Trauma Rotation – UCSD Hillcrest PGY 2, PGY 4, and PGY 5
PGY-2 (year after internship during clinical pathway or year after research in research pathway), PGY 4 and PGY 5 residents spend 10 weeks on the orthopedic trauma service at UCSD Hillcrest Hospital, a level one ACS certified trauma center. The trauma team is comprised on an intern, UCSD PGY 2 resident, Navy PGY 3 resident, UCSD PGY 4 and UCSD PGY 5 resident. There is a physician assistant who works in clinic. There are three full time, trauma-fellowship trained faculty and one trauma fellow, who functions similarly to a junior attending. There is a dedicated orthopedic trauma room Monday through Friday. There are 1-3 operating rooms per day with orthopedic trauma cases, and one clinic every day. Based on their level, the residents 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. The junior resident takes in-house call, whereas the senior residents take home call. There is always a trauma attending on call or on back-up call. Graduated independence is granted in the operating room. There are a large variety of trauma cases, including referrals from remote areas with little access to medical care. Most trauma is blunt, and includes MVA, MCA, falls from height, and ATV accidents. There are daily conferences, including monthly journal club, bi monthly trauma conference with the general surgery trauma service, and bimonthly fracture conference.
While of the trauma rotation, the orthopedic service is responsible for extremity infection the first 10 days of every month. 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.
Hand and Microvascular Surgery Rotation - UCSD Hillcrest and Jacobs Medical Center: PGY 2 and PGY 4
Residents rotate on the hand and upper extremity service in 10 week blocks during their PGY 2 and PGY 4 years. This service is very busy and includes both elective and acute management of upper extremity pathology. There are three full time hand fellowship trained attendings and one attending dual fellowship trained in hand and sports. There is also one hand and upper extremity fellow. There is a physician assistant who works both in clinic as well as the operating room. Residents learn in detail the functional anatomy of the upper extremity. Residents will be able to perform a problem-oriented and nerve/motor specific examination. Residents will learn the pathophysiology and treatment of common disorders of the upper extremities. There is a weekly anatomy session where the resident performs the dissection and bi monthly journal club. After completion of the rotation, 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 - UCSD Hillcrest and Jacobs Medical Center: PGY 2 and PGY 3
Residents rotate on the spine service twice during residency, 10 weeks each rotation. There are three spine fellowship trained spine surgeons and two spine fellows. There is one nurse practitioner and one physician assistant on the service. There is a plan to hire an additional surgeon and an additional allied health provider. The resident is responsible for participation in the care of all inpatients and assists with the pre-operative workup. Additionally, patients are seen in outpatient clinics at the UCSD Jacobs Medical Center. 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. There is a weekly community spine conference.
Upon completion of the spine rotations, 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: UCSD Hillcrest and Jacobs Medical Center PGY 3,6
The resident rotates on the arthroplasty service at UCSD twice during residency, 10 weeks each rotation. The residents have earlier exposure to arthroplasty at the VA hospital during their PGY 2 year (see description of VA rotation). This rotation involves basic and complex reconstruction of adult hip and knee. There are three full time fellowship trained arthroplasty surgeons. There is one fellow. There are two full time allied health providers plus one part time. The resident will learn various approaches to total hip arthroplasty, including anterior and posterior approaches. They are also provided with the unique exposure to biological reconstruction, including osteotomy and osteocartilaginous transplantation. This rotation provides an opportunity for the 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. There is also bi-monthly teaching conference.
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.
Adult Orthopaedics Service Rotation at VA Medical Center PGY 2,3,5
The resident rotates at the VA for 10 week blocks three times during residency, each with graduated responsibility. The resident is exposed a wide-variety of orthopedic pathology, both inpatient and outpatient. There is a large volume of arthroplasty, sports medicine, shoulder pathology, and fractures. This rotation serves to further the resident's education in the diagnosis and treatment of adult orthopaedic patients. The resident will be responsible to 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. There is a weekly Monday morning conference, attended by all VA faculty and residents. The goals of the rotation are:
- 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.
Sports Medicine UCSD and Navy Hospital PGY 3,4,5
PGY 3 and 4 residents rotate with the UCSD sports service. The chief of the sports service is the team physician for the San Diego Padres. There are three full time sports fellowship trained attendings, and one dual fellowship trained surgeon in both sports and hand/ upper extremity. During the PGY 5 year, the resident rotates at the Balboa Naval Medical Center. There is additional sports experience while rotating at the VA (please see description of the VA rotation). 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. 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. There is opportunity for the residents to be the team physician for high school football teams.
Specific attention is directed at gradual development of arthroscopic skills. Training includes model practice including simulation, 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)
- Meniscus tears and knee chondrosis
- Knee instability (including ACL, PCL, and Posterolateral Corner)
- Sports rated overuse syndromes
- Stress fractures and chronic exertional compartment syndrome
Foot and Ankle Rotation UCSD Jacobs Medical Center: PGY 2
The PGY 2 resident works one-on-one with the foot and ankle attending, who is dual fellowship trained in foot and ankle as well as trauma. This is a mostly outpatient rotation, with some inpatient consults. There is a large variety of surgeries as well as pathology the resident will learn. There is a part time physician assistant who works as part of the team. 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 - Rady Childrens Hospital: PGY 2 and 4
Rady Childrens Hospital is one of the top pediatric orthopedic programs in the country, routinely ranked in the top 2 to 4 in the USA. Residents rotate there two times during residency, 10 weeks each time. It is a busy rotation, with ample opportunities in nonoperative and operative treatment of pediatric orthopedic conditions. There are 10 attending surgeons, 4 fellows, and numerous allied health professionals and orthopedic technologists. The resident will learn details and specifics of numerous subspecialties, including spine/ scoliosis, pelvic osteotomies, sports, and foot and ankle. 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.