Authors of the didactic unit “Orthopaedic Traumatology” Anamaria Milonean, Adriana Neagu, Alina Pelea, Olivia Petrescu (Universitatea Babeș-Bolyai”, Cluj-Napoca, România) Oana Mureșan, Ovidiu Ursa (Universitatea de Medicină și Farmacie Iuliu-Hațieganu, Cluj-Napoca, România)

ORTHOPAEDIC TRAUMATOLOGY

Introduction:

This didactic unit will focus on orthopaedic trauma and potential ethical dilemmas interpreters may face regarding impartiality, transparency, and cultural differences while working under pressure.

Goals:

In didactic unit, we will:

• familiarize students with the basic vocabulary of orthopaedic surgery,

• give trainees the opportunity to test their skills in dialogue interpreting, an activity they have not trained for so far,

• test the trainees’ ability to adapt to fortuitous, unrehearsed scripts and working conditions, and make quick, optimal decisions when dealing with ethical dilemmas.

Learning outcomes:

By the end of this didactic unit, trainees will:

• acquire the basic terminology of orthopaedic surgery,

• become more aware of the challenges of a medical assignment (need for complete, coherent and accurate rendition of content; need for thorough documentation throughout the process; need for empathy),

• be better equipped to deal with ethical dilemmas concerning impartiality, transparency, and cultural differences while working under pressure.

1. TERMINOLOGICAL EXERCISE

a. The text below introduces basic aspects of orthopaedic trauma and presents the stages of patient examination. Read the text1 and do the tasks that follow it. Complete the sentences using one of the words or expressions in the box

Orthopaedic trauma refers to a serious injury of the skeletal or muscular system caused by an external factor, such as a fall or a car accident. Trauma can also be caused by overexertion – for example, running long distances may cause small hairline cracks in the tibia. While this type of injury is not always life-threatening, it can have serious effects on the patient’s quality of life, which is why it is crucial to seek medical attention right away. The objective of the orthopaedic trauma specialist is to restore the normal functioning of the injured parts of the musculoskeletal system.

The examination procedure in the case of patients with orthopaedic trauma involves the following stages: taking the patient’s medical history (anamnesis), visual inspection, palpation, anthropometric measurements and joint mobility assessment, as well as necessary paraclinical investigations (X-ray, ultrasound, MRI, scintigraphy, etc.)

During the history taking, the physician discusses the patient’s reasons for seeking medical care – discomfort, limping, deformity, etc. If the patient complains of trauma-related pain, the physician needs to elicit the time and the circumstances of the accident from the patient.

Visual inspection represents the first step in examining the patient. The physician determines the patient’s constitutional type, posture, head and pelvis inclination angle, spine curvature disorders (scoliosis, kyphosis, lordosis), upper and lower limb deformities (varus, valgus, flexion, extension, etc.), muscular atrophies and dystrophies, and limited range of motion in the joints. General inspection is followed by a detailed inspection of the injured segment or area. Special attention is paid to the swelling of the affected segment or articulation, the presence of exudate in the joint, as well as of post-traumatic ecchymosis. Visual inspection may reveal deformity of the injured segments caused by the shifting of the fractured bone fragments.

Palpation is intended to examine the main injured area and compare this area with the similar region in the healthy segment. Palpation may also reveal differences in temperature of the focal fracture and surrounding areas, tenderness, pain, and the presence or absence of tissue oedema. Digital palpation allows an assessment of the joint bone surface, as well as of protruding ligaments and tendons. Crepitations within the focal fracture area may also be found through palpation.

Anthropometry involves the measurement of the limbs and of their segments between bony prominences used as reference points. Limb deformities are assessed by comparing them with the dimensions and axis of the healthy limb.

