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Orthopaedics Decision Making - Application of basic biological Facts

*Dr Pankaj Kumar

Address for Correspondence
Dr Pankaj Kumar
Asst.Profesor, Department of orthopedics,
B.P.Koirala Institute of health sciences, Dharan, Nepal
Phone: +00977-25-525555-3260,2016

J.Orthopaedics 2006;3(3)e1

Importance of decision making-

  • Gives a broad idea about the expected outcome of the condition

  • Gives a direction to the treatment plan

  • Avoids delay in the definitive treatment

  • Utilizes the biological favorable opportunity at the right time

Decisions in Clinical Orthopaedics are increasingly being subjected to legal scrutiny and must be based on evidence (Data) rather than conjunction to avoid adverse judgments in a court of law. Timing of decision-making is very important. It should not be too hasty. It should not be too much of delay and avoiding to decide.  Thorough and relevant clinical examination is very important to establish a clinical diagnosis or an etiological diagnosis. It is very important to assess the situation whether you are dealing with OPD or emergency patients. Before decide any treatment modalities, observe the patients during his way, analyses gait (if patients able to walk). That is the best time to analyses the gait, because   analysis of   the gait while asking him/ her on a straight line his/her is to conscious about his problem, the waking pattern will be confusing. Carefully listen to the patients. Don’t irritate.

In Urgency of situation decision-making should be too early. what to do?  After through relevant clinical examination advice relevant and feasible investigation and best modalities of treatment. To establishing the etiology, assess in your mind the basic cause of the condition. Whether this is congenital, infective / inflammatory, traumatic/superimposed trauma, neoplastic or others. Are you sure about your diagnosis? If YES- plans the definitive treatment and if not, at least decide the broad categories. Whether this is infective or neoplastic, traumatic or infective, Congenital or acquired or lastly localized or generalized? After these entire basic thing in your mind. Decide to investigate. Your investigation should be confirmation of diagnostic suspicion, and assessing the biology of the condition. It is better to choose most relevant, simplest investigation that is X-ray? Right down precise requisition. The management decision upon the when diagnosis is clear.

When the diagnosis is unclear. How long to delay the decision-making? It possible to pinpoint a decision in every situation? Immediat or present plan and lastly, what are your ultimate target? If you are decided to treat. Which modalities you are preferring? Whether conservative or operative. Basic thing is to conserve the function of the limb. Whichever modalities are deciding to restores the best of function in optimum time frame or a combination of the two.

The basic thing that must be MASTERED-through knowledge of the relevant anatomy of the area, biology of basic inflammatory processes as applied to the particular area, consequences of scarring in the area and local mechanics of the bone and concerned joint. You should know the functional demand on the area for each patient, decision of essential components of function (stability v/s mobility) and effect of growth in case of children (favorable/unfavorable). Lastly you are “knife happy” orthopaedician or “plaster happy” orthopaedician or middle path. Newer generation orthopaedician are behaves like a monkey, if you will give knife in his hand, He will cut any thing? So, when to withhold the knife- when the biology is tremendously in favors of the patient, when the organ system and or the tissues will not tolerate the surgical insults and tissue response is uncertain. When to operate- An unfavorable biology can be made favorable e.g.- intra-articular fractures, helping the biology to run the natural course- drainage of an abscess, realignment of an area for cosmetics reasons. Principle v/s the procedure- surgical procedure that utilizes and reinforces the biology of the tissue response-good results, procedures that depend on mechanics alone with lesser consideration to the biology-questionable results, you own experience of tissue behaviour.

What should be the your choice of procedures-affordability/economics of treatment, trendy surgery. What should be the common targets of both modalities of treatments-Restoration of stable, painless, mobile limb without deformity, prevention of delayed complications and secondary changes and prevention of reactivation of the disease process? What should be therapeutics in Orthopedics? Are orthopaedician are bad physician? Where do you need drugs? Pain relief, Infection prevention and control, disease specific drugs and sedatives. Other supportive drugs as antiosteoporotic, antihypertensives, antitubercular, antihelminthics and calcium and vitamin-D derivatives.

Lastely know your basic well and keep them update, don’t try to fitting a patient in to a book chapter, use individual judgement, analyze the facilities, surgical expertise, ancillary services and related social factors, no hasty decision but do not delay unnecessary, think definitive, symptomatic treatment cannot be continued indefinitely.

Remember decisions fail even the most experience surgeons. TISSUE BIOLOGY IS THE ULTIMATE DECISION MARKER, GO WITH IT.


This is a peer reviewed paper 

Please cite as : Pankaj Kumar: Orthopaedics Decision Making - Application of basic biological Facts

J.Orthopaedics 2006;3(3)e1





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