Documentos de Académico
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Mr. Rhodes
22 February 2018
Five o’clock on a dark October evening, a young American soldier hides in the makeshift
barrack of his base in Iraq. Laying across the floor with the tip of his gun out a small hole in the
wall, he silently gazes through the eyeglass with an unbreakable focus. Anticipating a move from
the enemy, he keeps a sharp lookout for any sign of light in the pitch-black distance, hearing
nothing but the sound of his own heartbeat. The young soldier’s mind trickles with anxiety as he
hears a faint whistle and sees the outline of a missile fly through the air. The soldier makes a
rapid effort to dive into the nearest shelter but before he can fit his leg in, a huge blast of heat and
light engulfs the air around him. The soldier struggles into the shelter and slams the door. Yelling
out of pain and desperation, he looks down to see waterfalls of blood gushing out of his
cracked-open knee. As the soldier begins to lose consciousness, a faint ringing in his ears turns
into the piercing sound of sirens. Paramedics quickly rush him to the hospital, where they
proceed to amputate his left leg. Unlike wounded soldiers of the past, this man will walk again,
as a result of hundreds of years of groundbreaking work by pioneers in the orthopedic field. The
evolution of medical technology within orthopedics has made possible the treatment of people
like this wounded soldier. A career in orthopedics involves an extensive education, the study of
major historical developments, and constant attention to the changing use of technology.
Though the gradual development of the orthopedic subspecialty has occurred over the
Krehnbrink 2
last two centuries, the concept of fixing physical impairments dates back to the brink of human
existence. Ancient clinical records of primitive congenial and skeletal abnormalities, though
informal and non-diagnostic accounts, indicate the earliest efforts of orthopedic practice (Peltier
xxv). In fact, the basic understanding of human anatomy stems back to primitive times where,
according to recent evidence, the earliest orthopedic procedures took place. Cranial trephining,
the cutting open of the skull, first occurred among neolithic tribes where skull fractures resulted
from intertribal warfare, as well as hunting practices (Prioreschi 28). Despite the complexity of
the operation for the time, anthropologists recently discovered over 1,500 trephined skulls living
during the Neolithic Age spread over four different continents, demonstrating the quick diffusion
As humans evolved, so did the practice of skeletal correction. Many common orthopedic
treatments, such as splints and amputations, originated in ancient Egypt, a region that fostered a
great deal of advancements in orthopedic treatment. Records from 1,300 BC offer the first look
at humans’ attempt to treat injuries in a more methodical manner (Blomstedt 671). One of the
many cases from the records describes a fracture to the collar bone, where a physician uses two
leather splints to bind the patient’s bones to his arms. In a similar case, a patient experiences a
fracture to the humerus, in which leather stabilizes the disjointed bones. The study also reveals
the first use of wooden splints, typically reserved for the more extreme cases such as open
wound fractures (671). Alongside the expansion of splints came the development of prosthetics.
