DNB Orthopaedics in India: Check out NBE released Curriculum

The National Board of Examinations (NBE) has released the Curriculum for DNB Orthopedics.

I. OBJECTIVES OF THE PROGRAMME:

1. PROGRAMME GOAL

• Patient care Ability: A postgraduate in orthopedics surgery at the end of its three-year course should develop proper clinical acumen to interpret diagnostic results and correlate them with symptoms from history taking and become capable to diagnose the common clinical conditions/ disease in the specialty and to manage them effectively with success without making any serious complications and sincerely to take a such accurate decision, for the patient's best interest including making a referral to consultation with a more experienced colleague/professional friend while dealing with any patient with a difficult condition.

• Teaching ability: DNB students also should be able to teach a student about the commonly encountered conditions in orthopedics their diagnostic features, basic pathophysiological aspect, and general and basic management strategies.

• Research Ability: Should also acquire elementary knowledge about research methodology, including record-keeping methods, and be able to conduct a research inquiry including making a proper analysis and writing a report on its findings. Data analysis and the Use of basic statistical methods require for publication.

• Teamwork: Should be capable to work as a team member. He/she should develop a general human approach to patient care with communication skills with the patient's relatives especially in an emergency such as in the casualty department while dealing with cancer patients and victims of accidents. He/she should also maintain human values with ethical consideration.

2. PROGRAMME OBJECTIVES

• Cognitive knowledge: Embryology, applied anatomy, physiology, pathology, clinical features, diagnostic procedures, and therapeutics including preventive methods, (medical/surgical) about the musculoskeletal system.

• Clinical decision-making ability & management expertise: Diagnose conditions from history taking, clinical evaluation, and investigations and develop expertise to manage medically as well as surgically the commonly encountered, disorders and diseases in different areas as follows:

i. Pediatric orthopedics- The student should be exposed to all aspects of congenital and developmental disorders such as CTEV(Club-Foot), developmental dysplasia of the hip, congenital deficiency of limbs, Perth's disease and infections, and also to acquire adequate knowledge about the principles of management of these disorders.

ii. Orthopedic oncology- The resident is expected to be familiar with the tumors encountered in orthopedic practice. The recent trends toward limb salvage procedures and the advances in chemotherapy need to be familiar to him.

iii. Management of Trauma- Trauma in this country is one of the main causes of morbidity and mortality in our demographic statistics. The student is expected to be fully conversant with trauma in its entirety. In any type of posting after qualification, the orthopedic surgeon would be exposed to all varieties of acute trauma. Hence, it is his responsibility to be able to recognize, assess and manage it including the medico-legal aspects.

iv. Orthopedics Sports Injuries- A lot of importance is being given to orthopedics sports injuries, especially given the susceptibility of the athlete to injury and his failure to tide over them. It not only encompasses diagnostic and therapeutic aspects of athletic injuries but also their prevention, training schedules of personnel & selection.

v. Physical Medicine and Rehabilitation- The student is expected to be familiar with this in all its aspects. Adequate exposure in the workshop manufacturing orthotics and prosthetics is mandatory, as is the assessment of the orthopedically handicapped.

vi. Orthopedic Neurology- The student should be exposed to all kinds of nerve injuries as regards their recognition & management of cerebral palsy and acquired neurologic conditions such as post-polio residual paralysis also need to be emphasized in their entirety.

vii. Spine Surgery- The student is expected to be familiar with various kinds of spinal disorders such as scoliosis, kyphoscoliosis, spinal trauma, PIVD, infections (tuberculosis and pyogenic), & tumors as regards their clinical presentations and management.

viii. Basic sciences in Orthopedics- This deals with some of the fundamentals in orthopedics such as the structure and function of bone cartilage etc., and their metabolic process. In addition, the student learns about implants in orthopedics and their metallurgy.

ix. Radiology-Acquire knowledge about radiology/imaging and interpret different radiological procedures and imaging in musculoskeletal disorders. There should be a collaboration with the Radiology department for such activities.

x. Psychologic and social aspect- Some elementary knowledge in clinical Psychology and social, work management is to be acquired for the management of patients, especially those terminally ill and disabled- persons, and interacting with their relatives.

• Teaching: Acquire the ability to teach an MBBS student in simple language about the common orthopedic ailment/disorders, especially about their signs/symptoms for diagnosis with their general principles of therapy.

• Research: Develop the ability to conduct a research inquiry on clinical materials available in Hospitals and the community.

• Patient-doctor relation: Develop the ability to communicate with the patient and his/her relatives about the disease condition, its severity, and options available for the treatment/therapy.

