The National Medical COmmission (NMC) has released the Guidelines For Competency-Based Post Graduate Training Programme For MS In Orthopaedics

The purpose of PG education is to create specialists who would provide high quality health care and advance the cause of science through research & training.

A postgraduate undergoing training MS in Orthopaedics should be trained to identify and recognize various congenital, developmental, inflammatory, infective, traumatic, metabolic, neuromuscular, degenerative and oncologic disorders of the musculoskeletal systems. She/he should be able to provide competent professional services to trauma and orthopaedic patients at a primary/ secondary/tertiary healthcare centres.

The purpose of this document is to provide teachers and learners illustrative guidelines to achieve defined outcomes through learning and assessment. This document was prepared by various subject-content specialists. The Reconciliation Board of Academic Committee has attempted to render uniformity without compromise to purpose and content of the document. Compromise in purity of syntax has been made in order to preserve the purpose and content. This has necessitated retention of "domains of learning" under the heading "competencies".

This will be dealt with under the following headings:

• Practical and clinical skills (psychomotor domain)

• Attitudes including communication skills (Affective domain)

• Writing thesis / Reviewing Research activities (Scholarly activity)

• Training in Research Methodology (Practice based learning, Evidence based practice)

At the end of the M.S. Orthopaedics programme, the post graduate student should be able to:

1. Demonstrate sufficient understanding of the basic sciences relevant to orthopaedic speciality through a problem based approach.

2. Describe the Principles of injury, its mechanism and mode, its clinical presentation, plan and interpret the appropriate investigations, and institute the management of musculoskeletally injured patient.

3. Identify and describe the surface anatomy and relationships within of the various bones, joints, ligaments, major arteries, veins and nerves of the musculoskeletal system of the spine, upper limb, lower limb and the pelvis, chest, abdomen and head & neck.

4. Define and describe the pathophysiology of shock (circulatory failure).

5. Define and describe the pathophysiology of Respiratory failure

6. Describe the principles and stages of bone and soft tissue healing

7. Understand and describe the metabolic, nutritional, endocrine, social impacts of trauma and critical illness.

8. Enumerate, classify and describe the various bony/soft tissue injuries affecting the axial and appendicular skeletal system in adults and children.

9. Describe the principles of internal and external fixation for stabilization of bone and joint injuries.

10. Describe the mechanism of homeostasis, fibrinolysis and methods to control haemorrhage

11. Describe the physiological coagulation cascade and its abnormalities

12. Describe the pharmacokinetics and dynamics of drug metabolism and excretion of analgesics, anti inflammatory, antibiotics, disease modifying agents and chemotherapeutic agents.

13. Understanding of biostatistics and research methodology

14. Describe the clinical presentation, plan and interpret investigations, institute management and prevention of the following disease conditions

a. Nutritional deficiency diseases affecting the bones and joints

c. Endocrine abnormalities of the musculoskeletal system

d. Metabolic abnormalities of the musculoskeletal system

e. Congenital anomalies of the musculoskeletal system

f. Developmental skeletal disorder of the musculoskeletal system

15. Describe the pathogenesis, clinical features plan and interpret investigations and institute the management in adults and children in

a. Tubercular infections of bone and joints (musculoskeletal system)

b. Pyogenic infections of musculoskeletal system

c. Mycotic infections of musculoskeletal system

d. Autoimmune disorders of the musculoskeletal system

e. Rheumatoid arthropathy, Ankylosing spondylitis, seronegative arthropathy

16. Describe the pathogenesis, clinical presentation, plan and interpret investigations and institute appropriate treatment in the following conditions:

a. Post polio residual paralysis

c. Muscular dystrophies and myopathies

17. Identify the diagnosis and describe management of musculoskeletal manifestation of AIDS and HIV infection

18. Describe the aetiopathogenesis, identify, plan and interpret investigation and institute the management of osteonecrosis of bones.

19. Identify situations requiring rehabilitation services and prescribe suitable orthotic and prosthetic appliances and act as a member of the team providing rehabilitation care

20. Identify a problem, prepare a research protocol, conduct a study, record observations, analyse data, interpret the results, discuss and disseminate the findings.

21. Identify and manage emergency situation in disorders of musculoskeletal system

22. Understanding of the basics of diagnostic imaging in orthopaedics like:

f. Radio Isotope bone scan

g. Digital Subtraction Angiography (DSA)

h. Dual energy x-ray Absorptiometry

23. Describe the aetiopathogenesis, clinical presentation, Identification, Plan investigation and institute treatment for oncologic problems of musculoskeletal system both benign and malignancies, primary and secondary.

24. Understand the basics, principles of biomaterials and orthopaedic metallurgy

25. Describe the principles of normal and abnormal gait and understand the biomedical principles of posture and replacement surgeries.

