This morning, ortho M&M. It consisted principally of: DVT, PE, supratherapeutic INR, ad lib. And hardware failure/infection. They seem to have a pretty solid set of things that they keep going through over and over. Apart from the students, the only women in the room were two older PAs who work for the university orthopedic group. The rest – all guys, very large, very solid, very serious. Crazy.

Then, we went to the children’s hospital for a myelomeningocele clinic. They have it very cleverly arranged. Some 12 or 14 kids come every Wednesday, and have a room in the clinic. The whole team involved in their care – orthopedics, developmental pediatrics, neurosurgery, physical therapy, splint makers, and I don’t know who all else – is all there on that day, and takes turns rotating through their rooms. So they get all of this stuff done in one morning. The ortho doctors have priority, as they’re busiest; then the neurosurgeons, and the other doctors; the therapists shuffle around each other. In the afternoon our doctor had his own clinic at the children’s center; mostly fractures in various stages of healing. We got to watch a good many casts being put on, and my next step will be to ask if I can do a little bit of it.

Around noon, the resident was called to the ER to see a boy who had had his Achilles’ tendon transected in a freak accident. No other injuries, just one sharp cut, only 1 or 2cm across, right through the tendon; nothing else in the area damaged, but it was cut clean through. His Thompson test was definitively positive: relax the leg, then squeeze the gastrocnemius, and see if the foot plantarflexes (moves downward). His foot didn’t even twitch on that side, whereas you could see the normal reaction clearly on the other side. It’s too bad for him, particularly since he’ll have to miss this season of football, but it was extremely cool to see such a clear-cut example of a positive and unusual physical exam finding. (We senior students are now far beyond feeling guilty or caring for the patient’s inconvenience; we are solidly along with the residents in a ghoulish desire for unusual and severe pathology, so we can learn more about it.) That afternoon they made time for him, and took him to the OR, and incised up and down beside the tendon (giving the posterior tibial artery/nerve bundle a miss), and sewed the tendon firmly back together. He got a plaster cast (not fiberglass), which was wetter and messier and more fun. He’ll have to spend weeks have his foot gradually bent back to the normal ~90degree angle, so the tendon can heal together and not get re-ruptured by moving back too quickly.

Later on, the resident took us to see in the ER another boy (who looked about 25, but was only 16) who had been “wrestling” over a broken concrete surface, and torn his knee open. The only explanation we could think of was that he was drunk last night when it happened, because it was a huge injury, and there was concrete and grass inside it, and it was now extremely swollen, with pus oozing out. How anyone could think that would heal – without even trying to wash it out with soap and water – is unbelievable. They were going to fit him into the OR this evening, to wash it out in depth, and put a couple loose sutures in. I figured that case wasn’t worth staying for – I’m trying to study now – but I did ask the attending to call me if any “real” emergency cases come in. He’s on call the next three nights for the children’s hospital.

The fracture clinic was the best part of ortho so far. That’s something I’d like to get a basic handle on, when people need to be splinted, when they need a cast, when they need surgery, and how to put the cast on. The techs go so fast, whipping the bandages around and slapping the plaster on. Shp, shp, you’re done.

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