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Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (1)
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Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (1)
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Segment:0 .
Come on with us. I know. Yeah, Hi. Good let's get started, please. So, yeah, so this is your case. OK, so you've got these three questions. So what's this investigation? How is it created and what are the clinical indications for its use?
So if you want to put down some points for each of those three questions and then we can spend the next few minutes just going through, ok? OK 2 minutes over now, so we could start. OK, so do you want to give me? This is a picture of radioactive isotope scan showing and eat joint with the processes in place, and there is a high activity seen around the femoral prostheses on the posterior aspect and also over the entry in respect of the femur.
And there's also an increased uptake scene of Australia as part of that daimyo processes as well. OK, so what did you call? What was a scan particularly called? Is that the new isotope scan? I think it's OK. So see, peel-back, isn't it? Yeah, so. Emission tomography scan with a CT of a totally replacement, as you say.
OK, fine. And so how was it how was it created? So this is created on the principle that radioisotope is injected into the body and it goes into the tissues where it metabolize and release gamma radiation and gamma camera is used to detect those radiations, and then it makes a picture on the film.
And depending upon which part of the body is absorbing those radioactive dye and releasing gamma rays and the picture is taken and give the information or image it is used in cases like as we have seen used with bas status can or can be used with X-rays or bone scan and to see the metastases primary bone tumor loosening of the implant and eyeball fractures.
And then if you cannot see. So these are its uses. OK it's just out in the real fashion should be a normal renal function and to because the dice is fitted through the kidneys and there is a high radiation involved in this. It is expensive and not easily available. OK very good. So if we go through the answer for how is it created?
She covered some good points there. So is a form of nuclear imaging good and usually takes about 45 minutes to carry out. I'm not sure if you mentioned injection of XDG or fluid glucose. It's good to mention that type of because it's a radioisotope of fluorine 18. So that's combined with the glucose. And it's this that's taken up by some areas of high metabolic activity.
So the cells that are carrying high metabolic activity wherever they might be. Take this up. And so they undergo irreversible hospitalization and so they accumulate within the cells. They can't be exported. So the whole you've got this radioactive isotope now that's then emitting the positrons. OK, so these positrons then collide within the electrons in the soft tissues, and they generate photons as a form of energy.
And this is then picked up by the cameras that absorb it and then transfer that into electrical signals that create your image. OK, so that's a PET scan. But then you can combine that with a CT scan, and it can then provide an anatomical location of where that activity is. So it's an even better way of showing you where the activity is.
So I think you mentioned a lot of the points there. Maybe just a bit more detail of, you know, of the radioisotope that's used, the process in which you generate the images reliant on the, you know, the generation of the photons from the breakdown of the radiation that hits the electrons within the soft tissues. And that's how you get the signal and then the overlap of the city with the PET scan image because you get a PET scan.
But this is to so you're combining the two anatomical location for the pathology. So that maybe you've got an overall understanding there. Maybe just brush up on a bit more detail about the exact radioisotope and you go on to the next part. You then went on the clinical indications, so you mention that, you know, from indication point of view. So there is a malignancy, both benign and malignant tumors, parasitic infections, inflammatory arthritis and things like Paget's disease.
So anything that has high activity circulation, so it's great for showing those, but it doesn't always differentiate between those conditions because, you know, so it's not. It's sensitive, but it's not always specific, so, you know, it's showing there's activity, but you've got to put it as part of an overall clinical picture of what you're why you've arranged that investigation for that particular patient.
What you're querying, et cetera, that is that sort of. Is that clear? Yeah thank you. Any questions? OK so we can move to the third candidate. What do you make of this one then? So this is the AP and lateral radiograph of three-year-old child chose a anterolateral bowing of the leg.
This is a little bowing of the leg, as evidenced by the apex of the deformity being anterior. And lateral, it is associated with neurofibromatosis almost 50% of the time, this maybe as need to look for, assess the child in terms of looking for neurofibromatosis markers, kafeel spots anything in the AIIS. Any family history or any obvious neurofibromatosis along any of the nerves.