26. Describe social, economic, environmental, biological and emotional determinants of health in a given patient with a musculoskeletal problem.

1. Should be able to function as a part of a team, develop an attitude of cooperation with colleagues, and interact with the patient and the clinician or other colleagues to provide the best possible diagnosis or opinion.

2. Always adopt ethical principles and maintain proper etiquette in dealings with patients, relatives and other health personnel and to respect the rights of the patient including the right to information and second opinion.

3. Develop communication skills to word reports and professional opinion as well as to interact with patients, relatives, peers and paramedical staff, and for effective teaching.

Attitudes including Communication skills and Professionalism

• Exhibits participation in honest, accurate health related information sharing in a sensitive and suitable manner

• Recognizes that being a good communicator is essential to practice effectively

• Exhibits effective and sensitive listening skills

• Recognises the importance and timing of breaking bad news and knows how to communicate

• Exhibits participation in discussion of emotional issues

• Exhibits leadership in handling complex and advanced communication

• Recognizes the importance of patient confidentiality and the conflict between confidentiality and disclosure

• Able to establish rapport in therapeutic bonding with patients, relatives and other stakeholders through appropriate communication

• Able to obtain comprehensive and relevant history from patients/relatives

• Able to counsel patients on their condition and needs

b. Teamwork: Seek cooperation. Coordination and communication among treating specialties and paramedical staff

c. Counseling of relatives: regarding patients condition, seriousness, bereavement and counseling for organ donation in case of brain stem death

d. Leadership: Trauma prevention, education of the public, paramedical and medical persons.

Advocacy: with the government and other agencies towards cause of trauma care

e. Ethics: The Code of Medical Ethics as proposed by Medical Council of India will be learnt and observed.

1. At the end of the first year of M.S. Orthopaedics programme, the student should be able to:

1. Elicit a clinical history from a patient, do a physical examination, document in a case record, order appropriate investigations and make a clinical diagnosis

2. Impart wound care where applicable

3. Apply all types of POP casts/slabs, splints and tractions as per need

4. Identify shock and provide resuscitation

5. Perform aspiration of joints and local infiltration of appropriate drugs

7. Perform arthrotomy of knee joint

8. Perform incision and drainage of abscess

9. Perform split thickness skin grafting

12. Apply skeletal tractions including skull tongs

13. Triage a disaster situation and multiple trauma patients in an emergency room

14. Perform on bone models, interfragmentary compression screws, external fixation, Tension band wiring and Broad plating

15. Perform closed reduction of common dislocations like shoulder and common fractures like collar fracture, supracondylar fracture.

16. Perform on a cadaver standard surgical approaches to the musculo skeletal system

2. At the end of the second year of M.S. Orthopaedics course, the student should be able to:

1. Take an informed consent for standard orthopaedic procedures

2. Perform closed/open biopsies for lesions of bone, joints and soft tissues

3. Perform split thickness skin grafting and local flaps

4. Perform on bone models, internal fixation with k-wires, screws, plates. Dynamic hip/condylar screws/nailing.

6. Perform arthrotomy of joints like hip/shoulder, ankle, elbow

7. Perform repair of open hand injuries including tendon repair

8. Perform arthodesis of small joints

9. Perform diagnostic arthroscopy on models and their patients

10. Perform carpal tunnel/tarsal tunnel release

12. Perform soft tissue releases in contractures, tendon lengthening and correction of deformities

13. Perform amputations at different levels

14. Perform corrective surgeries for CTEV, DDH, perthes/ skeletal dysplasia

3. At the end of the third year of M.S. Orthopaedics programme, the student should be able to:

1. Assist in the surgical management of polytrauma patient

2. Assist in Arthroplasty surgeries of hip, knee, shoulder and the ankle

3. Assist in spinal decompressions and spinal stabilizations

4. Assist in operative arthroscopy of various joints

5. Assist /perform arthrodesis of major joints like hip, knee, shoulder, elbow

6. Assist in corrective osteotomes around the hip, pelvis, knee, elbow, finger and toes

7. Assist in surgical operations on benign and malignant musculoskeletal tumour including radical excision and custom prosthesis replacement.