• Preventive Aspect: Acquire knowledge about the prevention of some conditions, especially in children such as poliomyelitis, congenital deformities, cerebral palsy, and common orthopedic malignancies.

• Identification of special areas within the subject: To further develop higher skills within the specialty in a specialized area such as Arthroplasty, Neurology, Arthroscopy oncology, spine surgery, hand surgery, and Rheumatology, identify some areas of interest during the residency and do fellowship/ senior residency program in one of such areas.

• Presentation of Seminar/paper: Should develop public speaking ability and should be able to make presentations on disease conditions/research topics to colleagues in a Seminar/meeting/ conference using audiovisual aids.

• Research writing: Should be capable to write case reports and research papers for publication in scientific journals.

• Teamwork: Team spirit in patient management, working together in OPD, OT, and ward, and sharing responsibility with colleagues such as doctors, nurses and other staff are essential. A resident has to develop these attributes through a different mechanism of infection

• Disaster Management

• Rural community clinic for orthopedics

II. TEACHING AND TRAINING ACTIVITIES:

The fundamental components of the teaching program should include:

1. Case presentations & discussion- once a week

2. Seminar - Once a week

3. Journal club- Once a week

4. Grand round presentation (by rotation departments and subspecialties)- once a week

5. Faculty lecture teaching- once a month

6. Clinical Audit-Once a Month

7. A poster and one oral presentation at least once during their training period in a recognized conference.

The rounds should include bedside sessions, file rounds & documentation of case history and examination, progress notes, round discussions, investigations, and management plan) interesting and difficult case unit discussions.

The training program would focus on knowledge, skills, and attitudes (behavior), all essential components of education. It is divided into theoretical, clinical, and practical into all aspects of the delivery of rehabilitative care, including the methodology of research and teaching.

• Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia, and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary given inadequate exposure to the subject in the undergraduate curriculum.

• Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in three years to the combined class of teachers and students. A free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

• Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing, and management in rehabilitation practice.

• Bedside: The trainee would work up cases, and learn the management of cases by discussing them with the faculty of the department.

• Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation from other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

• Research: The student would carry out the research project and write a thesis/ dissertation by NBE guidelines. He/ she would also be given exposure to partake in the research projects going on in the departments to learn their planning, methodology, and execution to learn various aspects of research.

Methods of Training and Teaching: The following learning methods are to be used for the teaching of postgraduate students:

• Journal Club: One-hour duration, once per week. It should cover recent papers published in reputed journals on a particular topic.

• Seminar: One-hour duration, once per week. The topic should be prepared by the resident under the supervision of the faculty.

• Case presentation: Clinical case presentations by the postgraduate student before the faculty. Should preferably involve one long case or two short cases in each class.

• X-Ray Classes- Held twice weekly in the morning in which the radiological features of various problems are discussed.

• Surgical- pathological - radiological conference: Cases with relevant surgical pathology and radiology should be discussed in detail with help of other departments.

• Death and Complication Meet: The whole department should organize a death and complication meet on the last working day of every month. All deaths that occurred in emergency wards, and all complications that occurred during the management process should be discussed in necessary detail and the necessary steps to prevent them may be outlined wherever possible.

• Exposure to Special clinics like Scoliosis Clinic- Held once a week. Residents work up the cases of spinal deformity and present them to a faculty member and the management plan is recorded in the case file.

• Hand Clinic- Held once a week. All the cases of hand disorders are referred to the clinic and discussed in detail.

• CTEV Clinic- Held once a week corrective casts are given and the technique is learned by the residents. Surgical management is also planned & recorded in the case file.

• Polio- Clinic- Held once a week, various braces & Calipers are prescribed and surgical management is planned.

• Combined Round/Grand Round: These exercises are to be done once or twice per week involving the presentation of all inpatient cases. The workup and management plan should be discussed.

• Post Emergency Day Round: The resident should collect the overall data of all patients attending the orthopedic emergency. He should collect relevant radiographs and clinical data of all patients admitted in an emergency. Any important patient not admitted should also be included. All these data should be briefed (in necessary detail) to the faculty in charge.

• Instruments, Orthosis, Prosthesis, walking Aids, etc.

• Surgical Audit

• Preoperative planning for surgical cases to be operated

• Clinical teaching: In OPD, ward rounds, emergency, and operation theatres: the resident should make discussions on clinical diagnosis/surgical procedures/treatment modalities with senior residents or faculty on duty. The resident should get well-versed in preoperative planning, postoperative care, subsequent follow-up, maintenance of case records, and preparation of discharge slips and other necessary paperwork. The resident should also interact with physiotherapists about the management of patients.

