Orthopaedic Surgery: Back to Basics

Physical Examinaiton

noreply@blogger.com (Someonect) — Sat, 09 Feb 2008 19:00:00 +0000

One of the most important assets that an orthopaedic surgeon must have is good physical examination skills. It is definitely not as glamorous as the surgical procedures, but is important at determining the diagnosis, treatment, and possible surgical options.

The next few posts will be specifically about physical examination. I will provide a description of the physical examination, a video to demonstrate the examination, and an example of what should be documented.

All of the orthopaedic examinations consist of:

Observation includes posture, position, gait, and skin in multiple positions.
ROM includes ranges of motion for all of the examined joints.
Neurologic Examination
Special examinations are specific to the areas being examined.

When documenting these for coding purposes, you must remember to make mention of all of these points. It is also important to mention that you examined both sides. For example, if you are examining a knee, you examine the knee in question with the other knee used as a comparison. This assumes that the other knee is normal.

Neurologic Examination

noreply@blogger.com (Someonect) — Sat, 09 Feb 2008 18:00:00 +0000

For the orthopaedic examination, the neurologic examination has several components:

Motor Examination

Strength

Tone

Movement

Posture

Sensory Examination

Light touch/Pain

2 point discrimination

Reflexes
Gait

Gait

noreply@blogger.com (Someonect) — Fri, 08 Feb 2008 18:00:00 +0000

Gait Cycle

The following goals must be achieved in normal human gait

balancing head/arms/trunk segment of body at hips (HAT constitutes about 70% of body mass)

transfer and support of body mass to one leg during single leg support phase of stance

ground clearance of swinging foot during swing phase

generation of sufficient propulsive force for forward progression

It is also desirable to achieve these goals with minimum energy expenditure.

There are 2 phases of gait:

Stance Phase

consists of initial heel contact, foot flat, mid-stance (hip moves over ankle), heeloff, toe-off

constitutes about 60% of stride duration at preferred walking speed

double leg support begins with heel contact, followed by foot flat (comprises about 15% of stride)

two periods of double support as weight is transferred from one leg to the other (at beginning and end of stance) constitute about half of stance phase

single leg support begins immediately after foot flat as trailing leg is lifted from ground

Swing Phase

consists of early swing (acceleration), mid-swing, late swing (deceleration)

constitutes about 40% of stride duration at preferred walking speed

Normal Gait

Hemiplegic Gait

Diplegic Gait

Neuropathic Gait

Myopathic Gait

Choreiform Gait

Ataxic Gait

Reflex Examination

noreply@blogger.com (Someonect) — Fri, 08 Feb 2008 18:00:00 +0000

Reflexes

Stretch or Deep Tendon Reflexes (DTR's)

Biceps – C5-6
Brachioradialis – C5-6
Triceps – C7
Finger Flexors – C8
Patellar or Knee – L2-4
Ankle – S1-2

Grading DTR's

Absent
Decreased but present
Normal
Brisk and excessive
With clonus

Upper Extremity DTRs

Abnormal Upper Extremity DTRs

Lower Extremity DTRs

Abnormal Lower Extremity DTRs

Plantar Response

Abnormal Plantar Response

Hoffmann's Sign

Motor Examination - Tone

noreply@blogger.com (Someonect) — Fri, 08 Feb 2008 18:00:00 +0000

Tone

Muscle tone is assessed by putting selected muscle groups through passive range of motion. The most commonly used maneuvers for the lower extremities are flexion and extension at the knee and ankle.

Upper Extremity Tone

Abnormal Upper Extremity Tone

Lower Extremity Tone

Abnormal Lower Extremity Tone

Sensory Examination - Light touch/Pain

noreply@blogger.com (Someonect) — Fri, 08 Feb 2008 18:00:00 +0000

Dermatomes

(Image credit)

Light Touch

Light touch (both posterior column and spinothalamic tracts) is usually tested with a wisp of cotton swab.

Abnormal Soft Touch Exam

Pain

Pain (spinothalamic tract) sense can be tested with a splintered cotton tip applicator or broken tongue blade.

