What should I know as an intern in an orthopedic department?

Essential Knowledge for Orthopedic Interns

Core Clinical Competencies

As an orthopedic intern, you must master trauma management principles, understand multidisciplinary care coordination, and recognize psychosocial factors that profoundly impact patient outcomes. 1

Trauma Management Fundamentals

Immediate fracture stabilization within 24 hours is critical for multiply injured patients to prevent complications including adult respiratory distress syndrome, fat emboli, deep venous thrombosis, and decubitus ulcers 2. The "golden period" for preventing major complications in open fractures is 6 hours from injury 2.

Open Fracture Management

• Perform early aggressive debridement with wide surgical exploration of all affected tissue planes 3
• Use thorough irrigation and removal of all contaminated tissue 3
• Leave wounds open for delayed closure or serial debridements 3
• Minimize postoperative imaging—a 2018 systematic review showed immediate postoperative imaging only identified complications in 0.22% of cases 1
• Consider windowed casts for open fractures to allow wound monitoring 1

Pediatric Fracture Principles

• Maximize removable casts and splints over rigid immobilization 1
• Accept more initial deformity than traditionally tolerated—pediatric remodeling potential mitigates residual deformity risk 1
• Utilize telehealth for follow-up when imaging won't change management 1
• Perform imaging only when it will alter the treatment plan 1

Conditions Requiring Pediatric Orthopedic Specialist Referral

Refer these patients to pediatric orthopedic surgeons 1:

• Congenital limb malformations (clubfoot, limb deficiency)
• Developmental dysplasia of the hip (after primary care screening)
• Bone or joint infections (osteomyelitis, septic arthritis—coordinate with infectious disease)
• Perthes disease (femoral head osteochondritis)
• Slipped capital femoral epiphysis
• Significant spinal deformity (scoliosis, kyphosis)
• Neuromuscular-related disabilities (cerebral palsy, spina bifida, muscular dystrophy)
• Sports injuries in adolescents (ACL tears, meniscal tears, cartilage injuries)
• Multiple skeletal trauma or complex fractures

Psychosocial Assessment is Mandatory

Psychosocial factors are not optional considerations—they directly determine patient outcomes including pain levels, functional recovery, and return to work. 1

Required Psychosocial Screening

Evaluate every trauma patient for 1:

• Behavioral health conditions: anxiety, PTSD, depression, premorbid psychiatric disorders—all associated with increased pain, decreased function, decreased quality of life, and impaired return to work
• Marital status: married patients return to work markedly faster than single, divorced, or widowed patients
• Education level: higher education correlates with enhanced mental health, improved physical function, and lower pain/anxiety levels
• Social support and functioning: directly impacts recovery trajectory

When to Refer for Psychological Intervention

Refer to psychology, social work, or multidisciplinary treatment when 1:

• Social or psychological factors interfere with pain management and functional status
• Psychopathology (depression, anxiety) is present—coordinate with primary care
• Fear of movement or catastrophizing cognitions underlie sedentary lifestyle
• Sleep disturbance persists despite basic sleep hygiene education

Pain Management Algorithm

Implement a stepped-care approach starting with education, progressing to specialist interventions, then multidisciplinary treatment. 1

Step 1: Education and Self-Management

• Provide educational materials encouraging activity and sleep hygiene 1
• Offer psychoeducation and self-management interventions 1

Step 2: Specialist Interventions (if Step 1 insufficient)

• Physical activity: Refer to physiotherapy for individually tailored graded exercise or strength training if patient cannot initiate activity independently 1
• Orthotics: Refer to occupational therapy for splints, braces, assistive devices, or ergonomic adaptations when pain impedes daily function 1
• Sleep interventions: Refer to specialized sleep clinic if disturbance persists after sleep hygiene education 1
• Weight management: For obese patients, refer to dietitian, psychologist, or bariatric services 1
• Pharmacological treatment: Use acetaminophen first-line, NSAIDs with gastroprotection if needed, opioids at lowest effective dose for shortest duration 3, 4

Step 3: Multidisciplinary Treatment

When multiple interventions are indicated or psychological distress requires comprehensive management 1

Pharmacological Considerations

NSAIDs (e.g., Ibuprofen)

Critical warnings 4:

• Increased cardiovascular risk: heart attack or stroke risk increases with dose and duration—avoid after recent MI or CABG
• GI bleeding risk: ulcers and bleeding can occur without warning, especially with corticosteroids, anticoagulants, SSRIs, SNRIs, alcohol, or smoking
• Pregnancy contraindication: avoid after 30 weeks gestation (premature ductus arteriosus closure); monitor for oligohydramnios if used 20-30 weeks beyond 48 hours
• Renal/hepatic monitoring: check CBC and chemistry profile periodically in long-term users
• Drug interactions: diminishes ACE-inhibitor antihypertensive effects

Interdisciplinary Coordination

Effective orthopedic care requires seamless coordination with multiple specialties. 1

Essential Team Members

• Physiotherapy: for exercise prescription and mobility training 1
• Occupational therapy: for orthotics, assistive devices, and ergonomic adaptations 1
• Nursing: for clinical coordination and patient education 1
• Social services: for addressing social determinants affecting recovery 1
• Psychology: for behavioral health management 1
• Primary care: for coordinating medical comorbidities and medication management 1

Quality Indicators to Monitor

Track these metrics for your service 1:

• Waiting times: referral to specialist evaluation interval
• Access: facility appropriateness for disabled patients including parking
• Audit participation: engage in hospital/regional clinical audit
• Protocols: establish monitoring protocols with primary care
• Outcome measurements: use validated, reliable, feasible measures
• Emergency mechanisms: clear pathways for urgent cases

Surgical Ergonomics and Self-Care

Work-related musculoskeletal disorders affect 37-97% of orthopedic surgeons during their careers, with 9-33% requiring leave, practice modification, or early retirement. 5

Prevention Strategies

• Use proper visualization aids (surgical loupes for spine cases) 5
• Employ robotic assistance when available (most effective for hip/knee arthroplasty posture and caloric expenditure) 5
• Minimize lead apron use when safely possible 5
• Use appropriate power tools correctly 5
• Limit operating room personnel during high-risk aerosol periods (intubation/extubation) 1

Evidence-Based Practice Limitations

Many common orthopedic procedures have limited high-quality evidence supporting their effectiveness. 1 Recognize that:

• Arthroscopic subacromial decompression has good evidence of clinical ineffectiveness, yet guidelines still recommend it for pure impingement failing conservative treatment 1
• Arthroscopic partial meniscectomy is not recommended for degenerative tears with osteoarthritis, but may be appropriate for specific traumatic tears after failed conservative management 1
• Hip replacement has overwhelming observational evidence despite limited RCT data 1

Infection Management Principles

For septic arthritis and osteomyelitis with subperiosteal collection 1:

• Anticipate operative surgery and ongoing inpatient management
• Minimize procedures—place PICC line at time of initial surgery
• Use single most useful imaging modality to limit exposures
• Consider at-home intravenous antibiotic treatment when feasible
• Reduce dislocations in emergency department when possible; manage as day surgery if admission required