December

What is the Origin of Orthopaedic Surgery? 

A Brief History of Orthopaedics

Origin of the Word

The modern term orthopaedics stems from the older word orthopaedia, which was the title of a book published in 1741 by Nicholas Andry, a professor of medicine at the University of Paris. The term orthopaedia is a composite of 2 Greek words: orthos, meaning “straight and free from deformity,” and paidios, meaning “child.” Together, orthopaedics literally means straight child, suggesting the importance of pediatric injuries and deformities in the development of this field. Interestingly, Andry’s book also depicted a crooked young tree attached to a straight and strong staff, which has become the universal symbol of orthopaedic surgery and underscores the focus on correcting deformities in the young. While the history of the term is relatively recent, the practice of orthopaedics is an ancient art.

Ancient History of Orthopaedics

While the evidence is limited, the practice of orthopaedics dates back to the primitive man. Fossil evidence suggests that the orthopaedic pathology of today, such as fractures and traumatic amputations, existed in primitive times. The union of fractures in fair alignment has also been observed, which emphasizes the efficacy of non-operative orthopaedics and suggests the early use of splints and rehabilitation practices. Since procedures such as trepanation and crude amputations occurred during the New Stone Age, it is feasible that sophisticated techniques had also been developed for the
treatment of injuries. However, evidence continues to remain limited.

Later civilizations also developed creative ways to manage orthopaedic injuries. For example, the Shoshone Indians, who were known to exist around 700-2000 BCE, made a splint of fresh rawhide that had been soaked in water. Similarly, some South Australian tribes made splints of clay, which when dried were as good as plaster of Paris. Furthermore, bone-setting or reductions was practiced as a profession in many tribes, underscoring the importance of orthopaedic injuries in early civilizations.

The ancient Egyptians seemed to have carried on the practices of splinting. For example, 2 splinted specimens were discovered during the Hearst Egyptian Expedition in 1903. More specifically, these specimens included a femur and forearm and dated to approximately 300 BCE. Other examples of splints made of bamboo and reed padded with linen have been found on mummies as well. Similarly, crutches were also used by this civilization, as depicted on a carving made on an Egyptian tomb in 2830 BCE.

The Greek’s in particular had a great deal of orthopaedic knowledge with respect to fractures and dislocations. The School of Hypocrites wrote books describing traction, casting and bandaging. They even recommended early mobilization for fractures. Clubbed feet were treated with strong bandages leading to overcorrection which was maintained for a significant period of time. The Greeks also recognized scoliosis as a problem and tried many prolonged but often unsuccessful treatments. Galen understood that the brain sent out signals to the muscles by means of the nervous system.

During the middle ages, Italy maintained medical knowledge and it was the major center in Europe with the University of Bolgna being founded in 1113. It still functions until this day as a medical school. John Hunter became the father of modern surgery with the study of anatomical specimens. Lister developed asepsis in the mid-1800s and William Warton discovered ether anesthesia in 1876.

The Modern Era

In the 20th century, rapid development continued to better control infections as well as develop and introduce novel technology. For example, the invention of x-ray in 1895 by Wilhelm Conrad Rontgen improved our ability to diagnose and manage orthopaedic conditions ranging from fractures to avascular necrosis of the femoral head to osteoarthritis. Queen Isabella of Spain had organized the first field hospitals which were known as ambulances in 1487 but these truly came into their own following the two world wars, particularly in the Korean War and then in Vietnam. By significantly decreasing the amount of time between the injury and treatment, many lives were saved. This advance along with the development of antibiotics made delayed primary wound closure and skin grafting of wounds a possibility.

Spinal surgery also developed rapidly with Russell Hibbs describing a technique for spinal fusion at the New York Orthopaedic Hospital. Similarly, the World Wars serve as a catalyst in the development of the subspecialty of orthopaedic trauma, with increasing attention placed on open wounds and proficiency with amputations, internal fixation, and wound care. Dr. Smith Peterson at Harvard designed the three phalanged nail which made possible the mobilization of people with hip fractures. In 1942, Austin Moore performed the first metal hip arthroplasty, also for the treatment of hip fractures. The field of joint replacement was subsequently advanced by the work of Sir John Charnley at the University of Manchester in the 1960s.

March

Many years ago, neurosurgeons were primarily responsible for spine surgery, but in the past 20 to 25 years spine surgery has evolved so that both neurosurgeons and orthopaedic surgeons specialize in spine surgery, and for most of the typical spine operations both types of surgeons are equally well qualified.

