1Topic 3.7 Orthopaedics Overview & Cases AVMO 0019 (Cable)

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  1. Learning Objectives?
    • • Discuss the aeromedical implications of musculoskelatal disorders with respect to:
    • • The impact of the condition on the operating environment
    • • The impact of the aviation environment on the condition
    • • Immediate fitness to fly
    • • Outline what clinical information is required, including investigations and referrals, for determination of aeromedical disposition.
    • • Describe the aeromedical implications of possible treatments for musculoskeletal disorders.
    • • Discuss prognostic considerations that may impact on future fitness.
    • • Propose a likely MECR process and aeromedical disposition for musculoskeletal disorders.
    • • Apply an evidence-based aeromedical decision making framework to the aeromedical management of disorders affecting the musculoskeletal system.
  2. Effect of the Environment on Orthopaedic Conditions?
    • • Increased pain
    • • Vibration
    • • PPE (G-suit, harness, helmet)
    • • Posture
    • • +Gz
    • • Risk of further injury
    • • Physical nature of tasks
    • • Ergonomics
    • • Anthropometry
    • • Uneven surfaces (rollers etc)
    • • Ejection
  3. Effect of the Condition on Aviation Operations?
    • • Casts, external fixation or other splinting
    • • Functional ability
    • • Pain
    • • Weakness
    • • Decreased ROM and reach
    • • Decreased mobility – emergency egress
    • • Ability to operate controls fully
    • • Medication
  4. FLTLT Lisa Pilatus Internal Fixation Fractured Femur?
    • • What environmental factors are relevant to her condition
    • • How could the condition impact on her role
  5. Environment vs Condition?
    • • Ejection
    • • +Gz
    • • Vibration
    • • Ingress/egress
    • • Rudder forces & deflection
  6. Condition vs Aviation?
    • • Pain
    • • Strength
    • • Mobility
    • • Managing medications
    • • Risk of further injury
  7. Obtaining Clinical Information?
    • • Aim to:
    • • Establish the diagnosis
    • • Identify aviation-relevant factors
    • • Determine risk of incapacitation
    • • Quantify risk of progression or recurrence
    • • Determine impact of treatments on aviation safety
  8. Obtaining Clinical Information?
    • • Current pain levels
    • • Pain during performance of duties: Distraction?
    • • Level of function
    • • Strength, ROM
    • • Consider functional assessment – rudder operation, emergency egress, access all controls?
    • • History of previous trauma/surgery
    • • Previous injuries: risk of recurrence?
    • • Medication use
  9. FLGOFF Douglas McDonnell?
    • • 26 y.o. F/A-18 pilot.
    • • Injury to left shoulder playing rugby 1 week ago.
    • • Relocation of anterior dislocation performed in ED under sedation.
    • • He states the shoulder “feels fine now”.
  10. Referrals and InvestigationsInformation and reports required to make an aeromedical decision & process a MECR?
    • • Imaging – dependent on type of injury – to assess severity, treatment and healing
    • • Plain XR, US, MRI
    • • Physiotherapy referral & report
    • • Orthopaedic surgeon review
    • • Rheumatology report
    • • Neurology report: nerve conduction studies
    • • Functional assessment in aircraft
  11. Referring to specialists?
    • • Ask specific questions
    • • What is the diagnosis
    • • What is the % risk of incapacitation per year
    • • What is the prognosis and risk of recurrence
    • • What treatment, and what side effects
    • • What follow-up or monitoring is required
    • • DO NOT ask if they are fit to fly
  12. • What referrals do you arrange?
  13. • What questions do you ask?
  14. • What results do you need?
  15. WOFF Pallett: C130J Loadmaster?
    • • Painful right knee for 12 months
    • • Medial compartment OA found on arthroscopy
    • • Paracetamol, glucosamine, NSAIDS
    • • Now:
    • • Decreasing mobility
    • • Limping, genu varus.