Similar to the splint, the earliest known artificial limb dates back to Egypt, where in the fifth
century BC, a skilled artisan created a wooden toe allowing a person who previously had his or
her toe amputated to walk again (674). Though a seemingly simple task, the toe’s complex
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design allowed for proper balance and free movement, features thought unattainable for the time
(Shier 9). Within a few centuries, the use of prosthetics spread rapidly, with different versions of
artificial limbs developing all over Europe by the fifteenth century AD (Peltier 10). Though
orthopedic operations continued to evolve over time, the major growth of the profession occurred
in the middle of the eighteenth century, in the midst of the Industrial Revolution (xxv). Around
this time, medicine branched off into different specialties, largely due to the influx of people into
metropolitan areas (xxv). This led to larger hospitals, and in order to more efficiently examine
and compare patients, doctors grouped them by their physical ailments. Moreover, doctors had
more opportunities to perform autopsies as the negative health impacts of urban life increased the
overall death rate. Exposure to more people with skeletal abnormalities allowed doctors to make
new observations and discoveries (xxv). Not long after the Industrial Revolution, orthopedics, as
Modern orthopedic practice stems from the work of a variety of pioneer physicians who,
during this time, collectively laid down the foundation of musculoskeletal treatment. Dr. Hugh
Owen Thomas, one of the first with the official title of an “orthopedic surgeon,” made significant
contributions. After finishing his early education, Thomas attended Edinburgh University for
specialized medical training (Ashwood and Wren 198). Inspired by his medical professors, as
well as the exposure from his studies, Thomas believed he could apply his extensive knowledge
private hospital containing only eight beds (198). Dedicated to his practice, the physician spent
day and night performing extensive research, notably on prosthetic devices and the use of silver
wire to fix internal fractures (199). As a result of this dedication, Thomas made two significant
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contributions that have heavily influenced the medical technology today. First, he invented
Thomas’ Splint, a unique contraption incorporating a metal ring, two rigid rods, and a leather
strap to hold a broken leg in place (199). Though the design did not gain popularity until after his
death, its structure remains the foundation of the modern splint. Additionally, Thomas created a
specific medical assessment known as the Thomas Test, which tested patients for hip deformities
through a series of physical examinations of the back and pelvis (199). The validity of the test
proved remarkable for its time and has many uses in orthopedic diagnoses today. Despite his
expertise, however, Thomas faced harsh criticism from the community for steering away from
traditional amputation practices. His works did not gain recognition until almost 50 years after
his death, when his nephew published a series of books describing his findings. As they
resurfaced, the advancements Thomas made over his lifetime paved the way to several other
remarkable breakthroughs. His hard work, dedication and contributions to the field would earn
him the title “the father of orthopedics” in the years to come (200).
A series of discoveries in the late 1860s prompted yet another time of change within
orthopedics. With the back-to-back creation of aseptic surgery and anesthesia, surgeons could
perform longer and more complex operations (Markatos et al. 162). In response to these
creations, many surgeons worldwide began designing and testing orthopedic implants made of
different materials. In the early twentieth century, British surgeon Sir William Arbuthnot Lane,
along with a team of orthopedists, created the first fracture plate made of stainless steel (163). As
the design evolved, the materials changed based on test results and new research. Vanadium, a
very elastic material, replaced steel for its ability to adjust to the conditions of the human body.
Stellite then replaced Vanadium, for its chemical inertness. The trend continued until Vitallium,
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a metal alloy containing chromium and copper, became the main material used in the creation of
During World Wars I and II, an extensive amount of operative progress occurred as a
result of the vast experience acquired by surgeons working on the battlefields. One particular
researcher, Dr. Ernest Hay Groves, introduced the idea of common carpentry screws as a way to
treat femoral neck fractures. Groves tested his new methods of intramedullary nailing on
wounded soldiers, thereby establishing the quickest method of neck fracture repair ever. Not
only did the use of screws prevent further injury to vascular connective tissue, but it also allowed
the fracture to heal without the use of plaster (Markatos et al. 164). In the period following
World War II, larger and more incremental changes began to take hold in orthopedic practice.
With the creation of antibiotics, surgeons could perform procedures without the risk of bacterial
infection. Additionally, the first version of the computerized axial tomography (CAT) scan
allowed doctors to diagnose a skeletal deformity without needing to cut open skin (165). These
gradual developments led to a large expansion of the field, with women beginning to break into
professional medicine. In 1983, a group of orthopedists founded the Ruth Jackson Orthopedic
Society in order to foster professional development for women orthopedists. This society greatly
contributed to a steady increase in the number of women pursuing medicine (Mazloom et al.
114).
Despite a net increase in the number of women practicing medicine in the past several
decades, the field of orthopedics experienced very slow growth in its number of female doctors.
In fact, of all surgical specialties, orthopedics has the lowest number of female participation,
women comprising only 14 percent of all orthopedic medical residents (“Stepping to the Front”
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6). In a study exploring this statistic, the Women’s Professional Development Symposium for
orthopedic doctors to discuss possible reasons why females have continued to turn away from the
field. The panel participants suggested the primary factors discouraging women include negative
perceptions of the field, the fear of an inability to balance work and life, and the male stereotype
in the field (6). In addressing these issues, the women primarily recommended that beginning
Despite the male-dominated label, many women pioneers in orthopedics have expanded
their horizons and paved the way to greatness for prospective women orthopedists. Dr. Carrie
Diulus, a practicing spinal surgeon from Cleveland, Ohio, has worked to defy this label by
developing the Multidisciplinary Spine Center at the Cleveland Clinic’s Medina Hospital (Park).