In both specialties, the surgeons may subspecialize, such as in the case of surgeons who specialize in pediatrics, cervical spine, lumbar spine, hand and wrist surgery, plastic surgery, or in other areas or procedures.

Neurosurgeons and Orthopaedic Surgeons can Specialize in Spine Surgery

Neurosurgeons may be Medical Doctors or Doctors of Osteopathic Medicine, and complete a five to six year residency focused on the surgical treatment of neurological conditions. Neurosurgeons are trained in the diagnosis and treatment of disorders involving:

• Brain
• Spine and spinal cord
• Nerves
• Intracranial and intraspinal vasculature

Some neurosurgeons specialize exclusively on brain surgery, some on spine surgery, and some split their practice between the two.

Orthopaedic surgeons may be Medical Doctors (MD) or Doctors of Osteopathic Medicine (DO) who have completed a five-year surgical residency focused on the treatment of musculoskeletal conditions. Orthopaedic surgeons specialize in the diagnosis and treatment of almost all bone and joint disorders, such as:

• Spinal disorders
• Arthritis
• Sports injuries
• Trauma
• Bone tumors
• Hand injuries and deformities
• Total joint replacement

Some orthopaedic surgeons focus their practice exclusively on spine surgery, some on other types of joints (e.g. hips, knees, shoulders), and some split their practice among two or more areas.

Both neurosurgeons and orthopaedic surgeons may complete fellowship training to do most types of spine surgery, but there are a few types of spine surgery in which one specialty tends to be more qualified than the other, such as:

• Orthopaedic surgeons tend to be better qualified to do spinal deformity surgery, such as scoliosis , other types of spinal deformity.
• Neurosurgeons tend to be more qualified to perform intradural surgery (surgery inside of the dura in the spinal cord), such as thecal sac tumors.

Both orthopaedic surgeons and neurosurgeons may extend their training after residency by completing a spine fellowship program. These fellowships provide additional, specialized training for orthopaedic surgeons and neurosurgeons that have successfully completed their residency training and earned their board certification or eligibility in their specialty.

Completing a spine fellowship is a marker of a surgeon who has chosen to specialize in spine surgery and is willing to make the extra investment in training to become more skilled.

This was not always the case. Before spine surgery was a recognized subspecialty—15 to 20 years ago—it was not common, and often not an option, for orthopaedic surgeons or neurosurgeons to do a spine fellowship program. For surgeons who have been in practice with this length of tenure, if they have specialized their practice in spine surgery, then they have likely earned their additional training in their practice and may not be fellowship trained.

October

When your doctor recommends surgery or a major procedure or treatment, it's smart to get a second opinion from another expert. 

People make mistakes every day, and doctors are only human. More importantly, some doctors are more conservative while others tend to be more aggressive. So their findings and recommendations can vary, dramatically.

Don't waste time checking out choices if you need emergency treatment. However,  if your doctor recommends nonemergent or elective surgery, or a major procedure, it can be worthwhile to get a second opinion for any of the following reasons:

• Your diagnosis is unclear.
• You've been told you have a rare or life-threatening condition.
• You have several medical problems.
• The recommended treatment is risky, controversial, or experimental.
• You have a choice of treatments or medical tests that vary widely in cost.
• You're not responding to a treatment as expected.
• You have lost confidence in your medical care provider.
• Your health plan requires a second opinion.

Just feeling uncertain about having surgery or a major procedure may be reason enough. After all, no one knows everything about all conditions, or about all the new breakthroughs in treatment being reported.

Most health insurance plans will pay for a second opinion, but be sure to contact your plan beforehand to find out for sure. In some cases, if you don't get a second opinion for a procedure, you may have to pay a higher percentage of the cost.

If you choose to go for a second opinion, it's a good rule to ask someone with at least the same level of skill and knowledge of your health condition as your current health care provider. Consider contacting a specialist. Your current doctor may be able to suggest someone.

Even better, ask someone at an institution specializing in your condition. These centers will have the latest in medical technology, and a team of experts may be readily available to review your case.

Most doctors will acknowledge their patients' right to a second opinion, so you just need to be honest and straightforward.

Be sure to ask for your medical records so you can share them with the second healthcare provider. By law, your doctor must give these records to you. You may have to pay a fee to have the copies made.

These questions offer a good place to start:

• Is the diagnosis correct?
• What are my choices, and the pros and cons of each?
• What would happen if I waited or chose no treatment?
• What should I do with the results?

If the second doctor agrees with the first, you can move forward with more confidence.