  16. Treatment Considerations?
  17. Will treatment of the condition impact on function in the aviation environment?
    • • Conservative
    • • Recovery/immobilisation period may be long
    • • Risk of recurrence
    • • Medication: analgesics, NSAIDS, steroids, neuromodulators
    • • Surgical interventions: Internal fixation, external splinting, reconstruction, replacement
    • • Physical therapy/rehabilitation
  18. TMU?
    • is not required for occasional OTC use to provide relief from minor self-limiting conditions.
    • No combination medications containing codeine are to be used for this purpose.
  19. TMU?
    • is not required for occasional OTC use to provide relief from minor self-limiting conditions.
    • Paracetamol is preferable as there is less risk of gastric irritation.
    • No combination medications containing codeine are to be used for this purpose
  20. WOFF Pallett: C130J Loadmaster?
    • • What are the implications of medical treatment?
    • • What are the implications of joint replacement?
  21. Prognostic Considerations?
    • • Risk of subtle incapacitation
    • • Risk of acute incapacitation
    • • Risk of progression
    • • Risk of recurrence
    • • Likely future treatments
  22. Prognostic Considerations
    • • Very dependent on the type and severity of condition or injury
    • • Case-by-case consideration
  23. Aeromedical Disposition?
    • • Highly variable, condition dependent.
    • • TMUFF until pain resolved, casts, external fixateurs removed and function returned.
    • • Expect to return to flying if no permanent deficit.
    • • Case by case using evidence-based ADM process and risk management.
  24. Summary Likelihood of clinical event?
    • •Pain, ROM, strength
    • •Vibration, ejection, +Gz
    • •Physical nature of job
    • Determined from:
    • •Examination
    • •Investigations
    • •Specialist reports
    • •Functional assessment
    • •Evidence
  25. Low back pain?
    • • Common finding in general population but more so in aircrew population:
    • • Helo pilots 26.5%, transport 31.5%, FP 25.2%
    • • Associated with flight:
    • • Helo pilots 34.5%, transport 5.1%, FP 12.9%
    • • Helicopter pilots more at risk of back pain in flight
    • • Risk factors: poor body position, vibration
  26. Aeromedical Concerns?
    • • Will the aviation environment impact the condition?
    • • Vibration
    • • Nature of duties, eg. Lifting
    • • Prolonged sitting
    • • Posture while flying
    • • Anthropometry, the “helicopter hunch”
    • • Work station ergonomics
    • • +Gz
    • • Ejection
    • • Will the condition impact on the aviation environment/operation?
    • • Pain, weakness, decreased ROM, medication
    • • 64% of ADF helicopter pilots reported back pain
    • • Further 28% reported back pain while flying
    • • 55% mission interference rate
    • • 7% refused to fly because of back pain
  27. Important Clinical Information?
    • • Role and aircraft type
    • • Contributing factors – eg. obesity
    • • Severity
    • • Loss of function
    • • Presence of radiculopathy
    • • Analgesia
  28. Investigations and Referrals?
    • • Exclude other causes of LBP – eg. ankylosing spondylitis, malignancy
    • • Imaging only to exclude “red flags”
    • • Physiotherapy
    • • Lumbar supportsjQuery1101051351157997709_1488026966087
  29. Treatment Considerations?
    • • Medication requirements
    • • Analgesics
    • • Anti-inflammatories
    • • Use of lumbar supports
    • • Physical therapies
  30. Prognostic Considerations?
    • • Ongoing deterioration is likely
    • • May result in UAMECR/IAMECR
    • • Can be career ending if chronic or severe
  31. Aeromedical Disposition?
    • Military
    • • TMUFF during initial workup and exacerbations
    • • Significant back pain is disqualifying for transfer/recruitment
    • • Outcome of MEC depends on severity and treatment
  32. CASA?
    • Most cases fit for certificate unless debilitating and any disqualifying medications
  33. Neck injuries and +Gz?
    • Anonymous FCI WGCDR F/A18 pilot
    • Condition Overview
    • • Neck pain associated with exposure to high +Gz levels and specific risks:
    • • Dynamic force environment
    • • Visually-based situational awareness
    • • +Gz forces when head is in unfavourable positions, eg “Check 6”
    • • Support for head-helmet-mask, NVG, HMS&D
    • • ACM
    • • 85% reported neck injuries associated with flying (n=52)
    • • Injuries were strains, involving pain and stiffness. No serious injuries.