In terms of bowing of the legs. It may be anterolateral as in this associated with neurofibromatosis with a high risk of pseudoviruses. If it fractures, then there could be a middle bowing, which is associated with the fibula. And there could be postural medial bowing, which essentially self correct most of the time, but needs to be monitored for any limb length discrepancy as the child grows and could be having calkin your well guess, which also usually correct in terms of management for sorry.
Yeah, good carry on. In terms of management, I would want to protect this child with a brace while it is board to prevent any fractures. And he said it is painless. So but he'd need to be protected, protected because once it fractures, there's a very high risk of the pseudoviruses, non-union and difficulty to achieve union once it fracture.
So it has to be protected with the brace to prevent that. If if it presents with the fracture, then it's a very complicated scenario, it will need an MDT approach. I would discuss with the specialist with the principles of those management would involve a combination of osteotomy stabilization and grafting combination of those three, and it might need to be done in a staged manner.
OK, before I move on to the answers, I'll just ask you a couple of questions. So what type of fixation would you use? Would you use a plate and screws? You know it would have to be incrementally? OK all right. And is there any can have one more word that you might need to consider in this case should they go on to develop versus.
Osteotomy Yeah. If that fails. I'm OK. All right, let's move on. So this is the answer. So you were correct. This is an AP lateral radiograph, right? Lower limbs, mature patient.
It is a lateral bowing. And you pick that up correctly. You did mention the mdc-t approach, and these are the types, which you mentioned correctly. So the poster remedial one is the physiological one, which usually self correct the anterior medial. One is the one associated with Femi fibula Emilia. And again, you monitor it. You might need to reconstructive surgery, and it's got associations with things like ball and socket, ankle joint and things like that.
And then the anterolateral one is the one that you often get in the exam because it's the one that's associated with neurofibromatosis. And you correct 50% have got neurofibromatosis, but only 10% of neurofibromatosis patients have this disorder. Total contact cast into medullary nail. You're correct, you don't use a plate and screws. There's a very high risk of failure. You can use external fixation bone graft, as you said.
And you know, if you fail to get union, the last resort is amputation. And because their children, generally, you can fit them with an oasis and they do quite well. But that is the last resort and we do a lot of other things first. So well done for me, that was a very good answer. And you got all the points, but extra. What dimension was an amputation?
Yes Yeah. Yeah we just like to put that in at the end because it is a possible outcome. It's probably a lot rarer these days, but we have to put it in there because it's a big, you know, it's rare, but it's an important complication. OK, so next clinical, you may get spine. I had horrible spine. In my opinion.
Clinical side is my long case for my lung case. So how did you go with this young girl? So this is a clinical photograph showing this young lady's back. And also, it shows on the left hand side. And Jonathan said it shows Adam's forward ending this on the left hand side. They can see us a third circle lumbar curve was to the right and then pump on the right hand side.
So I will begin by taking history from the patient about the progression, so there is a progression. Is it painful or not? Does she have any signs of spinal problems like pins and needles and both legs weakness or bladder problems and any gait problems? Also, I would take history about when did not start and family history, about any similar conditions in the family or any needs places.
And also about, I think, any lumps elsewhere. OK, so the school nurse noticed it about six months ago. She doesn't have any pain. She's a bit fatigued at the end of the day, no neurological symptoms. She started mwaniki six months before. And there's no family history of any other problems, so tell me how you're going to examine this girl.
So Alexandra first examines the gait. So I was asked to walk and see if she has any sort of gait, including any. Lower limb problems, long blades discrepancies can cause a compensatory curve. Then I will examine her standing, so looking from the back, I have already had a look. Get a closer look to see if there's any evidence of spinal dystrophies that like bone, was hairy.