After completing her residency at the same hospital, Diulus saw the need for such a center, and
used her knowledge and resources to successfully build the practice. For her determination and
strong will, she has earned a superior reputation from her mentors, coworkers, and patients
(Park). Dr. Martha Murray, another woman pioneer in orthopedics, has also taken on the role of a
female leader. An associate professor of orthopedic surgery at Harvard University, Dr. Murray’s
achievements do not stop at her prestigious title (Romero 92). Recently, she conducted a small
study on the bridge-enhanced ACL repair (BEAR) procedure, an operation that makes normal
ACL reconstructive surgery much simpler by placing a blood-soaked sponge inside the torn
ligament (92). After observing patients who underwent the BEAR procedure, Dr. Murray
concluded the operation offers a much quicker recovery time and, because of its simplicity, costs
much less than normal ACL reconstruction (92). Just as Dr. Diulus made a profound impact on
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the orthopedic community, Dr. Murray’s work has contributed to the rise of this revolutionary
procedure.
As Dr. Diulus and Dr. Murray exhibit, one has many options when choosing a specific
track within orthopedics. The most popular subspecialties include sports medicine, prosthetics,
orthopedic nursing and orthopedic surgery, each career offering a unique application of
sports medicine professionals have a wide range of jobs, including certified athletic trainers for
high school, collegiate, or professional sports teams, chiropractic practitioners, and physical
therapists (Emeagwali 19). These professionals deal largely with athletes and treat temporary
musculoskeletal injuries (17). Sports medicine professionals typically work in a school or office
environment, but can also spend extensive time on the court, on the field, or in the gym (19).
Orthopedic nursing, on the other hand, has a more straightforward career path and traditionally
takes place in a hospital or clinical setting. Known for specializing in the broad treatment of
musculoskeletal injuries and disorders, orthopedic nurses have an array of responsibilities within
surgical units of hospitals and clinics. These include patient communication, surgery preparation,
surgical assistance and the oversight of patient rehabilitation (De Araujo and Eiras Cameron
1392).
If a student has an interest in orthopedics but does not want the one-on-one patient
interaction that comes with sports medicine or nursing, a career in prosthetics offers a great and
equally rewarding alternative. Prosthetics, a branch of surgery dealing with the artificial
replacement of missing or ill-suited body parts, has a few subspecialties, such as prosthetists and
orthopedics, primarily dealing with the design and implantation of artificial limbs to replace
amputated, damaged, or otherwise functionless body parts (Goggins et al. 2). Prosthetic
technicians, on the other hand, make and repair the braces and limbs prosthetists design. Unlike
the majority of sports medicine professionals and orthopedic nurses, prosthetists and prosthetic
technicians work in clinical lab settings ("Orthotic and Prosthetic Technician” 58).
Orthopedic surgery, perhaps the most rigorous subspecialty within orthopedics, comes
with many challenges that, once overcome, can make the profession extremely rewarding. The
branch of surgery dealing with the detection and treatment of musculoskeletal injuries and
deformities, orthopedic surgery has become one of the most quickly-changing branches of
medicine (“Orthopedic Surgery”). Orthopedic surgeons devote their careers to the treatment of
arthritis, bone fractures, dislocations, joint and ligament disturbances, and inflammation of
muscles and tissue (“Orthopedics”). Though most orthopedic surgeons work in hospitals, they
can also work in other areas, including specialized clinics or the United States military (Daniels
et al. e162). The annual salary of an orthopedic surgeon ranges between $250,000 and $500,000,
depending on the specialization and the location of the practice (Million Dollar Careers 108).
