Table Of ContentOrthopaedic Disorders in General
Practice
Richard L. M. Newell, BSC, MBBS, FRCS
Consultant Orthopaedic Surgeon, North Devon District Hospital, Barnstaple, and
Princess Elizabeth Orthopaedic Hospital, Exeter
Royal College of Surgeons Surgical Tutor, North Devon
Julian G. Turner, MBBS, MRCGP, DObstRCOG, DCH
Principal in General Practice, Barnstaple, North Devon
Course Organizer, North Devon Vocational Training Scheme
Examiner, Royal College of General Practitioners
Butterworths
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First edition 1979
British Library Cataloguing in Publication Data
Shabalin, E P
Fast pulsed and burst reactors.
1. Pulsed reactors 2. Fast reactors
I. Title
621.48'34 TK9203.P8 79-40428
ISBN 0-08-022708-2
Translated from
published by Atomizdat, Moscow, 1976
in order to make this volume available as economically
and as rapidly as possible the author's typescript has
been reproduced in its original form. This method un-
fortunately has its typographical limitations but it is
hoped that they in no way distract the reader.
Printed and bound in Great Britain by
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Preface
In Great Britain, about a quarter of all consultations with general
practitioners concern locomotor problems. The Duthie Report (1981)
on Waiting Time for Orthopaedic Out-Patient Appointments and
In-Patient Treatment has recognized the widespread lack of
understanding in general practice of the natural history of the
commonly encountered locomotor problems and of the indications
for orthopaedic operations. The Report attributes this lack of
understanding first to inadequate undergraduate and postgraduate
training in orthopaedics, and secondly to inadequate communication
between general practitioners and their consultant orthopaedic
colleagues.
The stimulus which led the consultant orthopaedic author to write
this book was the spectre of an ever-increasing out-patient waiting list
despite the conscientious efforts of all members of the hospital
orthopaedic teams. Within a year or so of his appointment as the
second orthopaedic surgeon in a geographically fairly isolated area
with a well defined catchment population, the number of patients
awaiting their first appointment began to increase exponentially,
creating alarm in the community both lay and medical.
Prevented by prevailing circumstances, staff and facilities,
discouraged by his judgement, and by experience of Parkinson's Law
from increasing the size or numbers of his orthopaedic clinics, he
began to seek alternative methods of reducing the backlog. In essence
this entailed reducing the quantity, and improving the quality (or
appropriateness) of referral from his general practitioner colleagues.
The publication of the Duthie Report helped to crystallize his thoughts
and ideas, reinforce his opinions regarding the main source of the
problem and its suitable remedy, and at the same time increased his
awareness of the general prevalence of the problem of waiting-time
for out-patient appointments throughout the United Kingdom.
Attempts at local postgraduate education in orthopaedic surgery for
general practitioners on a formal basis met with discouraging
response, although informal discussions with general practitioner
colleagues were rewarding and potentially valuable.
vi Preface
In addition, the author has become steadily more aware of the
increasing demands upon his time from operative surgery both in
elective orthopaedics and in trauma. With the increasing age of the
population and the development of new and promising but time-
consuming forms of operative treatment, the relative proportion of
the orthopaedic surgeon's time spent in the operating theatre to that
spent in the out-patient clinic will need to increase. It is consequently
even more important to ensure that the time which he is able to spend
seeing out-patients is used to the maximal benefit of those patients.
This places upon the general practitioner the onus of selection of those
patients for whom specialist orthopaedic referral is either essential, or
definitely likely to resolve their problem, and return them to health
and to work more quickly and efficiently than will occur in the absence
of such referral.
This book is therefore intended primarily to help 'the customer' —
the patient with an orthopaedic problem — by helping his family
doctor to solve his problem with the maximum of efficacy, the
minimum of morbidity and the minimum of delay.
R.L.M.N.
'My doctor was useless; he just gave me pills which made me feel ill.
The specialist said I didn't need any operation and that no treatment
was necessary. He offered me physiotherapy, but I wasn't trudging up
to the hospital three times a week. My friend recommended an
osteopath who had cured her back trouble with one treatment. He was
very nice; I only needed to go three times, and I was better. I'd still be
going to the hospital if I hadn't seen the osteopath. He said I had three
bones out of place, and it was a good thing I had come to see him.'
This familiar story reflects the dilemma of providing adequate care
to patients complaining of orthopaedic problems, interspersed as
these are with tendencies to:
— spontaneous resolution with time.
— significant degrees of psychological overlay.
— lack of knowledge and skill by GP's in the management of soft
tissue orthopaedic disorders.
— unhelpful attitudes of orthopaedic consultants.
— unrealistic expectations of cure from patients.
— alternative practitioners providing adequate relief and 'apparent'
cure.
— therapeutic effect of a fee for service!
This confusing situation is a potent cause of widespread
dissatisfaction.
— GP dissatisfaction at demanding patients, with unrealistic
Preface vii
expectations, pressurizing them to be referred, with the
constraints of time discouraging the GP from exploring further
their health beliefs, and the effects that the problem creates for the
patient in functional and psycho-social terms. Early referral is the
result, reinforcing patients' future expectations of 'prompt'
referral.