• Clinical interaction with physiotherapist: Clinical interaction with a physiotherapist about managing the patients in post-op mobilization.

• Research methodology: A course on research methodology, ethical issues in patient care, biostatistics, evidence-based medicine, language proficiency, etc. are to be arranged by the institute.

III. SYLLABUS:

1. Basic Sciences:

• Development of skeleton & mineralization of bone

• Soft tissue anatomy, histology, physiology, injury, and repair: meniscus, articular cartilage, muscle, tendon, ligament, nerve

• Bone: histology & histopathology of bone, physiology of fracture healing, delayed and non-union of bones, biophysical properties of bone, bone grafting, bone graft extenders and substitutes

• Biomechanics: gait, hip & knee arthroplasty, cerebral palsy

• Pathological tests for orthopedic disorders, tissue diagnosis, synovial fluid analysis, molecular diagnostic methods

• Imaging: application of USG, CT scan, MRI, nuclear medicine in Orthopaedics Ethics in Orthopaedics, evidence-based practice, outcome assessment, use of biostatistics

• Clinical examination: hip, spine, knee, shoulder, elbow, wrist and hand, ankle and foot, deformity, neurological examination

• Orthoses for orthopedic disorders

• Surgical approaches

• Electro diagnosis

• Biomaterials in orthopedics, Plaster of Paris, and metals

• Minimal access surgery, computer-assisted surgery &Navigation

• Peripheral nerve injuries

• Electro diagnosis

• Vascular Injuries

• Fluid Management & Nutrition in Traum atized patient

• Bone Bank

• Wound Healing

• OT discipline and Ethics

2. Infections:

• Pyogenic - osteomyelitis- acute and chronic, septic arthritis, infection in presence of implant and prosthesis, Necrotizing fasciitis, Gas gangrene, Toxic shock syndrome, Septic Arthritis, and its sequel

• Tuberculosis - spine, hip, knee, and other sites, medical, non-operative, and operative treatment, paraplegia care with care of the bladder, late-onset paraplegia;

• Syphilis, mycotic infections, salmonella & brucella osteomyelitis,

3. Metabolic bone disorders:

• Calcium, phosphate, and vitamin D metabolism

• Rickets, osteomalacia, renal bone disease, hyperparathyroidism

• Scurvy

• Osteoporosis

• Osteopetrosis

• Paget's disease

• Various storage disorders

4. Musculoskeletal oncology:

• Evaluation and staging

• Benign and malignant bone and soft tissue tumors

• Methods and principles of Biopsy

• Principles of surgical treatment, options for limb salvage surgery

• Chemotherapy and radiotherapy

• Metastatic bone disease-diagnosis

5. Arthritis:

• Osteoarthritis

• Rheumatoid arthritis

• Ankylosing spondylitis

• Noninfectious Arthritis

• Sero-negativespondyloarthropathy

• Crystal arthropathy- gout and pseudogout

• Neuropathicjoints

• Traumaticarthritis

• Others

6. Joint reconstruction:

• Corrective Osteotomies around joints like hip, knee, shoulder, elbow, etc.

• Arthrodesis: shoulder, hip, knee, elbow, wrist, ankle, subtalar; indications and technique

• Arthroplasty: Tribology, total hip, shoulder & knee replacement, basics of replacement of other joints, partial joint replacement, surface replacement, basics of complications and their treatment

7. Orthopedics Sports Medicine:

• Clinical Examination of

• Principles of arthroscopy

• Shoulder instability: acute, recurrent, surgical stabilization

• Rotator cuff tear

• Shoulder Impingement

• Lateral and medial epicondylitis, elbow injuries

• Ligament and meniscal injuries of the knee, diagnosis, and management of ACL and PCL deficient knee

• Multi-ligamentous knee injury

• Clinical Examination of various knee, shoulder, ankle, and elbow pathologies of joint

• Chondromalacia

• Management of osteochondral defects

• Recurrent patellar dislocation

• Ankle ligament injuries

• Tendo achiles rupture, quadriceps tendon rupture, rupture of muscles

• Tendonitis, displacement of tendons

• Stress fracture

8. Pediatric Orthopaedics:

• Congenital and developmental disorders of the knee, hip, upper limb, spine, ankle, and foot.

• Connective tissue disorder: osteogenesis imperfecta, Marfan syndrome, Ehler-Danlos syndrome, etc.

• Genetic disorders: Neurofibromatosis, skeletal dysplasias

• Neuromuscular disorders: Myopathy, Cerebral palsy, myelomeningocele, post-polio residual deformity

• Perthes' disease, slipped capital femoral epiphysis, and osteochondritis

• Osteochondritis at various sites

• Angular and rotational deformities of lower limb and deformity correction and LLD Correction

• Juvenile rheumatoid arthritis. Hemophilic arthropathy

• Obstretic palsy of brachial plexus

• Miscellaneous- Battered baby syndrome, Birth injuries, Obstetric palsy, etc.