But she's also in skin discoloration is completely. Then it would look from the side for the curves of the spines of the forces of the spine and of the lumbar spine. And then looking from the front the shoulder levels to. So it looks like the left shoulder is a little bit lower than the right. And I don't see much of it.
Also, there is a bit of pelvic complexity. So the left pelvis is a little bit higher than the Elvis. But I would like to block this to if there is any discrepancy identified by the knee levels too. If not, I will get the patient to lie down. Perform a full examination of the first sensation.
Also pull up the reflexes and tell me how you do the abdominal reflexes so that I divide the opportunity to four quadrants and I begin striking from lateral to the midline and seems like this moves towards my toes, my scratch. All right. So her neurological examination is normal.
Yes so what would you like to do next? I'll get a full standing X-ray for the whole spine. AP lateral, open muscular and lateral also get supine bending views to the right hand to the left. So I will be looking at the standing static views of the stunning views. I'm sorry, I will look up to the severity by measuring the cops angle and on the bending views, I will look for the credibility of the deformity.
Ok? and I guess I think that's come up to our five minutes. But so. So the history you're correct. Pain, neurological symptoms. Age of menarche. Why is the age of menarche important? Because the following year, he has the quickest or fastest rate of progression.
Or that's why if the patient is within a year or before, I would suspect that the disturbance will progress over. If it was a million years past, the contribution will be lower. And yes, the point of monarchy is that I agree with you it can progress quite rapidly, but usually the growth plates so you reach skeletal maturity round about the time round, about 18 months after the onset of menarche in women.
You can use that as one marker of skeletal age. The other thing you could talk about was. Signs to see when they're going to fuse. Because you know, when you're in, you're still growing. You've got a growth spurt, then the curve is going to progress quite rapidly. So that's why you need to have some idea of when they're going to fuse. So we know that girls generally are around about 14 years old, whereas boys are 16.
But the Heinicke and the rises and signs on the public sector will give you some idea in assessing their skeletal maturity. Adams forward bending tests look for prominence, structure, deformity. Yet you describe that to me. I know it's described as a rib hump. I was taught that saying hump in the hump in front of adolescent girls can make them quite paranoid.
I was an adolescent girl once. I don't think it would have made me paranoid, so I always make it a point of saying we prominence rather than hump. Having said that, I was in an exam and I said rib prominence, and the examiner said this girl knows what it is to call it a hump. So, you know, I think it's nicer to say prominence. But you know, if you say hump, you know, I think people know you described in a then that was fine indications for MRI.
There would be those things. I think in general, we tend to MRI scans anyway because everybody is everybody expects an MRI scan and everybody's a little bit scared. But we generally do. I think radiographs now I was taught that an AP radiograph gives less radiation to the breast tissue, but there's only certain areas that do it. It's not a generalized thing.
And I think as long as you're asking for the view and the bending X-rays to assess them because you're going to look for the Cobb angle, then that should be OK. You could mention AP, but as I said, not everywhere does them and then the principles of treatment. So, you know, this is a clinical exam, so you may not get to this, but you've got your choice of observation, bracing and surgery.
If you're going to observe, you need to be able to say how often you're going to review them. We used to review them every six months to see if they progress. Then we went to 12 bracing. What you need to know about bracing is the need to wear it. 23 hours a day. And if you're an adolescent girl and it's the middle of the summer, you are not necessarily going to be compliant with that brace.
So just be aware of that pressure area things. It's horrible, but it may be a better option for some. If they've only got, you know, a few months before they become seriously mature, then you may get away with the brace because the option is surgery and surgery to your spine is not really a pleasant thing to go through for anyone, either. So you could in this vibe, get to talking about how you would measure a cabango.
My experience of having spine in the exams of the clinical situations is that it's just about assessment and ruling out any major neurological problem. But if you've got it in vyver, you could be asked to calculate common goals and things like that. OK yeah, just going to give you a minute just to formulate your thoughts about this 45-year-old man with the groin pain.