— Consultant dissatisfaction at 'inappropriate' referral, wasting his
time and extending the waiting list still further. He is a surgeon,
largely by choice and competition, feeling most comfortable in
areas where diagnosis and treatment, preferably surgical, is well-
defined. He did not enter orthopaedic surgery to see patients who
manifestly do not need operation, and whose prolonged
morbidity has a largely psychological basis. He is uncomfortable
and untrained to cope with 'grey' areas, which leaves him
primarily concerned with his feelings and not with those of the
patient. The effect of cursory reassurance results in the prompt
discharge of a discontented patient back to the GP, accompanied
by a brief note. Furthermore the perpetuation of a long out-
patient waiting list can be a useful resource for the specialist as it
means that:
(a) Most patients' problems will have resolved spontaneously by
the time for appointment.
(b) The referring GP may be discouraged from repeating such
'prompt' referrals.
(c) General practitioners, whom he has consciously declined to
join, have confirmed their incompetence in dealing with
everyday orthopaedic problems.
Which justifies his attitudes and obviates any need for change.
— Patient dissatisfaction at NHS facilities, with GP's not being of
'much help', and surgeons being reluctant to wield the healing
knife. Their worries have not been discussed, or their expectations
met. They seek alternative advice, reinforced by apocryphal tales
of miraculous care by osteopaths, acupuncturists, homeopaths
etc., who are regarded by the more vociferous of the general
public to be the bearers of the banner of 'holistic' medicine;
perhaps, not without justification, when one considers the
attitude of the medical profession to the chronic back pain
sufferer!
The GP author has thus been concerned both as a principal at
unsatisfactory consultant orthopaedic service, and as a trainer/course
organizer at the inadequacy of postgraduate training in the
recognition and management of common locomotor disorders.
J.G.T.
viii Preface
This book attempts to reduce the scale of the problem by aiming to:
1. Improve GP's problem-solving skills.
2. Highlight the influence of non-physical factors on the
presentation and outcome of orthopaedic problems.
3. Rationalize the use of consultant opinion.
The contents of the book consist of two main sections:
1. Defining general principles of diagnosis and management
(Chapters 1-7).
2. Problem orientated approach (Chapters 8-14).
The decision to write separate Prefaces was mutually agreed by us
from the outset. We wished to illustrate the differing stimuli which
made us aware of the need for this book, and to indicate our individual
opinions of remediable deficiencies in the service to the patient as seen
from our separate professional viewpoints. This physical separation
of our views in no way indicates disagreement either in our aims for
the book, or over its contents.
R.L.M.N
J.G.T.
Acknowledgements
The authors are grateful to Mrs. J. Hillson for her invaluable help in
typing the manuscript, and to Mr R. H. Beattie, solicitor, for his
important contribution to our Medicolegal chapter. They would also
like to thank their wives and children for their patience and
understanding while the book was being written.
ix
Chapter 1
A Framework for Orthopaedic
Consultations
When patients present to their general practitioner with orthopaedic
problems, the basic techniques and process of consultation are no
different from if they presented with non-orthopaedic problems. The
doctor is therefore, involved in:
1. Defining the problem by:
(a) Defining the reason for attendance.
(b) Exploring the patient's health beliefs by determining
(i) the ideas that the patient has already formed of the
nature, cause and significance of their symptoms;
(ii) the effect that their symptoms have had on them;
(iii) the implications of these beliefs on their future health
and life-style.
(c) Considering 'at risk' factors, e.g. job, sport and other
continuing problems.
(d) Carrying out relevant examination.
(e) Deciding whether he can diagnose the condition accurately,
given the resources available to him, and whether the making
of an accurate diagnosis will influence his immediate
management.
2. Defining the solution by:
(a) Deciding whether he can by treatment, improve upon the
natural history of the condition, and whether such treatment
and the specialist referral which it may involve is needed
urgently.
(b) Explanation of the problems, in terms understandable to the
patient, especially with regard to diagnosis, seriousness, the
nature of treatment available, and the prognosis.
(c) Exploring the patient's expectations and/or suggestions on
management.
(d) Agreeing management with the patient, and establishing that
they understand both its nature and implications.
(e) Reinforcing health education, especially with regard to
l
2 A framework for orthopaedic consultations
physical fitness, although this will be largely dependent on
self-motivation, family, and work circumstances,
(f) Attempting to modify health-seeking behaviour, e.g.
allowing adequate time for natural resolution of 'back pain'
prior to consultation.
Chapter 2
The History
'Let a patient talk and he will make his own diagnosis'
George Perkins Foundations of Surgery, 2nd edn. Livingstone,
London (1962)
1. On taking a history from the patient, the doctor needs to know:
(a) Why has he presented?
(b) Why has he presented now?
(c) What does he believe the problem to be?
(d) What does he expect?
While listening to the patient, attention should also be paid to the
type and appropriateness of his mood, and to the form and
content of his conversation.
2. The patient should be encouraged to explain how the presenting
problem affects:
(a) His work — which may be important in the cause of the
problem.
(b) His family life.
(c) His leisure.
3. Enquiry should be made for any:
(a) Past history of injury or recent/significant illness.
(b) Relevant family history.
The main Orthopaedic symptoms' fall into four groups:
1. Pain.
2. Loss of mobility, possibly leading to loss of the patient's
independence.
3. Deformity or alteration of body image, including the
presentation of musculoskeletal swellings or lumps.
4. The neurological presentation.
Pain and its assessment
The doctor must initially decide whether the pain is 'orthopaedic' or
musculoskeletal in origin, or whether it originates in another system,
e.g. cardiovascular or renal.
3