9. Nontraumatic disorders:

• Muscle contractures: quadriceps, deltoid, gluteusmaximus

• Snapping syndromes: hip, knee, scapula, shoulder

• Tendinitis and bursitis

• Synovitis and synovectomy

• A vascular necrosis of femoral head: etiopathology, diagnosis, management & hip sandwich technique procedure

• Transient osteoporosis of the hip.

• protrusionacetabuli

10. Traumatology:

• Polytrauma and multiple injured patient care

• Basic splint age and transportation techniques, ATLS

• Complications of fracture: especially compartment syndrome, fat embolism, crush syndrome, neurovascular injury, myositis ossificans, reflex sympathetic dystrophy

• Principles of closed treatment of fractures

• Principles of fracture fixation - external and internal; implants, instruments and prosthesis, plating and nailing

• Open fracture management, common flaps in open tibia fractures

• Pathological fractures

• Amputations and prosthetics

• Fractures and dislocations in children: physical injuries, operative principles in children, fractures around elbow: supracondylar, medial and lateral condyle capitellum; pulled elbow, forearm, and distal radius fractures, fracture of neck, shaft and distal femur, proximal and distal tibial physis

• Fractures in adults: scapulothoracic dissociation, fracture clavicle, fractures of the proximal humerus, shaft and distal humerus, Monteggiaand

• Galleazi fractures, fractures of capitalism, coronoid, olecranon, radial head, forearm, distal radius, scaphoid, metacarpal and phalanges, fracture of neck, intertrochanteric, subtrochanteric, shaft, and distal femur, fracture patella, fracture of the tibial plateau, shaft and pilon.

• Pelvic, acetabular and sacral fractures

• Management of malunion (especially cubitus varus and valgus, neglected Monteggia injury, distal radius) and nonunion (especially infected nonunion)

• Management of acute dislocation and fracture-dislocations: the sternoclavicular and acromioclavicular joint, shoulder, elbow, terrible triad, radial head, perilunate, sacroiliac, hip, knee, floating knee injury, patella, ankle.

• Management of chronic unreduced and recurred dislocations: hip, shoulder, elbow, panels, etc.

• Principle and practice of destruction steohistogenesis

11. Spine:

• Fractures and dislocations of the spine, non-operative and operative treatment

• Various spinal instrumentations

• Management of Pott'sspine

• Paraplegia care, bladder rehabilitation

• Congenital anomalies of the upper cervical spine, Kippel Feilsyndrome

• Scoliosis: infantile, juvenile, adolescent, neuromuscular

• Scheuermann disease

• Spondylolysis, spondylolisthesis

• Low back pain, prolapsed intervertebral disc

• Degenerative cervical and lumbar spine, lumbar canal stenosis

• Spine in ankylosing spondylitis and rheumatoid arthritis

• Tumors of the spine- primary and metastatic

12. Hand:

• Basics of microsurgery

• Flexor and extensor tendon injuries

• Fracture and dislocation in hand

• Diagnosis and management of peripheral nerve injuries

• Reconstruction of the upper limb in nerve injuries: brachial plexus, radial, ulnar and median nerves

• Injuries of wrist: scaphoid fracture and nonunion, perilunarinstability

• Disorders of wrist: Keinbock's disease, DRUJ reconstruction, arthritic wrist

• Volkmann is chemiccontracture

• Carpal tunnel syndrome and other compression neuropathies

• Rheumatoid hand management

• Dupuytren's disease

• Tenosynovitis, DeQuervian disease, trigger finger

• Hand infections

• Tumor and tumor-like conditions of the hand

• Cogenital handanomalies

13. Foot and ankle:

• Fractures of the calcaneus, talus, Lisfranc's, and Copart's fracture-dislocations, metatarsal fractures

• Management of sciatic and peroneal nerve injury

• Flat foot, tarsal coalition

• Hallux valgus and other halluxdisorders

• Claw toe, hammer toe, mallet toe, bunion, bunionette

• Diabetic foot and other neuropathic foot disorders

• Pes cavus

• Tarsal tunnel syndrome, Morton'smetatarsalgia

• Painful healing, plantar fasciitis

• Ingrown toenail

• Tendonitis: tendo Achilles, tibialis anterior and posterior

14. Rehabilitation:

• Orthosis, prosthesis and reconstruction Traction and Splintage Biostatistics, Research Methodology and Clinical Epidemiology Ethics

Medico-legal aspects relevant to the discipline

Health Policy issues may apply to the discipline

IV. COMPETENCIES:

1. Clinical Program:

During the first six months of residency, the student is expected to:

• Attend a basic surgical skill laboratory and resuscitation course Basic and Advances (to be organized by the institution)

• Attend a course on research methodology and how to pursue a thesis (to be organized by the institution)

• Learn bedside history taking and clinical examination inward and emergency; appropriate use of splints and traction, dressing of infected and surgical wounds, etc.