Even if your second opinion just confirms what you already know, it can still be beneficial. Afterward, you will know that you have done everything you can to ensure that you have the correct diagnosis and a treatment plan that feels right to you.

A second opinion can also offer insight into additional treatment options that the first doctor may not have mentioned. As a result, you become more informed about what is available to you and can make educated decisions regarding your own healthcare and treatment plan.

August

Both pediatricians and pediatric orthopaedic specialists focus on children.

A pediatric orthopaedic specialist differs from specialists who treat adults because children's growing bodies are very different from fully grown and possibly aging bodies.

There are two types of pediatric orthopaedic specialists: Operative and Non-operative.

Non-operative pediatric orthopaedic specialists are pediatricians and family doctors who subsequently receive additional training in primary care orthopaedics or sports medicine. They may perform office procedures, but do not perform surgery.

Operative pediatric orthopaedic specialists, or pediatric orthopaedic surgeons, first complete training in general orthopaedic surgery and subsequently receive additional training in pediatric orthopaedic surgery.

Pediatric orthopaedic surgeons may further subspecialize in different areas of interest including: hip, spine, hand, sports, neuromuscular, and foot and ankle conditions.

July

There is no need for alarm. In most instances, an adult orthopaedic surgeon will be capable of handling pediatric orthopaedic issues with a fair degree of competence.

However,  children are not just small adults and special consideration is necessary to properly treat and care for children with pediatric orthopaedic conditions.

Pediatric orthopaedic surgeons know how to examine and treat children in a way that helps them to be relaxed and cooperative. In addition, pediatric orthopaedic surgeons often use equipment specially designed for children.

They also appreciate the worry that goes with having a child with a musculoskeletal problem and they have experience in communicating with anxious family members.

If your pediatrician suggests that your child see a pediatric orthopaedic surgeon, you can be assured that he or she has the widest range of treatment options, the most extensive and comprehensive training, and the greatest expertise in dealing  with children and in treating children’s orthopaedic disorders.

February

If you break a bone, you may require some form of immobilization to help your bones heal. Depending on your age and the type of fracture you sustain, a cast, brace, or splint may be appropriate to allow you to heal. A cast, splint, or brace may be necessary for up to 4 to 12 weeks.

Types of Casts

Casts are generally made of fiberglass or plaster that helps to keep bones, muscles, and tendons from moving and creating more injury.

Traditional bulky, white plaster cast are still used to treat fractures. These plaster casts cost considerably less and are more easily shaped than fiberglass casts. These casts are typically used in the emergency room or to body parts that require more intricate molding.

The newer fiberglass, or synthetic, casts, on the other hand, have many advantages over plaster ones. Synthetic casts can be different colors and are lighter than plaster. They are also more durable and porous than plaster.

When appropriate, you may be instructed to put some weight on your cast. You may even be given a cast shoe, a canvas, open-toe and open-heel shoe that protects the cast and provides stability when you walk.

Orthopaedic Braces

A brace is designed to stabilize a broken bone or surgery site and permits you to participate in weight-bearing activities and activities of general, daily living. There are some types of braces that are intended to increase circulation and decrease swelling.

Braces come in a variety of shapes, sizes, and colors. They can be used immediately following an injury or toward the end of healing, commonly, following removal of another type of cast.

Orthopaedic Splints

Splints differ from casts because they provide less support and protection for a limb that is injured or broken. A splint gives support to the broken bone on one or two sides, and it can be tightened or loosened without difficulty if the swelling in the limb increases or decreases. You may receive a splint when you are at risk of a lot of swelling or when a cast is not appropriate.

January

The growth plate in bones is also called the physis. Almost every bone has a physis. The physis helps the bone grow, both in length and width.

The physis is made of specialized growth cartilage and is located near the ends of the long bones. Because cartilage is not calcified, it looks like a dark line in the bone on the X-ray. 

When a child stops growing, the physis hardens into solid bone. Boys generally stop growing around 16 years of age, and girls around 14 years of age, although this varies greatly.  

Growth involves not only the length and weight of a body, but also includes internal growth and development.

Normal growth can be measured and compared on a growth chart to gauge how a child is growing. Although a child may be growing, his or her growth pattern may deviate from the norm.

Ultimately, the child should grow to normal height by adulthood. If you suspect your child or adolescent is not growing properly, talk with your child's pediatrician.

November

Orthopaedics or orthopedics?

We’ve all seen it spelled both ways but which one is correct? And – more importantly – does it make a difference?