    • • 4% had a neck injury with every flight
    • • 12% had neck pain with every high G flight (>+5 Gz)
    • • Mild-to-moderate pain was the most common
    • • Most treated with NSAIDs and/or physio
    • • 17% taken off flight duties due to neck injury
    • • Average grounding 2 weeks (range 3 days - 3 months)
    • • 38% reported interference with mission completion
  34. Types of Injury?
    • • Musculoskeletal pain, common
    • • “Burners and Stingers”
    • • Disc bulges
    • • Acute spinal injury rare
    • • Degenerative changes (arthritis)
    • • Common & recognised occupational risk
    • • Studies show association between exposure to sustained G and degenerative changes
  35. Biomechanics 1?
    • • Designed for head mobility
    • • Strength sacrificed for mobility (compare cervical spine with lumbar spine)
    • • Able to withstand high static loads
    • • Not so good at high dynamic loads
    • • Head C of G is forward of vertebral column
    • • Erector spinae (extensors)intrinsically strongest
    • • Average head mass = ~4 kg
    • • Weight of head at 7.5Gz =30kg but neck muscles best- adapted to supporting 4kg
  36. Pathophysiology?
    • Exposure to:
    • • Repetitive axial loading
    • • On-axis vs. off-axis exposures
    • • Acute musculo- tendinous injury
    • • Repetitive micro-injury
    • Leads to:
    • • Nervous tissue pressure/ stretch
    • • pain +/- radiation
    • • dysaesthesia
    • • Disc trauma and ageing
    • • Chronic degenerative change
    • • Vertebral osteophytes
    • • Disc degeneration
  37. Risk factors for Injury?
    • • +Gz exposure (peak, rate of onset, repetition)
    • • Unprepared
    • • Movement out of neutral posture (axial support)
    • • Fatigue &/or pre-existing injury
    • • “Check six” at extreme of head rotation and extension (high peak forces)
    • • Helmet assembly weight (mask, HMD etc).
  38. Neck Injury Prevention?
    • • System
    • • Screening
    • • Lightweight helmets
    • • Attachments
    • • Fitness and training – G Fit
    • • General – aerobic / anaerobic
    • • Core - upper body strength
    • • Neck - generic isometric or physio specific
    • • Pre-flight
    • • Stretch
    • • Warm up
  39. Ejection Injuries?
    • • +Gz medium duration acceleration
    • • Compressive force on axial spine
    • • Dynamic overshoot
    • • Windblast
    • • Opening shock
    • • High descent rate, ground impact
  40. A Reminder: Range of Injuries?
    • • Vertebral crush fractures:
    • • Lower thoracic, upper lumbar
    • • Femoral fractures
    • • Mandibular fracture
    • • Sternal fracture
    • • Cervical flexion injuries
    • • Shoulder dislocations
    • • Lower limb/other injuries on landing
  41. Aeromedical Concerns?
    • Environment vs condition
    • • Further ejection
    • • Prolonged +Gz
    • • Prolonged sitting
    • Condition vs aviation
    • • Chronic pain
    • • Mobility
    • • Medication?
  42. Investigations and Referrals?
    • • Information and reports required to make an aeromedical decision/process a MECR
    • • Imaging
    • • Orthopaedic review
    • • Functional assessment
    • Prognostic Considerations
    • • Once healed – unlikely to experience acute exacerbations
    • • Re-fracture highly unlikely
    • • Ejection seat aircraft not contra- indicated
  43. Hand pain: 40yo C130J loadmaster?
    • FSGT Jones presents with increasing hand pain.
    • The pain seems to have been gradually getting worse over a period of a couple of months.
    • Her pain started in her (dominant) right hand. She describes it as a “tingling” sensation which increases in severity until it
    • becomes painful.
  44. Further history?
    • • It seems to affect her mostly at night and is now starting to impact her sleep. In the past week she has noted similar symptoms in her left hand – hence her presentation today.
