Acute Orthopaedic Rotations
PGY-2 residents complete four-month rotations at UCSDMC and at the VAMC on the acute services. Specialty specific rotations occur for the PGY-3 and 4 levels. PGY-5’s serve as chief resident while on their rotations at UCSD Hillcrest, UCSD Thornton, and the VAMC. Chronic care as well as outpatient diagnostics and treatment are emphasized on all rotations. All residents become knowledgeable in the functional anatomy of the extremities, spine and pelvis. The residents should be able to properly perform an examination of the upper and lower extremities and spine and should be able to understand the pathophysiology and treatment of common orthopaedic disorders caused by traumatic, inflammatory, degenerative, infectious and neoplastic conditions.
- Trauma: Residents, based on their level, should be able to diagnose and formulate treatment of bone, joint, muscle, nerve and other soft tissue injuries of the extremities. This includes the treatment of open and closed fractures and dislocations of the extremities and the management of multiple traumatized patients.
- Degenerative Disease: The residents, according to expectations as noted above for particular year of training, should be able to examine, diagnose and formulate treatment plans for common degenerative disorders of the extremities and spine including osteoarthritis, post traumatic and post infectious deformities
- Inflammatory: Residents should be able to evaluate, diagnose, and formulate treatment plans for a variety of problems related to inflammatory conditions such as rheumatoid arthritis, psoriatic arthritis, gout, Reiter’s syndrome, and other inflammatory conditions.
- Infectious: Residents should be able to evaluate, diagnose, and formulate treatment plans for a variety of infectious process including septic joints, osteomyelitis, and soft tissue infections such as cellulitis, necrotizing fasciitis, gas gangrene, and abscess. TB and fungal infections are also treated.
- Neoplasm: Residents should be able to evaluate, diagnose, and formulate treatment plans for common tumors of the bones and soft tissues of the extremities and spine. This is usually done in conjunction with, and the assistance of fellows and orthopaedic staff.
Hand and Microvascular Surgery Rotation
Residents should know in detail the functional anatomy of the upper extremity. Residents should be able to perform a problem-oriented and nerve/motor specific examination. Residents learn the pathophysiology and treatment of common disorders of the upper extremities. This experience is divided into two-month blocks and after completion of the four months of training residents will be comfortable with the basic science principles and clinical practice of hand surgery, including:
- Overuse syndromes: DeQuervain’s; Trigger Finger, and Tennis Elbow.
- Compressive Neuropathies: Such as Carpal Tunnel Syndrome, Pronator Syndrome, Radial Tunnel Syndrome, and Thoracic Outlet Syndrome.
- Common Hand Tumors: Soft tissue tumors, ganglion retinacular cysts, mucous cysts, sebaceous cysts, giant cell tumors of tendon sheath and bone tumors such as enchondroma.
- Trauma: Residents will understand and be proficient at the non-operative and operative management of fractures and dislocations involving the carpus, metacarpals and phalanges. Residents will also understand the indications for replantation, have experience in the treatment of tendon and nerve lacerations; understand the functional disabilities associated with nerve palsied; and be familiar with and understand basic tendon transfers to restore function.
- Infections: Residents will be able to recognize and treat paronychais, deep space hand infections, flexor tenosynovitis and septic joints of the hand.
- Congenital problems: Residents will be familiar with the common congenital problems of the upper extremities including polydactyly, syndactyly, radial club hand, clinodactyly, camptodactyly, Madelung’s deformity, congenital amputations, and macrodactyly.
- Acquired disorders: Residents should understand the rationale and treatment of Dupuytren’s Contracture. Residents should understand the pathomechanics of hand and wrist deformities in rheumatoid arthritis and options for treatment. Residents should also understand the common disabilities of osteoarthritis of the hand, including arthritis of the thumb.
Spine Service Rotation
The resident is responsible for participation in the care of all inpatients and assists with the pre-operative workup. Additionally, patients are seen in clinics staffed by faculty and fellows at UCSD and the VA. The residents provide care (non-operative and operative) for patients at the Veterans Administration Hospital and in the VA Spinal Cord Injury Unit in a consultative manner.