Both “orthopaedics” and “orthopedics” are derived from orthopédie, a French term coined by 17th -century physician Nicholas Andry de Bois-Regard. The term used by Andry itself is derived from the Greek words ὀρθός (orthos), which means “correct” or “straight”, and παιδίον (paidion), which means “child”. As the etymology implies, orthopédie – or what we know today as orthopedics – was first practiced as a way to treat childhood spinal deformities such as polio or scoliosis. Of course, modern orthopedics has grown to encompass a diverse array of treatments as well as expand its focus to include all age groups.

In short, there isn’t a difference between “orthopaedics” and “orthopedics,” at least not in regards to meaning. Both of these terms refer to the branch of medicine dealing with the treatment of bones, joints, and muscles. This means, of course, that information you find regarding “orthopaedic treatments for back pain” is the same as “orthopedic treatments for back pain” and vice versa. This is also true of any of the other conditions that an orthopedist would treat, including:

- Congenital, developmental, and growth disorders and disturbances of joints, bones, or muscles

– Musculoskeletal trauma
– Spine deformities and disorders
– Sports injuries
– Injuries and disorders affecting joints, bones, or muscles
– Concussions

The choice between these two terms often comes down to the speaker’s dialect, stylistic choice, or simply just their personal preference. “Orthopaedics” is commonly regarded as the British and academic spelling of the term while “orthopedics” can be considered its Americanized version; however, you may see these spellings used interchangeably. In fact, the American Academy of Orthopaedic Surgeons, the American Association of Orthopaedic Medicine, American Medical Academy, Pediatric Orthopaedic Society of North America, and other American orthopaedic organizations all use the “ae spelling. In fact, it is difficult to find a professional medical organization that doesn’t use the “ae” version.

October

What is scoliosis?

Scoliosis is a common condition that affects many children and adolescents. Simply defined, scoliosis is a sideways curve of the spine that measures greater than 10 degrees on X-ray. Instead of a straight line down the middle of the back, a spine with scoliosis curves, sometimes looking like a letter "C" or "S." Some of the bones in a scoliotic spine also may have rotated slightly, making the person’s waist or shoulders appear uneven.

What causes scoliosis?

In more than 80 percent of the cases, a specific cause is not found and such cases are termed “idiopathic,” meaning “of undetermined cause.” Conditions known to cause spinal deformity are congenital spinal column abnormalities (abnormally formed vertebrae present at birth), neurological disorders, muscular diseases, genetic conditions (e.g., Marfan’s syndrome, Down syndrome) and a multitude of other causes such as infections or fractures involving the spine.

What does not cause scoliosis?

There are many common misconceptions and incorrect assumptions. To set the record straight, scoliosis does not come from carrying a heavy book bag or other heavy things, athletic involvement, poor sleeping or standing postures, lack of calcium, or minor leg length difference.

Who gets scoliosis?

In childhood, idiopathic scoliosis occurs in both girls and boys. However, as children enter adolescence, scoliosis in girls is five to eight times more likely to increase in size and require treatment. Progression is most common during the growing years. Severe curves may, however, progress during adulthood.

September

If your child has musculoskeletal (bone) problems, a pediatric orthopaedic surgeon has the experience and qualifications to treat your child. 

• Graduated from an approved medical school 
• Graduated from an approved orthopaedic surgery residency program 
• Completed additional subspecialty training in pediatric orthopaedics

Pediatric orthopaedic surgeons treat children from the newborn stage through the teenage years. They choose to make pediatric care the core of their medical practice, and the unique nature of medical and surgical care of children is learned from advanced training and experience in practice.

Pediatric orthopaedic surgeons diagnose, treat, and manage children’s musculoskeletal problems including the following:

• Limb and spine deformities (such as club foot, scoliosis) 
• Gait abnormalities (limping) 
• Bone and joint infections 
• Broken bones

  
Children are not just small adults. They cannot always say what is bothering them, or answer medical questions, or be patient and cooperative during a medical examination.

Pediatric orthopaedic surgeons know how to examine and treat children in a way that helps them to be relaxed and cooperative. In addition, pediatric orthopaedic surgeons often use equipment specially designed for children.

They also appreciate the worry that goes with having a child with a musculoskeletal problem and they have experience in communicating with anxious family members.

If your pediatrician suggests that your child see a pediatric orthopaedic surgeon, you can be assured that he or she has the widest range of treatment options, the most extensive and comprehensive training, and the greatest expertise in dealing  with children and in treating children’s orthopaedic disorders.