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Hello and welcome to number six in the surgical series. Today, we'll be talking about orthopedics. So, what is orthopedics? Despite popular belief, it's a specialty that deals with more than just the bones. It has a focus on the musculoskeletal system in its entirety. In this talk, we'll discuss the two core conditions separately. First, we'll go through joint anatomy using the knee as an example. Before discussing osteoarthritis, we will then go back to talk about the anatomy of the vertebrae and its relation to back pain. Finally, there will be some practice SBA S at the end. So let's get started on the anatomy. What is a joint, a joint is where two or more bones meet and articulate. They are important for growth as well as providing stability. While there is no universal way to classify joints, they can be put into three types based on their movement. Synovial joints are the most mobile while fibrous and cartilaginous joints have little to no mobility at all. We'll be focusing today on synovial joints. Synovial joints are so named because they have synovial membrane which produces synovial fluid. They also have articulate cartilage as well as a fibrous capsule that encapsulates the entire joint will go through these parts individually together. Articulate cartilages are a specialized type of hyaline cartilage. They increase the surface area of contact for joints, thereby spreading the force and reducing the weight. As seen in this diagram. They don't sit perfectly fresh with each other. There are some undulations which actually help trap some of your fluid. Furthermore, lubricin a large glycoprotein coats the cartilage surfaces. It is orientated in a way that the hydrophobic regions are facing the joint space, thereby repelling the opposite joint surface. This maintains the joint space and ties in the fluid film may be forced out. For example, when there's a sustained forceful load on the joint as we age, the undulations deepen and develop ragged projections. This can be accelerated in dry joints when the synovial fluid has been altered in some way. So, synovial fluid, which is where we get the name synovial joint from is the main lubrication to help reduce friction in these joints. The synovial fluid present helps to aquaplane the joints. If you've ever been in a car that has aquaplaned, you'll know what that feels like there's very little friction between the surface of the tire and the road and it's exactly what happens with the joints. This fluid can also be found in tendon sheaths and bursae that extend out from the joint space. It's a clear or sometimes straw colored viscous liquid, but there's usually not much liquid in the joint space. It's actually derived as a transudate from the blood. And because of that, it contains proteins such as the aforementioned lubricin and immune cells. The sun of your fluid is synthesized by the sun of your membrane. This membrane lines the insides of the fibrous capsule and once again can extend into bursa and tendon sees this is important as these are potential sources of infection. Some joints have folds of membrane, for example, the alla folds in the knee, one synovial joint is encapsulated by a fibrous capsule. This helps to stabilize the joint. However, there are also multiple accessory ligaments and tendons from surrounding muscles that add to give strength. There are spaces within the fibrous capsule which allow vessels and nerves entry into the joint. They are quite stiff to tension, but they have to have some give for movement and bending. In fact, the capsule won't resist movement until the edge of the very normal range of motion. So now let us look at the knee joint. In particular here, the fibrous capsule is highlighted in green. We can also see extra capsula or intrinsic ligaments that add strength. Some of the more famous examples are the medial and lateral collateral ligaments also called tibial and fibular collateral ligaments. In this image, we can see intracapsular ligaments such as the ACL and PCL, anterior cruciate ligand and posterior cruciate ligament. The anterior and posterior refers to their attachments to the tibia And if you ever want to know a nice way to remember which order it goes, take your fingers and cross them, place that same hand on the same knee. And that's the order that the ACL and PCL lie with your middle finger being the PCL and your index finger being the ACL. In these images, we can see the knee joint. Firstly, without a synovial fluid or membrane, then with the sign of your membrane added, finally unique to the knee joint. There are menisci which are cushions of cartilage and act as shock absorbers. So now we have an understanding of what a joint is. So how does this relate to osteoarthritis? Well, osteoarthritis is a chronic and degenerative joint disease. It's characterized by a breakdown of the articular cartilage. Some of the big