Upon completion of the four-month rotation it is expected that the residents will:
- Understand spine anatomy: Cervical, Thoracic, and Lumbar.
- Develop an organized approach to evaluation and treatment of spine-injured patients: intact, incomplete and complete.
- Assess spinal stability/instability.
- Develop an organized approach to evaluate and treat outpatients with complaints of back/leg, neck/arm pain as related to degenerative conditions, tumor, infections, spondylo-arthropathies, and deformities.
- Have familiarity with adult scoliosis.
- Develop an organized approach to spine surgery: pre-op, intra-op and post-op.
- Understand the rationale and indications for using spinal orthoses: commercial and fabricated.
- Improve surgical techniques.
Joint Reconstruction Rotation
Joint Reconstruction Rotation involves basic and complex reconstruction of adult hip and knee. The senior level resident is exposed to a large volume and wide spectrum of adult hip and knee disease. They are also provided with the unique exposure to biological reconstruction, including osteotomy and osteocartilaginous transplantation. The goals of the rotation are to:
- Understand the pathophysiology of adult hip and knee disease, including osteoarthrosis inflammatory arthrosis, traumatic arthrosis and avascular necrosis, as well as other cartilage diseases
- Understand the mechanics of the hip and knee joint, including normal, pathologic, and reconstructed joints.
- Understand the surgical anatomy of the hip and knee and multiple surgical approaches.
- Understand the indications for surgical treatment for adult hip and knee disease.
- Understand material science of prosthetic joint replacement.
- Understand design-engineering principles underlying total joint replacement.
- Understand the biological principles underlying osteotomy and cartilage transplantation.
- Understand the principle of prosthesis fixation and biological reaction to the prosthesis.
- To recognize patterns of prosthesis failure.
- To become technically proficient in the performance of basic hip and knee reconstructive procedures and have an understanding of the complexities of revision surgical procedures.
- Understand the basic concepts and details of rehabilitation after joint reconstructive procedures and the use of clinical pathway in patient care.
- This rotation provides an opportunity for the upper level resident to have intimate one on one interaction with attending staff, perform a large volume of surgical procedures, and participate in patient care. This rotation also allows the resident to improve communication skills with the patient and hospital staff, and gain better understanding of the multidisciplinary approach to care.
Adult Orthopaedics Service Rotation at VA Medical Center
Upon completion of the four-month rotations it is expected that the residents will (depending on level):
- Further his/her education in the diagnosis and treatment of adult orthopaedic patients.
- Establish an appropriate diagnosis for each patient by process of history taking, physical examination and instituting appropriate investigations for patients in the Triage Area, Outpatient and Inpatient services. This service provides more initial independence in patient care than most.
- Be able to propose a plan for therapy, operative or nonoperative, and be able to institute and coordinate such therapy to its satisfactory conclusion.
- Maintain adequate documentation of diagnostic and therapeutic plans for each of the patients.
- Extensively read the orthopaedic literature, especially in relation to current patients.
- Degenerative processes are the most frequently encountered problem at the VA, and understanding these conditions and treatment options is emphasized.
All of the junior residents (and orthopaedic interns) participate with the Rehabilitation Service where a small volume of patients are covered in depth. It is felt that early exposure is appropriate for rehabilitation experience. During this period, a longer time with a fewer number of patients is necessary in order to develop skills required for an adequate neuromusculoskeletal examination. Residents learn principles on the Rehabilitation Service, which he/she can use during the rest of his/her training. Under completion of the four-month rotation it is expected that the resident will:
- Understand the basics of upper and lower limb deformity caused by neuromuscular disorders including the treatment of spastic disorders and paralysis.
- Have increased his/her knowledge of surgical muscle and tendon lengthening, fracture releases and balancing procedures.
- Learn the basics of rehabilitation care and the ream approach to comprehensive rehabilitation programming for stroke-injured patients.
- Residents should be aware of indications and basics of amputation surgery and general reconstruction procedures including foot reconstruction.
