A Chiropractor's Perspective of the Fracture Clinic
For the past 3 months, I have been shadowing Dr. Martin Roscoe at St. Joseph’s Health Centre in the fracture clinic and in the operating room. This has been an incredible learning experience for me! I have been able to see a multitude of patients with a variety of complaints, ranging from chronic conditions such as hip and knee osteoarthritis to acute injuries such as fractures and torn ligaments. I even had the opportunity to see some non-musculoskeletal conditions come through the clinic.
During my first few days in the fracture clinic, I was in awe of the volume of patients that we examined and the relative ease that orthopaedic surgeons have in quickly diagnosing patients. Seeing so many patients was an awesome learning experience because I was able to interact with more patients in one day than I normally would in a week of private practice. I also saw a wider variety of conditions including fractures, meniscal tears and ligamentous tears. After seeing patients with these injuries, I have a better appreciation for the laxity of joints with complete ligamentous tears and I have developed a focused physical examination to help determine when a fracture is present.
I was also surprised by how frequently radiographs (x-rays) were taken. Throughout my education at the Canadian Memorial Chiropractic College (CMCC) we were always taught to be careful when requesting an x-ray for a patient and to ensure that x-rays were being used to confirm a diagnosis or contribute to the management of a patient’s condition. This is because each x-ray exposes the patient to a dose of radiation which could, over time and with multiple exposures, cause long-term complications. While this is true, radiographic imaging is also a vital tool which aids medical professionals in confirming their diagnoses. Although there are a lot of radiographs taken in the fracture clinic, every one of them is taken with the purpose of confirming a condition or ruling out a sinister pathology. With the combination of my chiropractic education and hands-on training in the fracture clinic, I have a more thorough understanding of both when a patient should and should not be sent for radiographs.
I also found it interesting to compare and contrast the physical examination styles of Dr. Roscoe (an orthopaedic surgeon) and myself (a chiropractor). I’ll start off by saying that they were more similar than you might think. We both observe the patient’s area of injury and take a look at the big picture, looking at their entire body. We also observe their movement and get an understanding of their joint range of motion. We both palpate the affected area feeling for restriction, laxity, heat and swelling and then proceed with orthopaedic tests to feel if there is clicking, locking or laxity of the joint. The similarities in our history taking and physical examination often lead us toward the same diagnosis (which is a good thing!). However, there are differences between our physical examination style too. In general, orthopaedic surgeons determine if there is a fractured bone or a condition affecting the joints but they do not examine for other sources of pain. As a chiropractor, my physical examination also includes feeling for muscle tension and joint restriction. I also consider the nervous system to be a significant source of pain and examine the spine and peripheral nerves. Once we developed an understanding of each other he gave me the opportunity to do the new patient intakes at the fracture clinic. This was an amazing learning experience because it allowed me to go through my own clinical reasoning process and develop my own history taking and physical examination style.
During my time at St. Joseph’s Health Centre I have seen many patients experience significant improvements in their pain levels and quality of life. The treatments for these patients ranged from surgery, casts, rehabilitation exercises and reassurance that everything would be okay. But, I have also seen patients that haven’t gotten better. Some of these were not surgical candidates and some have had surgery but still experience pain. It is unfortunate for these patients because in a busy fracture room environment, the orthopaedic surgeon may not always have the time to further investigate the cause of their pain. In some cases, they may become lost in the medical system, unsure of their next steps to take. I think this gap in the medical system is a great opportunity for manual therapists such as chiropractors and physiotherapists to step into a key role. When a patient’s pain does not appear to be caused by the joint or when surgery has failed, these patients should be sent out of the hospital for a second opinion where conservative treatment may be initiated.
The other area, specifically for chiropractors to help, is when patients present to the fracture clinic with back pain or radiating/referred leg pain. Dr. Roscoe is an excellent orthopaedic surgeon that focuses primarily on lower limb surgeries. He recognizes when the patient’s pain is not caused by the joint but he often doesn’t have anywhere to send these patients. A chiropractor that works in the hospital or in conjunction with the hospital would be an excellent addition to the medical system. Chronic back pain is a frustrating condition for many medical doctors to deal with because they are not equipped with the tools or resources to properly treat it. Chiropractors specialize in treating back pain and treat patients with a holistic approach, looking at the entire body. There were numerous times during this placement where I would have liked to examine the patient's low back pain and treat them at the hospital, but obviously that was not what the intent of this placement.
Dr. Roscoe has been accepting sports chiropractic residents for years. We are truly grateful for everything he has given us and we appreciate his generosity and openness in allowing sports chiropractic residents to experience such a setting. Placements such as this allow us to gain a better understanding of the medical system and the education that orthopedic surgeons and other medical doctors have, but it also gives us the opportunity to showcase the knowledge that chiropractors, specifically sports chiropractors, possess. Once again, I would like to thank Dr. Roscoe and the St. Joseph’s Health Centre for allowing this placement to take place.
Thanks for taking the time to read my first blog and stay tuned for the next one!
Dr. Chris Grant