OK do you want to? Tell me what you think of these images and what might be going on with this, so they do enough of the pelvis to show that there's increased exclusives on the left here, although I couldn't see any collapse of or any distortion of the LED light side on the left looks OK. And in the image below, the T2 weighted image of the MRI shows that there is area of May of sclerosis and the area of the sublicense on board from the one on the left side.
All right. Tell me about the MRI. So on the MRI on the left side, I could see that on the similar superior open muscular aspect of the female head, there is decreased signal intensity. And apart from that, most probably there is a sorry there is a line going there showing subconscious collapse.
Maybe the sign is there on the left side left it. And on the vote on the latest, there is a decrease in intensity on the CPI aspect, but there is no Christian there. OK, so so what do you think a diagnosis might be here? My diagnosis is a question of causes of the femoral head by lately more on the left side than light. What are the risk factors for developing a vein that you might be aware of?
So the risk factor, like if it could be one of the most common is post-traumatic, apart from the idiopathic and the is. Apart from that, other risk factors involved in the radiation or alcoholic, if the patient is a smoker and any sickle cell disease or any high level state any. Then if the patient is a diver, then we could think of chicest disease as well.
And apart from that, any other immunosuppressive immunosuppressant conditions like ongoing chemotherapy or radiation? That's fine. So what do you know? So the pathogenesis of arvn, you know what? What's the thought of what's been, what's going on? Why does it happen? So there's like a one off.
So there are different theories, but one of the theories like intravascular coagulation that is the arteries supplying the female head are affected. Then the other one is like venous tess's and the other one is like fat micro impolitely, the micro blood flow to the female head. That's fine. So tell me a little bit, do any how you might be able to classify it?
So in terms of classification, the dates are let's staging in with the stage 0 is like there is nothing on the changes on the female, on the left as well as MRI. The changes we see on the histology and then in stage one is the changes could be seen on the MRI only. Stage two there is sclerosis and fragmentation of the femoral head. It is divided into stage 2 and 2 2b.
There is the decrease sign present where there's a collapse and then in the stage three days for the fragmentation of the femoral head. Then in stage four legs complete outside on the femoral as well as on the acetabular side. So what? What's the significance of the present sign? So the Christian sign signifies that there is irreversible collapse of the female head.
And then it has it been like guiding our towards our management because if the Christian sign is present, then we have to go towards the replacement rather than doing any of the procedures like you touching, touching upon management now. OK, so how so how would you what would you consider to do for this, for this child, for you in terms of management, like on the left hand side, there is a potential for collapse already present.
So we could go for. Let's say that on the left side, it's not quite collapsed, it's maybe pre slap stage. Uh, so then there is the option of what's called. Are drilling through the cortex, our quad core decompression is about to get decompression. And what you consider before you do that because that's invasive, isn't it? Yeah so it comes like initially before I could go for like non-operated treatments such as this, like clinically examine and assess.
This is like how much is functional and daily activities are limited. If it's clinically not limited and the pain is not severe, then we can postpone any surgery as far as quality time as far as we can. OK apart from that, there is like options of starting bisphosphonate, but I'm not sure how much effective they are. OK, so that's an option, isn't it?
So that is not that might prevent collapse. OK you mentioned a core decompression. Yeah as opposed to compression could be done before the collapse of femoral head taken place. You can drill up to the bone to relieve the incautious pressure and stimulate the healing response. OK, fine. And what about if you've reached the collapsed stage now? What are you going to do sort of stage three?
So there's like if you want to delay the replacement, stay like this, what other procedure in which we can do this vascular rock the I can't remember the name, which was, let's say, is advanced to arthritis now. So what? Well, story in terms of advance authorities, then the decision five, isn't he? Yeah so he would need a replacement.
He's 45. So I would go for the uncommitted. Totally replacement for him. Yeah OK. What what sort of paring surface for this age group? So, yeah, in terms of bearing very surface, it would be I would try to use. best would be, I think, metal on metal polythene claw palsy in this age group.