Upper Extremity Pain Exam

Abnormal Upper Extremity Pain Exam

Lower Extremity Pain Exam

Abnormal Lower Extremity Pain Exam

Motor Examination - Strength Testing

noreply@blogger.com (Someonect) — Fri, 08 Feb 2008 18:00:00 +0000

Strength Testing

Muscle strength is rated on a scale of 0/5 to 5/5:

0/5: no contraction
1/5: muscle flicker, but no movement
2/5: movement through a full range of motion, but not against gravity (test the joint in its horizontal plane)
3/5: movement through a full range of motion, but not against resistance by the examiner
4/5: movement possible against some resistance by the examiner (sometimes this category is subdivided further into 4^–/5, 4/5, and 4⁺/5)
5/5: normal strength

Upper extremity Motor Testing

Abnormal Upper Extremity Motor Exam

Detailed Hand Motor Testing

Action	Muscles	Nerves	Nerve Roots
Finger extension	Extensor digitorum, Extensor indicis, Extensor digiti minimi	Radial nerve (posterior interosseous nerve)	C7, C8
Thumb abduction in plane of palm	Abductor pollicis longus	Radial nerve (posterior interosseous nerve)	C7, C8
Finger abduction	Dorsal interossei, Abductor digiti minimi	Ulnar nerve	C8, T1
Finger and thumb adduction in plane of palm	Adductor pollicis, Palmar interossei	Ulnar nerve	C8, T1
Thumb opposition	Opponens pollicis	Median nerve	C8, T1
Thumb abduction perpendicular to plane of palm	Abductor pollicis brevis	Median nerve	C8, T1
Flexion at distal interphalangeal joints digits 2, 3	Flexor digitorum profundus to digits 2, 3	Median nerve	C7, C8
Flexion at distal interphalangeal joints digits 4, 5	Flexor digitorum profundus to digits 4, 5	Ulnar nerve	C7, C8
Wrist flexion and hand abduction	Flexor carpi radialis	Median nerve	C6, C7
Wrist flexion and hand adduction	Flexor carpi ulnaris	Ulnar nerve	C7, C8, T1
Wrist extension and hand abduction	Extensor carpi radialis	Radial nerve	C5, C6
Elbow flexion (with forearm supinated)	Biceps, Brachialis	Musculocutaneous nerve	C5, C6
Elbow extension	Triceps	Radial nerve	C6, C7, C8
Arm abduction at shoulder	Deltoid	Axillary nerve	C5, C6

Lower Extremity Strength Testing

Abnormal Lower Extremity Motor Exam

Action	Muscles	Nerves	Nerve Roots
Hip flexion	Iliopsoas	Femoral nerve, and L1-L3 nerve roots	L1, L2, L3, L4
Knee extension	Quadriceps	Femoral nerve	L2, L3, L4
Knee flexion	Hamstrings (semitendinosus, semimembranosus, biceps femoris)	Sciatic nerve	L5, S1, S2
Leg abduction	Gluteus medius, Gluteus minimus, Tensor fasciae latae	Superior gluteal nerve	L4, L5, S1
Leg adduction	Obturator externus, Adductor longus, magnus, and brevis, Gracilis	Obturator nerve	L2, L3, L4
Toe dorsiflexion	Extensor hallucis longus, Extensor digitorum longus	Deep peroneal nerve	L5, S1
Foot dorsiflexion	Tibialis anterior	Deep peroneal nerve	L4, L5
Foot plantar flexion	Triceps surae (gastrocnemius, soleus)	Tibial nerve	S1, S2
Foot eversion	Peroneus longus, Peroneus brevis	Superficial peroneal nerve	L5, S1
Foot inversion	Tibalis posterior	Tibal nerve	L4, L5

Global Strength Testing

Abnormal Global Strength Testing

Total Knee Arthroplasty

noreply@blogger.com (Someonect) — Sun, 03 Feb 2008 04:10:00 +0000

Total knee replacement is a procedure that replaces a dysfunctional knee joint and eliminates the damaged surfaces that are causing pain. Knee joint replacement may be recommended for: knee osteoarthritis or arthritis; decreased knee function and some knee fractures. Knee joint replacement may also be recommended for someone who is unable to work, sleep through the night or walk more than three blocks because of knee pain.