8. Assist in open reduction and internal fixations of complex fractures of acetabular, pelvis, IPSI lateral floating knee/elbow injuries, shoulder girdle and hand

9. Assist in spinal deformity corrections

10. Independently perform closed/open reduction and internal fixation with DCP, LCP, intrameduallary nailing, LRS

11. Assist in limb lengthening procedures

13. Provide pre and post OP care

14. Perform all clinical skills as related to the speciality.

- Anatomy and function of joints

- Growth factors and facture healing

- Structure and function of muscles and tendons

- Stem Cells in Orthopaedic Surgery

(Should know the interpretation and Clinical Correlation of the following): -

- MRI and CT in Orthopaedics

- Pyogenic Haematogenous Osteomyelitis - Acute and Chronic

- AIDS and the Orthopaedic Surgeon (universal precautions)

- Tubercular synovitis and arthritis of all major joints

- Polio Lower limb and spine

- Management of Post Polio Residual Palsy (PPRP)

- Calcium Pyrophosphate Dihydrate (CPPD), Gout

- Acute Respiratory Distress Syndrome (ARDS)

- Orthopaedic manifestations of bleeding disorders

13. Regional Orthopaedic Conditions of Adults and Children

17. Traumatic Disorders of Joints (Sports Injuries)

- Arthrodesis of lower extremity and hip

- Biomechanics of joints and replacement of the following joints.

20. Minimally Invasive Surgery (MIS) Arthroscopy

- Arthroscopy of knee and ankle

- Arthroscopy of shoulder and elbow

- Amputations and disarticulations in the lower limb

- Amputations and disarticulations in the upper limb

22. Rehabilitation - Prosthetics and Orthotics

- Fractures and dislocations in children

- Congenital Dislocation of Hip (CDH)

a) Spinal trauma: diagnosis and management including various types of fixations

i. Rehabilitation of paraplegics/quadriplegics

ii. Management of a paralyzed bladder

iii. Prevention of bed sores and management of established bed sores

iv. Exercise programme and Activities of Daily Living (ADL)

b) Degenerative disorders of the spine

i. Prolapsed Inter Vertebral Disc (PIVD)

ii. Lumbar Canal Stenosis (LCS)

vi. Spinal fusion: various types and their indications.

25. Triage, Disaster Management, BTLS and ATLS

- Metal on metal arthroplasty of hip

- Designing a modern orthopaedic operation theatre

• Emphasis should be given to various small group teachings rather than didactic lectures.

• CASE PRESENTATION once a week in the ward, in the outpatient department and special clinics.

• Seminars / Symposia – Twice a month; Theme based student centered

• Journal club/ Review : Twice a month

• Academic grand ward rounds: Twice a month presentation of cases by residents and clinically applicable discussions.

• ORTHO RADIOLOGY MEETS: Twice a month discussions amongst Ortho & Radiology Residents under facilitation of faculty on various imaging modalities used and its interpretation

• ORTHO SURGICAL PATHOLOGICAL MEET: Special emphasis on the surgical pathology radiological aspect of the case in the pathology department. Clinician (Ortho resident) presenting the clinical details of the case, radiology PG student describes the Radiological findings and its interpretation and Pathology student describes the morbid anatomy and histopathology of the same case.

• SKILLS LAB SESSIONS: Once a fortnight for all two years.

• Clinical teaching in the OPD, Emergency room, ICU, OR as per the situation.

• Mortality & Morbidity meetings with SURGICAL AUDIT: Once a month

• Maintenance of log book: to be signed by the faculty in charge

• The post graduate students shall be required to participate in the teaching and training programme of undergraduate students and interns.

• A post graduate student of a postgraduate degree course in broad specialities/super specialities would be required to present one poster presentation, to read one paper at a national/state conference and to present one research paper which should be published/accepted for publication/sent for publication during the period of his postgraduate studies so as to make him eligible to appear at the post graduate degree examination.

• Should have attended two conferences/CMEs/Workshops during his tenure as a postgraduate

• Department should encourage e-learning activities.

A major portion of posting should be in Orthopaedics department. It should include in- patients, out-patients, ICU, trauma, emergency room and speciality clinics.

o Inter-unit rotation in the department should be done for a period of up to one year.

o Rotation in appropriate related subspecialties for a total period not exceeding 06 months.

There should be intra- and inter- departmental meetings for discussing the uncommon /interesting cases involving multiple departments.

Log book: Each student must be asked to present a specified number of cases for clinical discussion, perform procedures/tests/operations/present seminars/review articles from various journals in inter-unit/interdepartmental teaching sessions. They should be entered in a Log Book. The Log books shall be checked and assessed periodically by the faculty members imparting the training.

During the training programme, patient safety is of paramount importance; therefore, skills are to be learnt initially on the models, later to be performed under supervision followed by performing independently; for this purpose, provision of surgical skills laboratories in medical colleges is mandatory.

Assessment should be comprehensive and objective assessing the competencies stated in the course. The assessment is both formative and summate. Formative is spread over the entire duration of the programme and the summative is as per university examination pattern.

FORMATIVE ASSESSMENT, during the training,

Formative assessment should be continual and should assess medical knowledge, patient care, procedural & academic skills, interpersonal skills, professionalism, self directed learning and ability to practice in the system.