1 Adapted from S. Cooper, What is Orthopaedic Trauma? Definition, Treatment, and Prevention [https://www.floridamedicalclinic.com/blog/what-is-orthopaedic-trauma/ ] and F. Gornea, Ortopedie și traumatologie. [https://ortopedie.usmf.md/wp-content/uploads/2014/07/CarteaOrtopedietraumatologie.pdf]

It is important to measure the joint range of motion and amplitude. Any deviation from the normal signals a certain condition, which can be subsequently confirmed by radiography.

b. The medical terms (1-7) in the left-hand column are taken from the text above. Match each term with a suitable definition (A-G) in the right-hand column.2

c. Using a dictionary, write short definitions of the following terms found in the text:

Medical term Definition

paraclinical investigations

X-ray

ultrasound

magnetic resonance imaging (MRI)

2 Definitions adapted from Dicționare ale limbii române DEX Online. [https://dexonline.ro/]; SfatulMedicului.ro. [https://www.sfatulmedicului.ro/]

scintigraphy

upper and lower limbs

exudate

ecchymosis

oedema

crepitation

d. The text below3 describes the main types of complications following intra-articular trauma. Using a dictionary, study the meaning of the words in the box, then fill in the blanks with a suitable word.

bruising fractures stiffness

pain mobility tissues

joints microcirculation inflammatory

sprains ankylosis immobilization

Intra-articular trauma and long _____1_____ cause morphological damage in the soft _____2_____ and the _____3_____, which limit movement. Depending on the degree of damage in the joint, trauma may cause _____4_____ , i.e. an absence of motion in the joint, or _____5_____, i.e. an obvious reduction of the joint _____6_____, caused by the formation of connective tissue in the interspace between the joint areas.

As a result of trauma such as soft tissue _____7_____ , capsular ligament joint _____8_____, joint dislocation, bone _____9_____, the _____10_____ syndrome gradually recedes beginning with days 3-5, as soon as blood _____11_____ in the affected areas is restored. In _____12_____ disorders, pain gradually increases and it recedes much later.

3 Adapted from F. Gornea, Ortopedie și traumatologie.

e. Read the following descriptions (A-E) of the main types of orthopaedic surgery interventions. Match each description with a suitable intervention type on the right (1-5).4

f. Read the following paragraphs5and fill in the gaps to form the missing words6, based on the context and the given letters.

4 Definition adapted from Trauma and orthopaedic surgery. [https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/surgery/trauma-and-orthopaedic-surgery] and Dicționare ale limbii române DEX Online. [https://dexonline.ro/].

5 Excerpts adapted from: Dr. Mihai Tudor Gavrilă Tratamentul fracturii de claviculă. Global Medical.

[https://globalmedical.ro/tratamentul-fracturii-de-clavicula/]; Cum recunoști o fractură. EDU.REGINAMARIA.RO. (2017) [https://www.reginamaria.ro/articole-medicale/cum-recunosti-o-fractura]; Dan Scorpie. (2021) Chirurgia minim invazivă a umărului, cotului și genunchiului. [https://chirurgiaumarului.ro/anatomie/umar/scheletul/]; Dr. Robert Apostolescu, Durerea de umăr. In Ortopedia pe înțelesul tuturor. [https://www.doctorortoped.ro/afectiuni/durerea-de-umar]; Ortopedie Traumatologie. Centrul Medical de Diagnostic și Tratament "Dr. Victor Babeș". [https://www.cdt-babes.ro/servicii/ortopedie_traumatologie.php]; Dicționare ale limbii române DEX Online. [https://dexonline.ro/]; SfatulMedicului.ro. [https://www.sfatulmedicului.ro/].

6 The task can also be completed at the end of the unit or assigned as homework.

1. The musculoskeletal system is made up of the b_ _ _ _ and j_ _ _ _ _ of the limbs, and the v_ _ _ _ b _ _ _ c_ _ _ _ _, as well as the l_ _ _ m _ _ _ _, muscles and t_ _ _ o _ _ that bind the former or allow motion. 2. The shoulder consists of 3 bones: humerus - the upper arm bone; c_ _ v _ _ _ _ (collarbone) - a long elongated S-shaped bone, which acts as a shock absorber in the upper thorax; s_ _ _ _ l _ (shoulder blade) - the only flat bone in the shoulder joint, providing support and acting as an interface between the upper limb and the rib c_ _ _. 3. D_ _ p _ _ c _ d clavicle fractures (in which the bone fractures completely and the ends of the two pieces are no longer aligned) are immobilized in a figure-of-eight b_ _ d_ _ _ (orthosis), for 5-6 weeks. The treatment of acute pain includes a_ _ _ g _ _ _ c _ (pain relief medication), such as nonsteroidal a_ _ _ -i_ _ _ _ m_ _ t_ _ y drugs. If the bone fragments do not return to their anatomical position (the fracture is not reduced), s_ _ _ _ r _ is required, during which the patient is under general a_ _ _ _ t_ _ s_ _. 4. A sprained a_ k _ _ is a common condition of the musculoskeletal system that can occur during sports or physical activities, or as a result of a misstep. Sprains can be of three types: mild (grade I) – slight overstretching of the ligament fibres; moderate (grade II) - in which a partial t_ _ r _ _ g of the ligament takes place; severe (grade III) - in which the ligament r_ _ t _ _ e is complete. The evolution and p_ _ g _ _ _ _ s (prediction of the evolution of the lesion) depend on the type of sprain, its location, the treatment applied and the patient’s age. 5. In orthopaedics and traumatology, orthopaedic evaluation to establish an accurate d_ _ g _ _ s _ _ often includes a r_ _ _ _ l _ _ i _ _ l examination to detect a fracture or arthrosis. In case of post-traumatic s_ q _ _ l _ _ of the musculoskeletal system (as a result of fractures, dislocations or sprains), a medical r_ _ _ b _ _ _ t _ _ _ _ n treatment is required. This may include k_ _ _ s _ t _ _ _ _ _ y exercises (“medical gymnastics”), p _ y _ _ c _ _ t_ e _ _ p_ procedures (medical treatment using physical agents) and other procedures included in a therapeutic programme.