According to the National Inpatient Survey of medical procedures, more than 300,000 knee replacement procedures are preformed across the nation each year. Joint replacement is an elective procedure that can dramatically improve quality of life. Our Lady of the Lake Regional Medical center performs approximately 1,000 total joint surgeries a year - new knees, hips and shoulders for people who are ready to live more actively and comfortably.

(Information Source)

The surgery is performed by R. Bryan Griffith, Jr., MD.

(Video Source)

Total knee replacement performed by Jeffrey H. DeClaire, M.D

(Video Source)

Total knee replacement performed by Bradley Edgerton, MD.

(Video Source)

Mini Incision Total Knee Arthroplasty

noreply@blogger.com (Someonect) — Sun, 03 Feb 2008 03:30:00 +0000

Minimally invasive Total Knee Arthroplasy (TKA) performed by Carlos J. Lavernia, MD

(Video Source)

Minimally Invasive Primary TKA using a single radius knee design performed by Peter Bonutti, MD.

(Video Source)

Cervical Artificial Disc Replacement

noreply@blogger.com (Someonect) — Sun, 03 Feb 2008 03:13:00 +0000

Cervical disc replacement surgery would most typically be done for patients with cervical disc herniations that have not responded to non-surgical treatment options and are significantly affecting the individuals' quality of life and ability to function.

An artificial disc surgery may be done instead of an anterior cervical discectomy and fusion. The advantages of the artificial cervical disc replacement include:

Maintaining normal neck motion
Eliminating the need for a bone graft
Early postoperative neck motion
Faster return to normal activity

The indications for a cervical disc replacement include symptomatic cervical disc, which may be causing arm pain, arm weakness or numbness with some degree of neck pain.

The standard surgical procedure for a disc replacement is an anterior (from the front) approach to the cervical spine. The affected disc is completely removed including any disc fragments or bone spurs. The disc space is prepared to relieve pressure on the nerves and the artificial disc device is implanted. The patient typically can go home within 24 to 48 hours with minimal activity limitations.
(Information Source)

Surgery is performed by Jorge Isaza, MD and moderated by Fraser Landreneau, MD

(Video Source)

Evaluation and Management (E/M) Documentation

noreply@blogger.com (Someonect) — Sun, 03 Feb 2008 02:00:00 +0000

Something that is not emphasized in most orthopaedic programs is documentation. Over the last 10 years or so, we have become much more aware of this because of CMS's examination of academic hospitals and levying heavy fines because of improper documentation.

I speak with my residents constantly about documenting appropriately. This does no mean having a wordy dictation. It means only documenting what is necessary to give you the information you need to follow the patient, and to meet the guidelines from CMS.

Who makes the Guidelines? The Centers for Medicare & Medicaid Services (CMS) made the guidelines, i.e. they are federal guidelines. CMS has 2 different guidelines, the 1995 and 1997 guidelines. The difference between the 2 is in the physical examination documentation. The 1995 guidelines are based on systems and/or body areas, where as the 1997 guidelines for examination are based on a multisystem or single organ system examination table.

What are the basic components needed in documentation? The documentation is split up into 3 components: History, Physical examination (1997 or 1995) , and Medical decision making (MDM). An evaluation can be billed on time as well if counseling is involved. If billing on time, greater than 50% of the visit must be spent on counseling.

For new patients, the new patient codes are:

99201

History - Problem Focused

Exam (1997 or 1995) - Problem Focused

MDM - Straight Forward
Time - 10 minutes face-to-face with the patient and/or family

99202

History - Expanded Problem Focused

Exam (1997 or 1995) - Expanded Problem Focused

MDM - Straight Forward
Time - 20 minutes face-to-face with the patient and/or family

99203

History - Detailed

Exam (1997 or 1995) - Detailed

MDM - Low Complexity
Time - 30 minutes face-to-face with the patient and/or family

99204

History - Comprehensive

Exam (1997 or 1995) - Comprehensive

MDM - Moderate Complexity
Time - 45 minutes face-to-face with the patient and/or family

99205

History - Comprehensive

Exam (1997 or 1995) - Comprehensive

MDM - High Complexity
Time - 60 minutes face-to-face with the patient and/or family

For established patients, the out-patient codes are:

99211 (No provider required. A nurse only visit)
99212

History - Problem focused

Exam (1997 or 1995) - Problem focused

MDM - Straight forward

99213

History - Expanded Problem Focused

Exam (1997 or 1995) - Expanded Problem Focused

MDM - Low Complexity

99214

History - Detailed

Exam (1997 or 1995) - Detailed

MDM - moderate Complexity

99215

History - Comprehensive

Exam (1997 or 1995) - Comprehensive

MDM - High Complexity

E/M Documentation - Medical Decision Making

noreply@blogger.com (Someonect) — Mon, 21 Jan 2008 01:50:00 +0000

Documentation of the Complexity of the Medical Decision Making

The levels of E/M services recognize four types of medical decision making. Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

The number of possible diagnoses and/or the number of management options that must be considered;
The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and
The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

To qualify for a given type of decision making, two of the three elements in the table must
be either met or exceeded.

NUMBER OF DIAGNOSIS OR MANAGEMENT OPTIONS

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
For a presenting problem with an established diagnosis, the record should reflect whether the problem is a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” (R/O) diagnosis.
The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.
If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.

If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, e.g., lab or X‐ray, should be documented.
The review of lab, radiology, and/or other diagnostic tests should be documented. A simple notation such as “WBC elevated” or “chest X‐ray unremarkable” is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results.
A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.
Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “old records reviewed” or “additional history obtained from family” without elaboration is insufficient.
The results of discussion of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented.
The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.

RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

The risk of significant complications, morbidity, and/or mortality is based on the risks associate with the presenting problem(s), the diagnostic procedure(s), and the possible management options.

Comorbidity/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.
If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the E/M encounter, the type of procedure, e.g., laparoscopy, should be documented.
If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.

SUMMARY MEDICAL DECISION MAKING

STRAIGHT-FORWARD

Dx/Mgmt - 0-1 elements
Data - 0-1 elements
Risk - Minimal

LOW

Dx/Mgmt - 2 elements
Data - 2 elements
Risk Low

MODERATE

Dx/Mgmt - 3 elements
Data - 3 elements
Risk - Moderate

HIGH

Dx/Mgmt - >3 elements
Data - >3 elements
Risk - High

E/M documentation - Physical Examination (1997 guidelines)

noreply@blogger.com (Someonect) — Mon, 21 Jan 2008 01:50:00 +0000

Content and Documentation Requirements (1997 CMS guidelines)

Level of Exam Perform and Document:

Problem Focused - One to five elements identified by a bullet.
Expanded Problem Focused - At least six elements identified by a bullet.
Detailed - At least twelve elements identified by a bullet.
Comprehensive - Perform all elements identified by a bullet; document every element from the area in blue text and at least one element in each other area.

MUSCULOSKELETAL EXAMINATION

Constitutional Measurement of any three of the following seven vital signs:

sitting or standing blood pressure,

supine blood pressure,

pulse rate and regularity,

respiration,

temperature,

height,

weight (may be measured and recorded by ancillary staff)

General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Head and Face
Eyes
Ears, Nose, Mouth,
and Throat
Neck
Respiratory
Cardiovascular

Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)

Chest (Breasts)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic
Palpation oh lymph nodes in neck, axillae, groin, and or other location
Musculoskeletal

Examination of gait and station

Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four of the following six areas:

head and neck;

spine, ribs and pelvis;

right upper extremity;

left upper extremity;

right lower extremity; and

left lower extremity.

The examination of a given area includes:

Inspection, percussion andior palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions

Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity

Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Note: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element iscounted separately for each body area. For example, assessing range ofmotion in two extremities constitutes two elements.

Skin

Inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafe‐au‐lait spots, ulcers) in four of the following six
areas:

head and neck;

trunk;

right upper extremity;

left upper extremity;

right lower extremity; and

left lower extremity.

Note: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremities constitute two elements.

Neurological/Psychiatric

Test coordination (e.g., finger/nose, heel/ knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)
Examination of sensation (e.g., by Couch, pin, vibration, proprioception)
Brief assessment of mental status including:
Orientation to time, place and person
Mood and affect (e.g., depression, anxiety, agitation)

E/M documentation - Physical Examination (1995 guidelines)

noreply@blogger.com (Someonect) — Mon, 21 Jan 2008 01:50:00 +0000

Content and Documentation Requirements (1995 CMS guidelines)

The levels of E/M services are based on four types of examination that are defined as follows:

Problem Focused - a limited examination of the affected body area or organ system.
Expanded Problem Focused - a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
Detailed - an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
Comprehensive - a general multi-system examination or complete examination of a single organ system.