Internal Assessment should be frequent, cover all domains of learning and used to provide feedback to improve learning; it should also cover professionalism and communication skills. The Internal Assessment should be conducted in theory and clinical examination.

Quarterly assessment during the MS training should be based on following educational activities:

1. Journal based / recent advances learning

2. Patient based /Laboratory or Skill based learning

3. Self directed learning and teaching

4. Departmental and interdepartmental learning activity

5. External and Outreach Activities / CMEs

The student to be assessed periodically as per categories listed in postgraduate student appraisal form (Annexure I).

SUMMATIVE ASSESSMENT, at the end of the course, Post Graduate Examination

The summative examination would be carried out as per the Rules given in POSTGRADUATE MEDICAL EDUCATION REGULATIONS, 2000.

The Post Graduate examination shall be in three parts: -

Every post graduate student shall carry out work on an assigned research project under the guidance of a recognised Post Graduate Teacher, the result of which shall be written up and submitted in the form of a Thesis. Work for writing the Thesis is aimed at contributing to the development of a spirit of enquiry, besides exposing the post graduate student to the techniques of research, critical analysis, acquaintance with the latest advances in medical science and the manner of identifying and consulting available literature.

Thesis shall be submitted at least six months before the Theory and Clinical / Practical examination. The thesis shall be examined by a minimum of three examiners; one internal and two external examiners, who shall not be the examiners for Theory and Clinical examination. A post graduate student shall be allowed to appear for the Theory and Practical/Clinical examination only after the acceptance of the Thesis by the examiners.

The examinations shall be organized on the basis of 'Grading'or 'Marking system' to evaluate and to certify post graduate student's level of knowledge, skill and competence at the end of the training. Obtaining a minimum of 50% marks in 'Theory' as well as 'Practical' separately shall be mandatory for passing examination as a whole. The examination for M.D./ MS shall be held at the end of 3rd academic year. An academic term shall mean six month's training period.

There shall be four theory papers as follows:

Paper I: Basic Sciences as applied to Orthopaedics

Paper II: Traumatology and Rehabilitation

Paper IV: Recent advances in Orthopaedic surgery + General Surgery as applied to Orthopaedics

3. Practical/Clinical: The practical examination should consist of the following and should be spread over two days, if the number of post graduate students appearing is more than five.

1. One long case: History taking, physical examination, interpretation of clinical findings, differential diagnosis, investigations, prognosis and management.

2. Short cases from various sections of the speciality (three)

3. Rockwood And Greens – Fractures In Adults, Vol 1& 2

4. Fractures In Children – Rockwood & Wilkins

5. Physiological Basis Of Medical Practice – Best And Taylor's

6. Arthroscopic Surgery Of The Knee – Johannes

8. Concise System Of Orthopaedics And Fractures – Graham Apley

10. Outline Of Fractures Adams, Hamblen

11. Textbook Of Orthopaedics And Trauma – Kulkarni, Vol 1

12. B.D. Chaurasia's Human Anatomy, Vol1,Vol 2, Vol 3

14. Orthopaedics Anatomy And Surgical Approaches Frederick Wreckling

15. The Art Of Aesthetic Plastic Surgery – John R Levis, Vol 1

16. Current Concepts In Orthopaedics Dr. D. K. Tareja

17. Custom Mega Prosthesis & Limb Salvage Surgery Dr. Mayilvahanan

19. Green's Operative Hand Surgery-Vol. 1&. 2, Green, David P; Hotchkiss, Robert N

20. Tachdjian's Pediatric Orthopaedics-Vol. 1, Vol 2, Vol 3, Herring, John Anthony

21. Surgical Exposures In Orthopedics:The Anatomic Approach, Hoppenfeld, Stanley; De Boer,Piet

22. Adams's Outline Of Orthopaedics, Hamblen, David L; Simpson, Hamish R

23. Text Book Of Ilizarov Surgical Techniques Bone Correction And Lengthening, Golyakhovsky, Vladimir; Frankel, Victor H

24. Current Techniques In Total Knee Arthroplasty, Sawhney G S

25. Applied Orthopaedic Biomechanics, Dutta, Santosh; Datta,Debasis

26. Essential Orthopaedics And Trauma, Dandy, David J; Edwards, Dennis J

27. Adams's Outlines Of Fractures;Including Joint Injuries, Hamblen, David L; Simpson, A Hamish R W

28. Orthopedic Physical Assessment, Magee, David J

29. Turek's Textbook Of Orthopaedics Vol 1 & 2, Turek's

03-05 international Journals and 02 national (all indexed) journals

Medical Dialogues Bureau consists of a team of passionate medical/scientific writers, led by doctors and healthcare researchers.  Our team efforts to bring you updated and timely news about the important happenings of the medical and healthcare sector. Our editorial team can be reached at editorial@medicaldialogues.in.