• Learn proper record keeping- clinical examination notes, progress notes, neural charts, interdepartmental referral notes, drug prescription, consent forms for various surgeries, tabulation of investigations, medico-legal documentation, pre-operative preparation orders, post-operative notes in detail, discharge slip preparation, resuscitation and death notes, etc.

• Be present in ward rounds and grand rounds, also attend calls from other departments with senior colleagues

• Learn and perform the closed reduction of common fractures and dislocations under supervision, application of plaster slab and cast, and give necessary advice to patients managed on an outpatient basis.

• Attend operation theatre, learn to scrub, and assist in cases.

• Attend OPD, examine patients, put clinical notes, and advise accordingly, under faculty supervision.

• Be familiar with a digital camera, computer, and internet; take clinical and surgical photographs and videos, make audiovisual presentations, search for references on the internet, keep data and record in digital format and analyze data for research work.

• Participate regularly in academic activities in the department

• Start thesis work under the allotted faculty member.

After 6 months till the end of 3 years, the student is expected to:

• Attend OPD, operation theatre, ward rounds, emergency duties, and specialty clinics as per departmental schedule

• Attend and present seminars, journal clubs, case conferences / difficult cases, death, and complication meet, surgical - pathological - radiological conferences regularly as allotted

• Get actively involved in the diagnosis and treatment of patients in the ward and emergency

• Assist or perform under supervision surgical work wherever necessary

• Attend/ participate / present scientific paper in national/zonal/state conferences

• Actively participate/help in the organization of departmental courses and workshops

• Maintain the log book properly and get it verified from time to time

• Submit thesis progress report six monthly and complete thesis work on time

2. Practical Training:

A Junior Resident doctor, pursuing a DNB course is expected to perform major and minor surgical procedures independently as well as under the supervision of a faculty member/senior resident.

• Student should be able to do many major procedures independently

i. Closed reduction of fractures

ii. External fixation of compound fractures

iii. Debridement of crush injuries

iv. Amputations

v. Internal fixation of common simple fractures

vi. Polio surgery such as TA lengthening, Steindler's procedure, etc. vii. Intra-articular injections

viii. Steroid injections for various painful conditions

ix. Sequestrectomy in chronic osteomyelitis

x. Corrective POP casts for club foot & other congenital deformities

xi. Biopsy from amass

• Student should be able to do the complicated surgical procedure under the supervision/guidance of senior colleagues/ faculty members

• Should be assisted

i. Joint Replacement

ii. Spinal Instrumentation

iii. Arthroscopy

iv. Limb salvage surgery

• Humanity/Ethics

• Lectures on humanity including personality development, team spirit, and ethical issues in patient care and human relationship including, public relations, by Psychologists and public relations officers, are to be arranged by the department/college.

• Should be trained to manage and handle mass casualties and natural disaster

V. LOG BOOK:

A candidate shall maintain a log book of operations (assisted/performed) during the training period, certified by the concerned postgraduate teacher / Head of the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal at the time of the final examination.

The logbook should show evidence that the before-mentioned subjects were covered (with dates and the name of the teacher(s) The candidate will maintain a record of all academic activities undertaken by him/her in the logbook.

1. Personal profile of the candidate

2. Educational qualification/Professional data

3. Record of case histories

4. Procedures learned

5. Record of case Demonstration/Presentations

6. Every candidate, at the time of the practical examination, will be required to produce a performance record (log book) containing details of the work done by him/her during the entire period of training as per the requirements of the log book. It should be duly certified by the supervisor as work done by the candidate and countersigned by the administrative Head of the Institution.

7. In the absence of the production of a log book, the result will not be declared.

VI. RECOMMENDED TEXTBOOKS AND JOURNALS:

JOURNALS

1. Indian Journal of Orthopaedics.

2. Journal of Bone and Joint Surgery (British & American Volumes).

3. Orthopaedic Clinics of North America.

4. Clinical Orthopedics and Related Research

5. Yearbook of Orthopaedics.

6. British journal of Rheumatology and Physical Medicine.

7. Journal of rehabilitation, Bombay.