Orthopedics

Introduction

Orthopedic medicine offers physician assistants (PAs) unique opportunities to practice team-based medicine at a high level. As a result of the opportunities in orthopedics, as well as the value PAs bring to the orthopedic care team, in 2018 more than 1 in 10 PAs in the United States practiced in orthopedic surgery. Musculoskeletal complaints are common in all medical settings; therefore a quality orthopedic experience can prepare the student to approach musculoskeletal complaints in nonorthopedic environments as well. This chapter will introduce PA practice in orthopedics, what to expect as a student on an orthopedic rotation, and how to best position yourself for a rewarding and educational experience.

Patient approach

In general, orthopedic practitioners approach the patient with a goal-oriented mindset. Goals for orthopedic care can include healing injured structures, managing pain associated with a musculoskeletal complaint, and returning the patient to athletic activity or activities of daily living. Progress toward these goals begins with a thorough and accurate history and physical examination, which can lead to a diagnosis in up to 76% of patients. A thorough understanding of the patient’s goals and expectations is also crucial in guiding the treatment and management approach.

PAs in orthopedics must approach the patient with a solid understanding of the anatomic structures involved and their related physiology. If the student can consider the relevant anatomy and physiology within the mechanism of injury or overuse, they will be well on their way to understanding the associated pathology and the indicated treatment. Orthopedic practitioners must also have detailed knowledge of medical comorbidities that affect bone metabolism and wound healing, such as osteoporosis, chronic steroid use, tobacco use, diabetes, and renal disease to provide the highest quality care to their patients.

A typical day in orthopedics

Most orthopedic practices include a variety of providers to address the range of musculoskeletal disease. These doctors can include general orthopedists and those with subspecialty training in spine, hands, feet, and sports injuries. PAs may work with one or more of these physicians. Some PAs are very tightly coupled with a particular surgeon, or a few surgeons, sharing the same clinic and operating room schedule. Others may have more independence, seeing their own patients in clinic and having varying levels of surgical responsibility. PAs often take first call for emergent consults and may take the lead in responding to patient phone calls or messages.

One of the appealing aspects of orthopedics is the day-to-day variety. Most PAs will have both clinic and surgical responsibilities. Clinic and surgery days usually alternate, but in the case of emergent surgeries, schedules may change at any time. In clinic, duties generally include diagnosing and treating new patients, assessing follow-up and postoperative patients, performing in-office procedures, documenting visits in the medical record, helping to coordinate equipment representatives and other logistics for operative cases, applying dressings and casts, administering injections, answering calls, and performing hospital consultations. PAs who share a clinic schedule with a surgeon work to ensure a smooth flow of patients as the PA and physician work together to “divide and conquer” the visit list. In some cases, the surgeon prefers to see each patient, if only for a moment. In other cases, PAs see certain types of patients independently. It is important that the PA and surgeon communicate clearly to facilitate clinic operations and provide the best care to patients.

If morning surgical cases are scheduled, the PA’s day starts early. The PA will visit his or her patients in the preoperative holding area. This visit provides a last-minute opportunity to answer any patient questions and ensure everything is in place for a successful surgery. The surgeon will typically meet the patient to obtain formal informed consent and mark the extremity on which the operation will be performed, with the goal of avoiding wrong-site surgeries or incorrect procedures.

After the preoperative work is complete, the nursing staff brings the patient into the operating room (OR). If available, it is helpful for the PA (and PA student) to be present as the patient is transferred to the OR care team to provide consistency for the patient and operative team. When the patient enters the OR, PAs aid the anesthesia provider and circulating nurse in moving the patient from the stretcher to the operating table. When the desired level of sedation is accomplished, PAs help pad all bony prominences, shield the patient with a lead apron if radiography or fluoroscopy will be used, and apply a tourniquet to the operative extremity if necessary. The circulating nurse will then begin sterilely prepping the operative area. It is important for all to be aware which areas are sterile, to avoid any inadvertent contamination of the surgical field. Finally, the PA leaves the OR to go scrub for the case. It may be necessary to wear a lead apron and neck cover if radiographs will be taken during the surgery. Always wear a mask and eye protection. Scrub using the 5-minute scrub technique.

During surgical cases, more than two skilled hands are often required. PAs, therefore, serve as experienced and knowledgeable first assistants to the surgeon. As a surgical assistant, the PA’s main role is to understand the procedure, anticipate the next step in the case, and provide the needed surgical care at each point, under the direction of the surgeon. PAs may position anatomic structures, retract, suction, suture, or apply an appropriate dressing or splint. When the case is concluded, the patient is extubated by anesthesia staff, and PAs work with the anesthesia provider, circulating nurse, and scrub technician to move the patient from the operating table to the stretcher. The patient is then transferred from the OR to the postanesthesia care unit (PACU). There the PA will write the postoperative orders for antibiotics, fluids, pain medications, and nursing care and will request consultations by physical therapy, internal medicine, or other clinical services. If the patient had outpatient surgery, the PA will write discharge orders and prescriptions for the patient to fill. Before, between, or after all cases, PAs may round on and discharge inpatients. It is important to remember that the PA scope of practice does not include independent performance of surgical procedures. That said, it is very common for PAs to perform nonoperative procedures, such as joint or soft tissue injections and joint reductions.

Expectations of physician assistant students on orthopedic rotations

As a PA student you will be expected to arrive on time (or early), dress appropriately for performing an orthopedic examination, and engage actively in learning opportunities. Often these learning opportunities may present at inconvenient times. This may mean that there are late nights and/or early mornings. It is helpful for the student to talk with their preceptors to understand the expectations of the orthopedic team for the student. A simple initial conversation can do much to ensure a successful rotation. Even knowing little things like where the clean scrubs are located or how to get to all operating facilities is helpful.

In an orthopedic setting, the ability to be flexible in terms of schedule and duties is important. There can be great variability in practice types and in the scopes of those practices. In all settings, however, it will likely be expected that the student sees patients to obtain a history and perform a physical exam, develop a differential diagnosis list, and have a sense of treatment options. Documentation in the medical record and rounding will likely also be expected.

Students must be willing to learn the clinic’s routine, including triaging, performing and documenting history and physical examinations, presenting patients, removing sutures and staples, applying dressings and casts, and writing prescriptions. Common splints and casts are illustrated in Figs. 30.1 through 30.9 . Students must also be able to perform common orthopedic tests as displayed in Table 30.1 and Figs. 30.10 through 30.12 .