2. ROLE-PLAY

Daniel, a 12-year-old boy from the UK, accompanied by his sports teacher, arrives at an orthopaedic hospital in Cluj-Napoca for an examination. He has had severe pain pain in the area of the right shoulder blade since he fell off a horse. Together with his class, the boy is on a week-long holiday in Romania. This morning, the group visited a riding school near the city. The children were allowed to ride, but Daniel’s horse got scared and got out of the instructor’s control.

Doctor: Bună ziua, vă rog să luați loc.

Daniel/Teacher: Good afternoon. Thank you!

Doctor: Înțeleg că băiatul acuză dureri foarte puternice în zona omoplatului drept. Vă rog să-mi spuneți ce s-a întâmplat mai exact. Înțeleg că dvs. sunteți profesorul care însoțește copiii în această deplasare...

Teacher: We’re on a trip in your city and we heard about the horse riding centre. You know how kids are. They heard about it and insisted that we take them there. We didn’t want to let them ride, but they kept pressing us, saying they’d be good and take care. We gave in... I knew it’s dangerous, that I’d get into trouble.... I thought.... Briefly, Daniel’s horse got scared and the trainer couldn’t master it anymore...

Doctor: Văd că Daniel are brațul imobilizat, dar acuză dureri foarte mari. Cine l-a bandajat?

Teacher: They have some therapy centre there... hippotherapy, they call it. There was a doctor and he said we should go to the A&E.

Daniel: Sir, it really hurts… I can’t bear it anymore…

Doctor: Este vizibilă deformarea la nivelul claviculei… Vedeți umflătura aici?… Iar umărul este căzut, adus în interior. Băiatul nu poate ridica brațul din cauza durerii insuportabile. Mă tem să nu fie o ruptură de claviculă... Cred că va trebui să facem rapid o radiografie, să vedem cum stau lucrurile mai exact.

Daniel: But I don’t want any of that! What does it mean? It’ll hurt even more…

Doctor: Stai liniștit. Facem doar un filmuleț, să vedem cum stau oasele de la umărul tău… Vom trece în camera de alături, pentru o radiografie. Îl rugăm pe domnul profesor să rămână aici.

They come back after a while.

Doctor (to the teacher): Da, din nefericire, avem de-a face cu o fractură de claviculă cu deplasare, iar singura soluție este intervenția chirurgicală.

Teacher: Oh, no! Goodness! Surgery? I’ll have to call his parents...

Doctor: Da, întrucât este necesar să facem o anestezie generală, trebuie să aflăm dacă copilul este alergic la vreo substanță, dacă a avut probleme de sănătate… Da, trebuie să ne mișcăm cât mai repede, pentru că durerea este prea mare.

The teacher makes a WhatsApp video calls to the parents on WhatsApp. The child’s father picks up.

Teacher (to the father): Hi... Robert Woods speaking, you know… there’s a problem with Daniel… Don’t worry. I thought I’d offer them a special experience. Something to remember. And I let them ride a horse and Daniel fell off. I’m so sorry! He fell on his arm, his clavicle’s broken and now he needs surgery.