For purposes of examination, the following body areas are recognized:

Head, including the face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity

For purposes of examination, the following organ systems are recognized:

Constitutional (e.g., vital signs, general appearance)
Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic

The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

E/M documentation for out-patient encounter- History

noreply@blogger.com (Someonect) — Mon, 21 Jan 2008 01:50:00 +0000

For the E/M guidelines, the history is split into 4 components.

Chief Complaint (CC) - a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. A chief complaint is a REQUIRED ELEMENT for all levels of outpatient visits.
History of Present Illness (HPI) - a chronological description of the development of the patient’s presenting illness or problem from the first sign and/or symptom, or from the previous encounter to the present. There are 8 elements that are used to provide information about the patient's condition

Location - Place, site, position of signs & symptoms. Where is the problem located?
Duration - How long has the patient been experiencing the signs or symptoms?
Timing - When does the patient experience signs or symptoms? What regularity/frequency of occurrences? What time of day?
Severity - What is the intensity, degree, or ability to endure signs or symptoms? Scale of 1 to 10?
Quality - What description or characteristics identify the type of signs or symptoms?
Context - Circumstances, cause, precursor, outside factors to describe where patient is or what he is doing when signs or symptoms are experienced.
Modifying factors - What treatment/actions have affected (positive or negative) or altered the signs or symptoms?
Associated Signs and Symptoms - Are there any other symptoms that appear to accompany the main symptoms? What other factors does patient experience in addition to this discomfort/pain?

Review of Systems (ROS) - an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. Information included in the review of systems is used to identify the patient problem, assist in the arrival at a diagnosis, identify differential diagnoses, and determine the testing necessary to attain a definitive diagnosis.

Constitutional - Measurement of any 3 of 7 vital signs; General appearance of patient
Eyes
Ear, Nose, Mouth, and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (Skin)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

Past Medical, Family and Social History (PFSH) - Past medical history includes recording of prior major illnesses and injuries; operations; hospitalizations; current medications; allergies; age-appropriate immunization status; and/or age-appropriate feeding/dietary status. Family history involves the recording of the health status or cause of death of parents, siblings and children; specific diseases related to problems identified in the chief complaint or history of presenting illness and/or system review; and/or diseases of family members that may be hereditary or place the patient at risk. Social history contains marital status and/or living arrangements; current employment; occupational history; use of drugs, alcohol and tobacco; level of education; sexual history; or other relevant social factors.

The history is broken up into 4 levels.

Problem focused

CC
Brief HPI (less than 4 elements documented)
No Review of Systems required, but some may be documented

Expanded Problem-Focused

CC
Brief HPI (less than 4 elements documented)
Problem-pertinent Review of Systems (at least one system documented )

Detailed

CC
Extended HPI (4+ elements documented)
Extended ROS – problem- pertinent review plus a limited number of additional systems (2-9 systems documented)
Pertinent PFSH is one specific item from any of the three history areas

Comprehensive

CC
Extended HPI (4+ elements documented)
Complete ROS: Pertinent positive or negatives must be individually documented. For remaining systems, a notation of “All Other Systems Negative” is permissible. In the absence of such a statement, at least 10 systems must be documented.
Complete PFSH: At least one element in EACH of the three areas for new patients. At least one element in TWO of the three areas for established patients.

Introduction

noreply@blogger.com (Someonect) — Sun, 06 Jan 2008 04:30:00 +0000

Hello everyone,

This is the first post of my new blog. My other blog is specifically one attending's subjective look at orthopaedics and orthopaedic residency. The purpose of this blog is to be a reference to orthopaedic educators and learners. I will present topics that relate to many subjects in orthopaedic surgery. This blog will be more of an objective look at orthopaedics and will consist of video and pictures as they relate to the topics. I will try my best to leave my personal opinions out of the discussions. Please feel free to point out any bias that I may present.

I thank you for visiting my site and invite any suggestions for future topics.

Someonect