risk factors is age, age is the biggest risk factor over fifties. This is the most common cause of joint pain. Unfortunately, females do have a higher risk of osteoarthritis and there are other things that you can imagine would put extra strain on the joints such as obesity, a previous injury and genetics. Often the pain is worse when the joint is being used and eased with rest. Typically, they will also experience early morning stiffness which lasts for less than 30 minutes. There will be a loss of range of motion and crepitus will be present. Osteoarthritis is the most common cause of effusion in the joints. Osteoarthritis will be diagnosed from the clinical presentation. Imaging should not be routinely ordered unless there is some uncertainty about the diagnosis. However, there are characteristic uh characteristics found on imaging. Think of the loss acronym L for loss of joint space osteophyte formation, subcontrol sclerosis, which is thickening of the bone in the joint and subcontrol cysts, small fluid filled sacs that will show up in X ray as dark darkened areas. Furthermore, the joints themselves can have specific symptoms. For example, hand osteoarthritis, often in advanced disease states can have what's called squaring of the thumb joint. The management is fairly simple, low impact exercise that is supervised. So maybe under the supervision of a physiotherapist, weight loss is important as well. Pain relief is nsaids first, you try topical, then oral, it is no longer recommended to provide paracetamol alone for osteoarthritis corticosteroids. Injections can be recommended after 2 to 3 weeks of trying conservative management. First, it should not be used routinely and you have to explain to patients that the relief is only temporary. Finally, the definitive treatment is a joint replacement surgery. I wanted to talk about an exam. Favorite osteoarthritis versus rheumatoid arthritis, learn the difference. Remember that osteoarthritis is the wear and tear arthritis and the one seen in orthopedics. Whereas rheumatoid arthritis is an autoimmune inflammatory type of arthritis. This one is seen by rheumatology, a completely different specialty. Furthermore, osteoarthritis tends to affect the knees, hips and the distal interphalangeal joint. Whereas rheumatoid arthritis is famously D IP sparing. There are also differences in early morning stiffness if present in osteoarthritis, it shouldn't last for longer than 30 minutes. Also, rheumatoid arthritis usually is better with use. Whereas in osteoarthritis, it's better on rest. So now let's talk about the vertebrae. I always like to think about form and function together. So what is the function of the vertebrae? Well, they, they create the spinal column which protects the spinal cord, they're there for structural support as well as to maintain our upright bipedal posture. There is limited movement with the spinal cord as well. 33 vertebrae make up the entire vertebral column and they are divided into five groups, anatomically, cervical, thoracic lumbar, sacral and coccygeal. In total. There are 24 true unfused vertebrae, whereas at the end, there are fused false vertebrae, the sacral and coccygeal areas. The reason why the vertebral column is divided in such a way is because no two vertebrae are alike, even ones within the same region having said that there are similarities across the vertebrae and we'll talk about the general parts. Now, before that, we need to orientate ourselves. This is anterior and this is posterior anteriorly. We have a large cylindrical shaped bone called the ventral body. This increases in size as we go down the spinal column and it's primarily there for strength behind it. There is a vertebral arch. This is made up of two pedicles and two lamina when joined with the vertebra body. It creates the spinal canal which the spinal cord travels through the pedicles themselves also form little notches called intervertebral notches. When joined with a vertebrae above and below it, these notches create intervertebral foramina which allow spinal roots to emerge from. Finally, there are a total of seven processes in a spine, one spinous process, two transverse processes and four articular processes, two superiorly and two inferiorly. Let's talk about the cervical vertebrae. These are the first seven in the neck. They're their thinnest, but they're the most mobile for our head to move. They have some distinct characteristics, for example, transverse foramina. These are there for vertebral vessels and sympathetic nerves to pass through. They also have cubicles, both anterior and posterior. And they are famous for having a bifid spinous process. As you can see here, bifo like a snake's tongue. C 3 to 6 are fairly typical vertebrae and are nearly identical to each other. C one is also called the Atlas. Think about the Atlas that holds the globe. C one is the vertebrae that holds the skull. It lacks a vertebral body