complaint?" → Stiffness/ROM (Past paper Q13, 2020) [12] |
| SAQ | Red flags for back pain, differential diagnosis using the sieve, principles of fracture management | "Name four red flag signs for back pain" (2023 Minicase) [13] |
| Minicase | Orthopaedic presentation requiring structured history, investigation, and management plan | Spine infection minicase (2023) — directly tests the infection category from this sieve [13] |
| Viva/OSCE | Demonstrate orthopaedic examination, explain management aims | "What are the three aims of orthopaedic management?" |
| Past Paper | Relevant Connection |
|---|---|
| 2020 MCQ Q13 [12] | Goniometer for shoulder examination — tests "function" assessment (ROM measurement) |
| 2020 MCQ Q14 [12] | Greenstick fracture management → conservative (cast) — tests conservative vs operative decision |
| 2022 MCQ Q60 [14] | Osteosarcoma surgical method → wide local resection — tests tumour surgery principle (remove) |
| 2023 Minicase Case 3 [13] | Back pain + fever → spinal infection → red flags, DDx, Ix — directly tests the "infection" category |
| 2023 SAQ Q8 [15] | Spinal cord injury → motor/sensory distribution — tests neurovascular category |
| 2024 SAQ Q8 [16] | Neck of femur fracture → post-op DVT — tests trauma + rehabilitation complications |
Common Mistakes
- Confusing valgus and varus — Remember: in vaLgus, the distal segment angles away from the midLine (toward lateral); in varus, toward midline (medial).
- Forgetting rehabilitation as part of management — The "5 Rs" includes rehabilitate. Post-op rehab is always expected in management plans.
- Treating “conservative first” as an absolute rule — Present appropriate non-operative and operative options, but lead with urgent surgery when limb, life, neural function or stability is threatened.
- Confusing repair vs reconstruct — Repair = fix the original structure. Reconstruct = build something new. ACL reconstruction uses a graft (not primary repair in most cases).
- Overlooking the disease sieve — When asked for differentials of a musculoskeletal complaint, systematically go through: congenital, trauma, infection, neoplasm, inflammation, metabolic, neurovascular, degeneration, idiopathic.
"What are the aims of orthopaedic management?" → (1) Relieve pain (2) Improve function (3) Correct deformity [1]
"List the orthopaedic disease classification." → Congenital/developmental, Trauma, Infection, Neoplasm, Inflammation, Metabolic, Neurovascular, Degeneration, Idiopathic [1]
"What are the 5 Rs used to organise orthopaedic management?" → Remove, Release, Repair, Reconstruct, Rehabilitate (the "5 Rs") [1]
"What is the Hong Kong Operation?" → Anterior radical debridement and bone grafting for spinal tuberculosis, pioneered by Professor Arthur Hodgson at HKU [1]
High Yield Summary
-
Orthopaedic surgery
- = "straightening the child" (etymology) → now encompasses the entire musculoskeletal system (bone, joint, soft tissues) across all ages.
-
Disease sieve
- (9 categories): Congenital/Developmental, Trauma, Infection, Neoplasm, Inflammation, Metabolic, Neurovascular, Degeneration, Idiopathic.
-
Three aims of management
- Relieve pain, Improve function, Correct deformity.
-
5 Rs of orthopaedic management
- Remove (meniscus, disc, tumour, limb), Release (trigger finger, carpal tunnel, contracture), Repair (fracture fixation, tendon/ligament/nerve suture, replantation), Reconstruct (TKR, ACL reconstruction, toe-hand transfer), Rehabilitate (splints, orthotics, prosthetics, training, exoskeleton).
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Non-operative vs operative is a clinical decision
- Many stable conditions begin with non-operative care; emergencies that threaten life, limb, neural function or stability require prompt operative assessment.
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Multidisciplinary
- — orthopaedics involves surgeons, allied health (PT/OT/P&O), nurses, physicians, and patient families.
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HKU historical fact
- Professor Arthur Hodgson — "Hong Kong Operation" for spinal TB; Professor SP Chow — first thumb replantation in HK (1977).
Active Recall - Introduction to Orthopaedic Surgery
[1] Lecture slides: CFB (OT01) Introduction to Orthopaedic Surgery.pdf [2] Lecture slides: MBBS IV History taking Ortho.pdf [3] Lecture slides: GC 228. Knee Osteoarthritis_Part A.pdf [4] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (Osteosarcoma section) [5] Lecture slides: GC 229. Hip Arthritis.pdf [6] Lecture slides: GC 230. Knee Sport Injuries_Part 1.pdf [7] Lecture slides: GC 227. Cervical Spine Pathology.pdf [8] Lecture slides: GC 231. High Energy Trauma & Open Fracture_Part 1.pdf [9] Lecture slides: GC 237. Musculoskeletal infection [Updated in 2025].pdf [10] Lecture slides: CFB (OT02) Childrens Orthopaedics and Deformities.pdf [11] Lecture slides: Primary bone tumour and bone metastasis_Dr Ho Wai Yip.pdf [12] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q13, Q14) [13] Past papers: 2023 Fourth Summative Minicase.pdf (Case 3) [14] Past papers: 2022 Fourth Summative MCQ.pdf (Q60) [15] Past papers: 2023 Fourth Summative SAQ.pdf (Q8) [16] Past papers: 2024 Fourth Summative SAQ.pdf (Q8) [17] American Academy of Orthopaedic Surgeons. Clinical Practice Guideline for the Management of Acute Isolated Meniscal Pathology. Published 10 June 2024. https://www.aaos.org/quality/quality-programs/acute-isolated-meniscal-pathology/ [18] National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59), recommendation 1.3.8. https://www.nice.org.uk/guidance/ng59/chapter/Recommendations [19] Scoliosis Research Society. Scoliosis and Education Glossary (radiographic definition and Cobb method). https://www.srs.org/Patients/Conditions/Scoliosis [20] American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome Clinical Practice Guideline. Published 17 May 2024. https://www.aaos.org/quality/quality-programs/carpal-tunnel-syndrome/ [21] National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management (NG226). Published 19 October 2022. https://www.nice.org.uk/guidance/ng226/chapter/recommendations [22] American Academy of Orthopaedic Surgeons OrthoInfo. Ganglion Cyst of the Wrist and Hand. https://orthoinfo.aaos.org/en/diseases--conditions/ganglion-cyst-of-the-wrist-and-hand [23] AO Foundation Surgery Reference. Basic principles of plating (compression and bridge plating). https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/basic-technique/basic-principles-of-plating
CFB MED12 Introduction To Geriatric Medicine
Geriatric medicine is the branch of medicine focused on the diagnosis, treatment, and prevention of disease and disability in older adults, emphasizing functional status, multimorbidity, and comprehensive assessment.
CFB OG04 Menstrual Disorders
Menstrual disorders are abnormalities in the frequency, duration, amount, or regularity of menstrual bleeding, including conditions such as amenorrhea, oligomenorrhea, menorrhagia, dysmenorrhea, and premenstrual syndrome.