The educational goal of the Sports Medicine Service is to foster the clinical and surgical skills needed to provide excellent arthroscopic and sports medicine care after completion of the residency program. The sports medicine service focuses upon evaluation and treatment of shoulder and knee disorders, with particular emphasis upon basic and advanced arthroscopic surgical techniques. This experience is divided into two-month blocks and after completion of the four months of training residents will be comfortable with the basic science principles and clinical practice of orthopaedic sports medicine.
Education is provided side by side with faculty physicians in the outpatient clinic as well as in the operating room. Considerable opportunity is available for longitudinal follow-up of patients from preoperative assessment through postoperative management. Team coverage is provided in the training room of the UCSD Intercollegiate Athletic Program.
Specific attention is directed at gradual development of arthroscopic skills. Training includes model practice and progresses from basic arthroscopic techniques through advanced procedures such as arthroscopic rotator cuff repair, instability management of the shoulder, posterior cruciate ligament reconstruction and meniscal allograft replacement. Emphasis is placed upon the basic science foundations of current procedures in preparation for future scientific and technologic advances in the field of sports medicine.
A large number of arthroscopic and open procedures are performed. Residents are expected to learn the surgical principals and techniques of open knee and shoulder surgery as well as diagnostic and surgical arthroscopy. Commonly treated disorders include:
- Shoulder instability and superior labral (SLAP) tears
- Impingement syndrome and rotator cuff tears
- Glenohumeral arthrosis (including shoulder arthroplasty)
- Adhesive capsulitis
- Meniscus tears and knee chondrosis
- Knee instability (including ACL, PCL, and Posterolateral Corner)
- Patellofemoral disorders
- Sports rated overuse syndromes
- Stress fractures and chronic exertional compartment syndrome
Foot and Ankle Rotation
Upon Completion of the rotation it is expected that the resident will have:
- Developed and expanded basic orthopaedic fund of knowledge in the areas of foot and ankle conditions.
- Have knowledge of basic anatomy, biomechanics and the pathophysiology of foot and ankle conditions.
- Under direct clinical and surgical supervision and instruction perform non-surgical and surgical management of a wide variety of foot and ankle conditions.
Pediatric Orthopaedics Rotation
The goals for the pediatric orthopaedic rotation include:
- Cognitive Goals: Completion of a comprehensive reading program in pediatric orthopaedics including complete reading of Lovell and Winter text on pediatric orthopaedics, a practical fracture text (Rang) as well as a more comprehensive text on children's fractures (Wilkins-Rockwood and Green). This reading, plus weekly journal club and teaching conferences on pediatric orthopaedic topics, will initiate the development of a cognitive base. The goal for clinical skills includes understanding the diagnosis and treatment of all common pediatric orthopaedic surgery problems (especially fractures and infections). The resident in the senior year will be expected to read on more complex children's orthopaedic topics including myelodysplasia (Menelaus), cerebral palsy (Bleck), hip dysplasia (Tonnis), and scoliosis (Moe, Bradford, Winter, Lonstein). This reading plus weekly journal club and teaching conferences on pediatric orthopaedic topics will expand the cognitive base for the resident. The goal for clinical skills includes understanding the diagnosis and treatment of all common pediatric orthopaedic surgery problems (especially fractures and infections) and also to assist in managing more complex problems. They will further their cognitive knowledge base by organizing the topics for journal club.
- Psychomotor Goals: The residents will learn to reduce common children's fractures both with local and general anesthesia. They will learn basic operative skills related to pediatric orthopaedics including treatment of closed and open fractures, aspiration and surgical drainage of suspected infections, as well as performing
- Common orthopaedic elective operations (simple tendon lengthenings, muscle releases in cerebral palsy, simple corrective osteotomies, etc.). They will also assist with complex pediatric orthopaedic operations (surgical treatment of scoliosis, congenital dislocation of the hip, Legg-Perthes disease, etc.).
- Affective Goals: The resident will learn the affective components of being a physician including good inter-professional and doctor patient skills. This will be achieved through close association with the attending staff who serve as a role model. Professionalism in the hospital, clinic, and operating room will be emphasized.