Prospective orthopedic surgeons have a very specific education path to follow in order to set
must first obtain a bachelor’s degree at a college or university. Generally, a major pertaining to
health science, such as biology, chemistry, or pre-medicine, will provide a student with the
strongest foundation in order to continue on his or her education path. While obtaining an
undergraduate degree, a student who desires a competitive edge when applying to postgraduate
Krehnbrink 9
research (Occupational Outlook Handbook 3 70). Once the student obtains a degree, he or she
must apply to medical school. A very competitive process, admission into most medical schools
requires undergraduate transcripts, letters of recommendation, an interview, and scores from the
Medical College Admission Test (MCAT) (370). Upon admission, a student spends the first two
years taking courses in general medical knowledge, including anatomy, microbiology, and
biochemistry (370). A student also studies the practice of healthcare, learning how to properly
interact with patients. In the final two years of medical school, a student will complete a series of
rotations in different areas of internal medicine, working directly with patients under the
should perform research and even complete sub-internships to prepare for residency, the next
step in the education process (Jazrawi et al. 18). After medical school, a student must apply to a
residency program specific to orthopedic surgery, where he or she will gain practical experience
and complete intensive research (96). This lasts a minimum of five years, but may run longer
depending on the location (138). Upon completion, a student has the option of completing a
fellowship if he or she wants to specialize further in areas such as spinal or knee surgery (118).
However, orthopedic surgery, as a general practice, does not require any training beyond
residency (138). Once a student has completed the five required years of residency, he or she
must pass the United States Medical Licensing Examination (Occupational Outlook Handbook
370). After successfully completing the exam, a student has all of the credentials to officially
The University of North Carolina at Chapel Hill (UNC-Chapel Hill) and Duke University
both offer great undergraduate and graduate programs for North Carolina students wishing to
pursue orthopedic surgery. UNC-Chapel Hill, offering degrees in biology, chemistry, and
medical school (“Studies: University”). Duke University, offering the same majors, will also
equip a student with the right assets to continue his or her medical path (“Studies: Duke”).
Though they have similar programs, these universities differ greatly in terms of affordability.
Duke University, a private institution and thus the most expensive option, has an annual
undergraduate tuition totalling $47,243, with an additional $13,290 for room and board
(“Colleges: College Search"). A student who decides to pursue medical school at Duke
University will pay an annual $43,134, without additional fees (“Tuition”). With an acceptance
rate of 10 percent, a Duke student will have a competitive edge when applying to medical
schools (“Admission: Duke”). Similarly, UNC-Chapel Hill has a fairly low acceptance rate of 27
significantly lower annual tuition for in-state students than Duke, at $8,336 plus an additional
$10,592 for room and board (“Colleges”). An in-state student who pursues medical school at the
UNC-Chapel Hill will pay an annual $65,524, all fees included (“Cost of Education”).
Though orthopedic surgeons can practice once they pass their license exam, the education
does not stop. An orthopedic surgeon in practice must participate in continuing medical
education (CME) for the purpose of retaining all knowledge gained in medical school and
technologies (Leong 3). In order to meet the Maintenance of Certification (MOC) requirements
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of the American Board of Orthopedic Surgery (ABOS), surgeons must obtain and submit CME
Surgeons (AAOS), along with programs geared toward orthopedics. Depending on a specialty or
interest, he or she has a wide variety of educational courses to choose from to fulfill these credits
("Getting Your CME Credits” 12). Though most medical professions must undergo CME, it has
proven particularly important within orthopedics due to the rapidly-changing uses of technology
Over the last 50 years, a broad series of technological developments has led to massive
advancements within orthopedics. Artificial intelligence (AI), a recent phenomenon, has already
had a substantial impact on the way doctors approach orthopedic treatment. Current studies
surrounding AI’s potential use in analyzing skeletal radiographs provide compelling evidence in
support of its importance in the future of orthopedics (Olczak et al. 581). In a recent studying
seeking to determine the accuracy of AI in this radiograph analysis, a group from Karolinska
Institute of Technology in Stockholm, Sweden concluded that several deep learning programs,
including the Visual Geometry Group Convolutional Neural Networks (VGG CNN), matched
identifying central properties in radiographs (581). In fact, some programs exceeded human
performance in image analysis. The implementation of AI in hospitals and clinics comes with
many advantages, as doctors will have the ability to analyze radiographs quickly and in
unlimited quantities, opening the door to new studies with much clearer image viewing
(McLaughlin). AI also has extremely high potential in an emergency room setting where
screening must occur immediately. Moreover, the programs identify new patterns of bone
Krehnbrink 12
injuries in tracing limitless amounts of fractures. Ultimately, using AI will eliminate the risk of
historically-human tasks raises a few fundamental and ethical questions. The few programs
available for this purpose do not analyze any image with the slightest mark or scratch, presenting
a major setback (Olczak et al. 585). Additionally, the programs can not analyze multiple images
at once, so if a particular injury diagnosis requires multiple views, an AI program will not derive
it from a single image (585). Lastly, a radiograph report generated from a computer will not
answer a patient’s questions about his or her injury as a doctor could. Consequently, the thought
of technological devices performing doctors’ duties creates apprehension among patients (585).