completely and a spinous process. C two is the axis, the axis is what the Atlas spins around and its particular feature has the dens. Finally, C seven has a long non buffered spinous process. And in fact, has more in common with thoracic vertebrae and it marks a transition from cervical to thoracic spine. We'll now talk about the thoracic and lumbar vertebrae. The thoracic spine is composed of 12 vertebrae and they have costal facets and Demi facets for the attachment of the ribs. Lumbar vertebrae are made up of five and they're thicker and stronger representing the larger load that they carry. In fact, L5 is the largest vertebrae in a human, the spinal cord in an adult human ends at L1 to L2. This is called the medullary cone. This is important for certain procedures such as a lumbar puncture, often lumbar vertebrae are considered stereotypical vertebrae. And as they have all the general features that we discussed earlier, we now get to the sacral vertebrae. The sacral spine looks the most different compared to the others and is formed by five sacral vertebrae fused together. It's a part of the pelvis and helps to transmit the weight into our lower limbs. The surfaces of the sacrum at the base apex, pelvic or anterior dorsal, which is behind that and lateral surfaces think of it as an upside down triangle. With this being the base and these forming the sides to the apex at the bottom. The sacrum is then divided into certain parts. There are lateral parts, both left and right. The median part which is formed by the pedicles, lamina articular processes and spinous processes fusing together and anterior posterior foramina. The landmarks that are important to know are the ala which are winglike structures on each lateral part and the sacral canal which is found on the median part of the sacrum. The sacral canal contains the quarter equina and ends at the sacral hiatus. The anterior and posterior foramina communicate with this sacral canal and help to transmit anterior and posterior rami of the 1st and 4th sacral nerves, respectively. The anterior foramina which are slightly wider, also transmit blood vessels. Finally, we have the coccyx also called the tail bone. It has 3 to 4 fused coccygeal vertebrae and as important as a attachment site for the gluteal muscles. The surfaces are the same as a sacrum with a base apex, pelvic, dorsal and lateral borders. The main landmarks are the coccygeal corneal and the transverse processes. When discussing lower back pain. It's important to also understand the joints between vertebrae between the vertebrae. There are intervertebral discs, the adjacent vertebral bodies are joined by synthesis and this is the disc of that synthesis. The parts of the rings are the fibrous outer ring and a gelatinous nucleus called the nucleus, pulposus. They function as shock absorbers and help to maintain the structural integrity of vertebral column to further strengthen the vertebral column. There is an anterior and posterior longitudinal ligaments and there are ligaments between the processes of the spine. Sometimes discs can start to bulge out from the synthesis. This is known as a slipped disc, lumbar discs are the most susceptible to this herniation due to the increased load that they carry So now we get to our core conditions which are all related to back pain. Lower back pain is a very common presentation and is defined as pain in the lumbosacral area. From around the 12th rib to the buttocks and gluteal folds. As mentioned, it's extremely common with about 60% of the adult population experiencing symptoms. Unfortunately, a vast majority of this will be nonspecific and it's usually pretty self limiting. You should expect to see most symptoms resolve within two weeks. There are certain risk factors that also contribute to receiving back pain, those being obesity, a lack of physical activity, some occupational hazards such as heavy lifting, uh and even stressful life events and depression. However, you need to be aware of some red flag symptoms when assessing back pain. Your history is crucial. Don't forget your Socrates. Some really important red flags are sudden onset and severe severe pain. Neurological symptoms are always a worry. Another set of symptoms that are particularly concerning include being at an age of 50 with a gradual onset of symptoms accompanied by a certain bee symptoms such as unexplained weight loss, night sweats and pain at night. When lying down, this could actually indicate a metastasis into the spine. A really good pneumonic to know is the tuna fish, pneumonic have this in the back of your mind whenever you're taking a history from someone presenting with back pain. So when you're taking the history of someone presenting with lower back pain. They may present with certain red flag symptoms that point you towards ca equina syndrome. What is the corda quina? It literally means the horse's tail and it's sort of the fibrous looking