Father: My God, how could this happen? I can’t believe it… How is he?

Teacher: His right arm is in a brace. It hurts him when he moves it.

Doctor (to the father): Veți primi detalii despre întâmplare mai încolo, important este acum să primim acordul dvs. pentru intervenția chirurgicală. Băiatul trebuie operat, sub anestezie generală, și nu știm dacă a avut probleme de sănătate în trecut, dacă este alergic la vreun medicament…

Father: But is surgery really necessary? Are you absolutely sure? Can’t you just cast it?

Doctor: Este o fractură cu deplasare care impune intervenția chirurgicală! Nu putem risca să se fixeze defectuos.

Father: I want to talk to the teacher.

(to the teacher) We don’t trust him. We want some other specialist to see Daniel. Surgeons always recommend surgery... Recovery is difficult for children and maybe it’s not even necessary to go through this. We had another situation like this in our family… Really… I don’t know how you could tell this to the doctor… I don’t want to offend him. I’d like to ask the translator… I’m sure she knows how to put it in his language so that he won’t get mad. [ethical dilemma]

Teacher: But how can I know how risky it is not to have him operated on? And what could happen next…

Father: I don’t want to let him operate on my child. I don’t trust that doctor, whatever his name, from I don’t know what hospital.

Teacher [to the interpreter]: Daniel’s father doesn’t agree to the operation. He asks you to put the child’s arm into a cast until new investigations are conducted when Daniel gets home. [ethical dilemma]

Doctor: Dar riscăm să nu se așeze corect oasele...

Father: We insist that you respect our decision. Mr. Woods is authorized to sign on our behalf. And please tell us what we should do next.

Doctor: Este decizia dvs., dar vă jucați puțin cu sănătatea copilului. În acest caz, e de dorit să nu fie prea mare deplasarea. Într-adevăr, oasele sunt aliniate și, dacă deplasarea e mică, ar putea exista șanse... Dar eu nu aș risca...

Father: I repeat: it’s our decision. We just need to know what we should do next.

Doctor: Păi, atunci, nu ne rămâne decât să fixăm brațul cu un bandaj în 8 care va menține poziția corectă pentru vindecare. Pentru durere, îi vom da analgezice pe bază de paracetamol și antiinflamatoare nesteroidiene. Este cumva alergic la vreo substanță?

Father: He’s never had any allergies. We even gave him paracetamol when he was small.

Doctor: Pe măsură ce durerea scade în intensitate, va putea începe niște exerciții ușoare pentru umăr. Trebuie să luați legătura cu un kinetoterapeut. Și, mai ales, mare atenție la poziția brațului în timpul călătoriei.

Father: Thank you for your understanding.

Doctor (to the interpreter): Sunteți sigur că ați explicat că nu e de glumă? [ethical dilemma]

Teacher (to the interpreter): Please tell the doctor it’s not my fault. It’s the father who doesn’t trust him. Personally, I wouldn’t take the risk.

Doctor: Trebuie să respectăm procedura legală.

• Should the discussion between father and teacher be interpreted?

• At which point should the interpreter introduce herself to the father?

• At the end of the conversation between father and teacher, will the interpreter render the father’s or the teacher’s opinion? Or will he – as the father asks – formulate the request as he considers suitable?

• What could be the reaction of the interpreter when the doctor expresses his doubt about the way in which the gravity of the situation has been rendered?

• What practical difficulties poses the WhatsApp video call for the interpreter? How can the interpreter ensure a natural communication in these conditions?

3. CASE STUDY

Situation

A junior professional Romanian tennis player, aged 16, ranked 21 in the ATP, participant in the Wimbledon Grand Slam tournament, suffers a severe ankle injury. He is rushed to the Accident and Emergency Service of The Royal National Orthopaedic Hospital in London. Even though he understands and can speak English fluently, a professional healthcare interpreter is being sent for. The interpreter arrives at the hospital shortly. The injury turns out to be a complete ligament tear.

Diagnosis

The patient manifests severe acute inflammation in the right ankle. To control the pain and reduce the swelling, the teenager is being administered an analgesic intravenously. The X-ray shows a rupture of the ATFL, the anterior talofibular ligament, frequently encountered in competition tennis players, due to joint overuse. Two treatment options are available.

