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REVIEW: Procedures Consult – Musculoskeletal (for iPhone)

12/5/2009 by Dr. Jessica Otte, Dr. Ottematic

In my Residency program, we have a 3 week rotation specifically in Musculoskeletal (MSK) things; most of this time is spent at the office of a local Orthopaedic Surgeon (“orthopod”) who does not do major surgeries but rather many physical examinations and small procedures like joint injections and aspirations. We also spend time at the cast clinic with the orthopods and plastic surgeons, practice reading plain films in radiology, and spend time with a sports medicine doc in town. This means lots of procedures!

Don’t let the “Internal Medicine” part of the title throw you – there aren’t a lot of General Internists who would be doing these procedures on a regular basis. More likely, Rheumatologists (a sub-specialty of Internal Medicine concerned with disease of the joints and connective tissues), ER docs, small town GPs, sports medicine specialists, and orthopedic surgeons will be the ones sticking needles into joints; and ER doctors will be the ones reducing dislocations and splinting things. However, on occasion, other types of physicians may need to aspirate a possibly septic joint on the ward, throw on a splint on something, or reduce a painful dislocation before referring a patient to another caregiver.

As a Family Practice resident, who may work rurally or overseas, I’m planning on being able to do some of these basic procedures on my own. That’s where the software comes in. A very simple opening screen hides a wealth of information. Behind it lies almost everything you ever wanted to know about 22 common MSK procedures, namely joint aspirations (athrocentesis), dislocation reductions, and splinting of the various upper and lower extremity bits and bobs, including:

• Arthrocentesis: Ankle
• Arthrocentesis: Elbow
• Arthrocentesis: Knee
• Arthrocentesis: MCP
• Arthrocentesis: MTP
• Arthrocentesis: Shoulder
• Arthrocentesis: Wrist
• Coaptation Splint
• Dislocation Reduction of the PIP & DIP Joints
• General Splinting Techniques
• Long Arm Splint
• Long Leg Splint
• Short Arm Splint
• Short Leg Splint
• Sugar Tong Splint
• Thumb Spica Splint
• Ulnar Gutter Splint
• Dislocation Reduction of the Ankle
• Dislocation Reduction of the Elbow Joint
• Dislocation Reduction of the Hip Joint
• Dislocation Reduction of the Patella
• Dislocation Reduction of the Shoulder Joint

So, will this software do the trick? Each of the 22 procedure sections are layed out similarly, with Pre-Procedure considerations (indications, contraindications, equipment list, and anatomy review), Procedure information (photos for patient positioning along with a video, step-by-step instructions, and the all-important procedure video with clinical pearls), and Post-Procedure care and complications explanation. The multimedia approach is definitely great for my – and I think most peoples’ – learning styles, and it does not occur at the expense of needing an active Internet connection. That’s right – this is a totally standalone app!

The procedures I’ve done most recently in clinic or the ER are knee aspirations, hip dislocation reductions, and an ulnar gutter splint. Exploring these specifically, I found the software gave me a more technical and precise approach than I remember being instructed with at the bedside. However, I think the “do one” stage is where the real learning occurs, as many of these procedures depend on certain tactile feedback to know how to find the joint capsule, how much force to use on that hip prosthesis, or how to mold the splint. That said, it’s always nice to go into a new situation armed with a bit of knowledge, or to refresh one’s memory if it’s been a long time since seeing, say, a posterior shoulder dislocation.

The preamble to each procedure is a quick read but covers the critical points; the integration of a little deep and surface anatomy review is a helpful feature for those in need.  It’s nice to see such attention paid to the preparation stages as well, as proper set-up can often make the success of the procedure. The videos demonstrate the important points clearly and are generally well-paced; they could easily be watched while the patient is changing for the procedure. I found the post-procedure sections might be too vague for newcomers, with statements like “monitor for infection” (are there guidelines for follow-up for this outpatient procedure?). Also, there are no reminders as to what to specify on the lab requisition or any basics about synovial fluid analysis which would help guide treatment after athrocentesis.  Likewise, the follow-up for splinting is nonspecific, lacking critical information like the average duration that the splint must remain in place, or when repeat radiography should be performed.

This truly is a Procedural competency software; you can get the job done safely and sleekly with the clear instruction provided – you just might not know what to do afterwards!