    • • She also notes that her hands have been feeling “clumsy” at work – she has had some difficulty operating tie-down straps and levers in the aircraft as a result. She finds that if she shakes her hands, this gives her some relief.
    • • PMH reveals a fit and healthy 40yo woman who takes no regular medications and has NKDA.
  45. Examination?
    • • General examination is NAD
    • • Examination of the hands is normal other than Phalen and Tinel tests which are both positive.
    • • The FSGT demonstrates that the areas shown below are most affected by her symptoms.
    • • What are the important aspects of history that will help you decide on an initial aeromedical management plan
    • • What is the
    • • impact of the condition on the operating environment
    • • impact of the aviation environment on the condition
  46. What now?
    • • You correctly diagnose carpal tunnel syndrome in both hands.
    • Based on your aeromedical deliberations about her operating environment and the effect of the condition, you decide to make her TMUFF.
    • • What investigations and referrals, if any, do you think are necessary at this point
  47. Managing the case?
    • • Referral to a neurologist for nerve conduction studies confirm delayed median nerve conduction consistent with carpal tunnel syndrome bilaterally.
    • • What treatment strategies would you consider and what are the aeromedical implications of each of these?
  48. Definitive treatment?
    • • You trial a variety of conservative management techniques such as physio, OT, NSAIDS and US guided steroid injection over a couple of months, with little success. The FSGT returns stating that she is “fed up” with the symptoms and wants to try something more definitive.
    • • The patient decides to undergo surgery.
    • • What is the MECR process required and what is the likely aeromedical disposition post-operatively
  49. Acute painful knee – CO Hornet SQN?
    • • 45yo WGCDR Martin Baker presents with an extremely painful right knee
    • • He woke with the pain this morning, yesterday he was fine.
    • • What are the important aspects of history and examination that will help you decide on an initial management plan?
  50. History?
    • • On further questioning, WGCDR Baker tells you that he is the CO of the Hornet SQN and flies at least one sortie per week – he believes this is an important part of his role as CO.
    • • He describes his pain as intense and his appearance supports this.
    • • He is having great difficulty moving the knee.
    • • He has never had anything like this in the past.
    • • He denies any recent trauma.
    • • He is otherwise well. J11 A1
  51. Examination?
    • • T 37.3 BP 150/90 PR 95
    • • Examination reveals a hot, intensely painful right knee
    • • All other joints are NAD
    • • Limited ROM in right knee due pain
    • • Overlying skin is red and hot
    • • FBC
    • • WCCs Mildly raised (neutrophils)
    • • ESR moderately raised
    • • CRP normal
    • • Serum uric acid – borderline high
    • • Anything else?
  52. What now?
    • • What is your most likely diagnosis
    • • What is your immediate administrative/occupational management plan
    • • Are any further investigations or referrals required
  53. You aspirate the joint?
    • • Sterile
    • • Monosodium urate crystals observed on microscopy
    • • Confirms your suspicion of gout
    • • What is the impact of the condition on the operating environment of this pilot?
    • • What is the impact of his working environment on the condition?
  54. What now?
    • • What is your immediate clinical management plan?
    • • What other manifestations or consequences of your diagnosis are relevant in this case?
    • • What are the aeromedical implications of the treatments you might choose?
    • And what of the future?
    • • You ensure that the CO is TMUFF while he is acutely symptomatic and you commence treatment.
    • You also decide to explore lifestyle issues that might be relevant to his diagnosis.
    • • What prognostic factors might be relevant to his ongoing aeromedical fitness?
    • • What MECR procedures might be required in this case, and what do you think might be the outcome?
  55. Back Pain in a Pilot Trainee?
    • • 19yo OFFCDT Bernoulli presents to you complaining of lower back and hip pain. The pain seems to have been gradually getting
    • worse over a period of a couple of months.
  56. History?
    • • On further questioning, he tells you that he is a Direct Entry pilot applicant who has not yet commenced training at BFTS. Until this last month, he has been in a holding pattern, working as the OPSO at 77 SQN. He started ground school 4 weeks ago and is scheduled for his first flight tomorrow.