Despite these limitations however, the rapid development of AI will undoubtedly influence the
In the last decade, orthopedic research and diagnosis evolved faster than ever. Optimal
understanding of orthopedic injuries requires high quality 3-D imaging that did not exist half a
century ago (Chen et al. 131). The heavy application of digital technology in identifying a
problem, coming up with the best operative plan, and mapping out recovery proves its great
biomechanics has led to the creation of “digital orthopedics,” a broad integrative field of study
that combines image processing, medical technology, and orthopedic simulation (132). One of
the most notable breakthroughs in digital orthopedics involves the application of virtual reality
(VR) in orthopedic surgeon training. In the past, inexperienced surgeons trained by studying
x-ray screenings and manually modifying them in preparation for an operation. However, VR
Krehnbrink 13
allows doctors to program surgical scenarios on a screen and create a preoperative plan,
eliminating any sources of error at the time of surgery (132). Though most full VR systems
remain in developmental stages, the programs have vast potential in the future of orthopedic
surgery (132).
Another area of digital orthopedics, called rapid prototyping (RP), has proven paramount
control of lasers, RP encompasses the creation of body parts, such as bone and tissue, using
synthetic materials and computer aided design (CAD) software (Chen et al. 132). Through
extremely meticulous layering processes, RP quickly creates these parts with high precision
(133). Thus far, RP has advanced many orthopedic treatments, including jaw deformity repairs,
cranioplasties, and bone tissue engineering (133). Specifically, it aided in the design of new
materials for specific procedures, such as titanium plates for cranial reparation and
polycaprolactone scaffolds for skeletal tissue replacement. Aside from the benefit of more
durable tissue and bone replacements, RP models have great use in planning complex surgical
procedures (133).
In addition to RP, other new technologies have fostered great advancements in the
creation and testing of prosthetic devices. Programs within computational biomechanics, a new
and advanced field surrounding technological research of musculoskeletal behavior, allow for the
quick testing of relative strengths of fracture repair appliances (Chen et al. 134). Moreover, the
creation of “bio-inspired dexterous robotic hands” out of a variety of materials marks one of the
many ways these technologies impact prosthetic treatment (Saikia et al. 256). The Zurich-Tokyo
hand, a newer bionic device, has pressure sensors allowing the user to explore surfaces and grasp
Krehnbrink 14
objects on his or her own (257). The iLimb hand, arguably the most advanced bionic hand to
date, combines all of the newest breakthroughs in material and computer science. Aside from its
extremely versatile design, each finger on the iLimb runs on its own motor, giving the hand
extremely precise articulation (258). Its newest feature involves the placement of electrodes on
the skin of the amputee, allowing the transfer of myoelectric signals between the skin and a
software program that interprets the signals and controls the hand (258). This technology makes
the iLimb’s freedom of movement much more accessible to amputees. This accessibility,
coupled with the advanced skin technology, proves just how much of a reliance orthopedics will
and vital component of medicine for its application to a growing number of lives. From the
wooden plates used at the foundation of mankind, to the creation and design of bionic limbs, the
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