The Patient

The teenager is in a state of shock, this is his first Grand Slam tournament. He was confident that he was in the best shape ever, ultra-competitive, and bound for victory. Driven by an irresistible desire to stay in competition, he pleads with the interpreter to talk the surgeon into putting him on steroids and painkillers, so that he can finish the match and play the semi-finals, indeed perhaps the very final, and the chance of a lifetime, on which he would not miss out for the world.

Surgeon and therapeutic options

The trauma and orthopaedic surgeon cannot be firmer in the diagnosis and prognosis: if reconstructive surgery is performed immediately, the athlete stands considerable chances to return to high performance sport, following a 6–8-week treatment and 3-4 months complete rehabilitation. Conversely, if surgery were to be postponed and a compression bandage applied, he could resume the match, but would risk deterioration and chronic instability of the ankle. As well as this, he may have to give up competition altogether, and experience lifelong impairment, or even become unable to practice any sports, not even as an amateur.

Given the severity of the long-term consequences, the specialist insists on proceeding to emergency surgery. Under the British law, although underage, the 16-year-old has the capacity to consent to the medical act. Finally, optional consent of the parents / legal guardian for the medical procedure that will follow is also requested by the doctor.

After reading the case study, answer the following questions:

• The patient asks the interpreter to give his/her opinion as to whether he should go along with surgery or not. How should the interpreter react to this?

• The patient does not agree with his parents’ very clear-cut opinion and asks the interpreter to tone down the answer. How should the interpreter tackle this demand?

• What should the interpreter focus on while preparing the terminology for this particular assignment?

Bibliography

- https://www.indrumaremedicala.ro/consultul-de-ortopedie/ - https://ortopedie.usmf.md/wp-content/uploads/2014/07/CarteaOrtopedietraumatologie.pdf - https://www.spitalul-municipal-timisoara.ro/data_files/content/sectii/clinica-de-chirurgie-generala-i/protocol-traumatologie-artroze.pdf - https://www.doctorortoped.ro/afectiuni/fractura-de-clavicula - https://micromedica.ro/fracturile-claviculei/ - https://centrokinetic.ro/fiziokinetoterapia-explicata/tehnici-chirurgicale/umar/fractura-clavicula-treimea/

Answer Key:

1. Terminological exercises

b. 1-C; 2-G; 3-E; 4-D; 5-A; 6-F; 7-B.

c. Answers may vary. Example answers7: - paraclinical investigations – general investigations (laboratory tests, imaging tests, ECG, spirometry, etc.) designed to assess the patient's health; - X-ray – a photograph of a part of the body made using X-rays; - ultrasound – diagnostic method using ultrasonic waves; ultrasonography; - magnetic resonance imaging (MRI) – a non-invasive technique that allows scanning of the human body by placing it inside a magnet - scintigraphy – a method of exploring an internal organ or tissue using a radioactive substance; scintigraphy; the image thus obtained; - upper and lower limbs – the arms and the legs; - exudate – secretion which is formed during an inflammatory process of the mucous membranes and of the various tissues of the body; - ecchymosis – the purple or black-and-blue area resulting from a bruise; - oedema – swelling, local change in shape and volume, caused by disturbances in blood circulation, generally resulting from a local inflammatory process; - crepitation – noise caused by the rubbing together of the ends of fractured bones or by air entering diseased lungs.

d. 1- immobilization, 2- tissues, 3- joints, 4- ankylosis, 5- stiffness, 6- mobility, 7- bruising, 8- sprains, 9- fractures, 10- pain, 11- microcirculation, 12- inflammatory e. A-2, B-1, C-5, D-3, E-4 f.

1. bones; joints; vertebral column; ligaments; tendons 2. clavicle; scapula; cage 3. displaced; bandage; analgesics; anti-inflammatory; surgery; anaesthesia (British English) 4. ankle; tearing; rupture; prognosis 5. diagnosis; radiological; sequelae; rehabilitation; kinesitherapy; physical therapy

7 Definition adapted from Dicționare ale limbii române DEX Online. [https://dexonline.ro/]; Investigații paraclinice. [https://medo.ro/investigatii-paraclinice]; SfatulMedicului.ro. [https://www.sfatulmedicului.ro/dictionar-medical]; Medical Dictionary. The Free Dictionary by Farlex. [https://medical-dictionary.thefreedictionary.com/]; Cambridge Online Dictionary. [https://dictionary.cambridge.org/dictionary/]