bits of the spinal cord that go through the sacral canal. This is an emergency presentation as compression of the corda quina if left for too long, can lead to permanent neurological dysfunction. Lumbar disc herniation is the most common cause of this compression. But there are other causes to consider such as tumors, abscesses or sometimes even caused by other health professionals. The classical symptoms that cordia quina syndrome presents with include lower back pain, bilateral sciatica, AAD, anesthesia, urinary and bowel incontinence, an absent anal sphincter tone and erectile dysfunction. Why is that? Well, the region that we are talking about has the sacral nerve roots. S 23 and four, a good rhyme to remember is that s 234 keeps the poo or P or penis off the floor. These are the nerve roots of our pedal nerve. Now, the investigation and diagnosis is through MRI. MRI is the gold standard and this needs to be urgently ordered if there are symptoms, surgical decompression is needed within 48 hours. In this image. Here, we can clearly see a quarter recliner being compressed on by a bulging disc. The next co condition to consider is degenerative disc disease. What is degenerative disc disease? Well, as we age the disc does degenerate. Anyway, remember when I mentioned the two parts, the gelatinus nucleus pulposus is mainly filled with water. This can dry out and over time, even the fiber around it loses its elasticity. This causes a progressive loss, intervertebral space, thereby reducing the shock absorbing ability of the disc. Putting an increased risk of fractures. Sometimes the breakdown of the nucleus pulposus releases nitrogen from this tissue. And it can be seen as a sort of vacuum disc sign on imaging. As you can see here, it's a very dark, dark bit compared to this joint space. Unfortunately, the management is the same as for general back pain and oral nsaids are first line. Again, physical therapy can help. And if nsaids are not suitable, cocodamol can be considered, however, only for short periods of time. Now we come to sciatica. Well, what is our sciatic nerve? As you can see here, sciatic nerve has the nerve roots of L4 to S3. It exits the pelvis via the sciatic foramen and it emerges inferiorly to the piriformis muscle. It's mostly a motor neuron which innervates the posterior compartment of our thigh. In sciatica, something compresses this nerve causing radiating pain going down the leg. Once again, the most common causes of this condition is a disc herniation from L5 to S one spondylosis, spondylosis is also another cause which is when um a vertebral above moves forward relative to the vertebral below it thereby causing a kind of compression that way. And finally, another cause to consider a spinal stenosis. Again, that is when the vertebrae thicken in certain parts, thereby restricting the foramen of where the nerve usually exits and potentially compressing it. The classical signs and symptoms of sciatica is usually lower back pain with unilateral leg pain radiating below the knee, paresthesia can be seen along certain dermatomes which match whichever nerve root is being affected. There can be weakened, weakness or reduced reflexes and there is usually positive straight leg raise test. The exact symptoms can vary again based on which nerve root is being compressed. However, often times in real life, more than one nerve root is being compressed and patients will complain of a lower back pain with that unilateral shooting leg pain. Some examinations to consider a dull screen is is a good one. in some patients gait is affected, then you would also want to carry out a lower limb musculoskeletal and neurological examination. In most cases, no imaging is required for sciatica. The management is once again the same for all lower back pain. Oral nsaids are the first line cocodamol can be considered if people cannot take nsaids. Contrary to what patients might want to do, you must encourage them to keep active, warn them though that when keeping active symptoms can feel worse for a period. But bed rest and not using your back at all will actually make sciatica worse. Sometimes you can apply heat. A referral to a physio is also important. Importantly, if the symptoms are not better after two weeks, they'll need a follow up. Finally, do not offer gabapentin aids such as gabapentin, benzodiazepines or other antiepileptics or corticosteroids to treat sciatica. Ok. So that brings us to the end of all the cod conditions that we wanted to talk about. We first discussed the anatomy of the joints as well as using the knee joint as a good example. We then talked about osteoarthritis. Finally, we talked about the vertebrae and the anatomy there as well as back pain. Thank you very much for listening. We have practiced S VA S at the end. We also have a feedback slide. After this one, please fill that out. Your feedback is greatly appreciated. Until next time. Bye for now.