    • • He would like to know if you can prescribe something for the pain (ibuprofen has proven effective) as it starting to affect his concentration.
    • • His pain is not disabling and is centred in his lower back.
    • Sometimes he feels it radiating to his hips. Other aspects you elicit include:
    • • Insidious onset – no history of injury or trauma
    • • Seems to be some improvement with exercise
    • • He says he ceased his normal physical activity for 2 weeks but did not notice any improvement and has, therefore, restarted his exercise
    • • Pain at night – disturbing sleep – routinely takes 400mg ibuprofen nocte with good effect.
  57. • What is your immediate administrative/occupational management plan?
  58. History?
    • • PMH reveals a fit and healthy young man who takes no regular medications (other than the prn ibuprofen). He has only had one visit to hospital in the past. He cannot remember the diagnosis but states that he had a sore,
    • red eye. He was prescribed some drops and it cleared up without further problems. On further questioning he states he did not mention this episode during the recruitment process as he did not think it was relevant – his VA has always been 6/6 bilaterally.
    • • What are your current DDx and what investigations, if any, are necessary to help narrow it down
  59. What now?
    • You arrange for an x-ray – as shown here
  60. A positive clue?
    • • Blood tests are normal with the exception of a mildly elevated ESR and positive HLA-B27.
    • • What is the impact of the likely condition on the operating environment of this pilot?
    • • What is the impact of his working environment on the likely condition?
  61. What else?
    • • What other manifestations of your diagnosis are relevant in this case?
    • • Are there any further referrals or investigations that you would need to
    • organise at this point?
  62. Diagnosis confirmed?
    • • A rheumatologist confirms the diagnosis of ankylosing spondylitis, with no other extra-articular manifestations.
    • An ophthalmology report reveals no ocular problems at this point. Cardiology review excludes cardiopulmonary manifestations.
    • • What are the aeromedical implications of the possible treatments that the specialist would recommend
  63. What now?
    • • The rheumatologist recommends the use of ongoing NSAIDs for the moment, exercise/physio, and annual review.
    • • What will you tell the trainee
    • • What MECR procedure will be required and what do you think will be the likely outcome
    • • Is there any extant policy to guide you? If so, what is it
  64. CAPT Bader, 34 y.o. Blackhawk pilot
    • • Recreational light aircraft accident, crashed heavily from 200ft AGL.
    • • Major trauma to both lower limbs requiring bilateral BK amputations.
  65. History?
    • • Significant blood loss required blood transfusions. No other significant injuries, in particular no head trauma.
    • • Prolonged hospitalisation, and rehabilitation but achieved a good recovery with prostheses successfully fitted.
    • • No other relevant past medical history and no ongoing medical treatment
    • • What is the impact of the condition on the operating environment of this pilot?
    • • What is the impact of his working environment on the condition?
  66. Can I fly again doc?
    • • CAPT Bader is determined to return to military flying. He begins the process of regaining his CASA medical certificate.
    • • He comes to see you to begin the conversation about how he can regain his military flying career.
    • • What clinical information, investigations or specialist reports do you require to assist in the aeromedical decision making process?
  67. Reports are in…?
    • • All reports from the orthopaedic surgeon, rehabilitation specialists, physios, OTs and psychologist are highly favourable and indicate that CAPT Bader has made a full recovery from his injuries, has adapted well to his prostheses, and is a highly motivated and determined individual with no evidence of psychological trauma.
    • • What should you now do?
    • • What is the impact of his prosthetic limbs on his military aviation career and general military duties?
  68. Yes he can….?
    • • A functional assessment on the Squirrel and Blackhawk helicopters shows that CAPT Bader can perform all tasks required of him under normal and emergency operating conditions. The loadmaster had no idea that the pilot had no legs.
    • • What MECR procedures would be appropriate for this case.
    • • What do you think the ultimate aeromedical disposition should be?

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1Topic 3.7 Orthopaedics Overview & Cases AVMO 0019 (Cable)
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2017-02-25 12:49:44
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