45 years. I'm not sure. Yeah 45 years. We don't use that. OK great, right? Better get through to think through the answers. So you start off well. So, you know, you did the diagnosis. You mentioned the changes on the radiographs quickly mention it's a T2 coronal MRI.
OK? and you can see this sort of double line sign. And this is all consistent with avascular necrosis. So classification you rattle through this quite well. I think you covered that quite well, which which is good. I don't think I had a major issues with what you said about that one. Largely, the management is guided by that, isn't it, so you've got sort of a split up and your had sort of pre collapse collapse in 08.
So, you know, the first sort of two stages. You thinking about pre collapse, it still can still salvage something here. Protected weight bearing consider bisphosphonates core decompression. I mentioned some people drill up and put stem cell injection as well up there. Some people use fabulous drug grafts as well. There's the tantalum rods as well.
You might have seen those some people use that as well. That's a consideration. And then once you go into the stage three, you kind of, you know, you've got some collapse now you've got the Crescent sign you thinking possibly the rotation osteotomy can be considered, you know, to offload that and put it onto the weight of different parts of the femoral head. And then once you get into the stages of 4 to six, it's just basically different stages of it.
And then you're talking about salvage at this point, there's nothing really else you can offer this guy apart from either continue as he is or bite the bullet and go down a replacement route. So you've got to make sure that about the enger data to the young guy. Don't mention all metal on poly, OK? You know you got to be thinking ceramic bearing and really ceramic on poly actually works quite well.
You can say ceramic on ceramic, but the angle does suggest that ceramic and poly do better. And you can argue ceramic and ceramic has got risk factors. You know, it's more expensive, it's squeaking, it's brittleness and fracture and things like that which you don't necessarily get with ceramic on poly. So and you can use on cement as you might think. While the local biology might not be great because he's had this condition that's not been proven you can use on cement it in these cases.
OK, so good. So overall, you've got the knowledge, just Polish up, then you'd be fine.
Segment:0 .
Come on with us. I know. Yeah, Hi. Good let's get started, please. So, yeah, so this is your case. OK, so you've got these three questions. So what's this investigation? How is it created and what are the clinical indications for its use?
So if you want to put down some points for each of those three questions and then we can spend the next few minutes just going through, ok? OK 2 minutes over now, so we could start. OK, so do you want to give me? This is a picture of radioactive isotope scan showing and eat joint with the processes in place, and there is a high activity seen around the femoral prostheses on the posterior aspect and also over the entry in respect of the femur.
And there's also an increased uptake scene of Australia as part of that daimyo processes as well. OK, so what did you call? What was a scan particularly called? Is that the new isotope scan? I think it's OK. So see, peel-back, isn't it? Yeah, so. Emission tomography scan with a CT of a totally replacement, as you say.
OK, fine. And so how was it how was it created? So this is created on the principle that radioisotope is injected into the body and it goes into the tissues where it metabolize and release gamma radiation and gamma camera is used to detect those radiations, and then it makes a picture on the film.
And depending upon which part of the body is absorbing those radioactive dye and releasing gamma rays and the picture is taken and give the information or image it is used in cases like as we have seen used with bas status can or can be used with X-rays or bone scan and to see the metastases primary bone tumor loosening of the implant and eyeball fractures.
And then if you cannot see. So these are its uses. OK it's just out in the real fashion should be a normal renal function and to because the dice is fitted through the kidneys and there is a high radiation involved in this. It is expensive and not easily available. OK very good. So if we go through the answer for how is it created?
She covered some good points there. So is a form of nuclear imaging good and usually takes about 45 minutes to carry out. I'm not sure if you mentioned injection of XDG or fluid glucose. It's good to mention that type of because it's a radioisotope of fluorine 18. So that's combined with the glucose. And it's this that's taken up by some areas of high metabolic activity.
So the cells that are carrying high metabolic activity wherever they might be. Take this up. And so they undergo irreversible hospitalization and so they accumulate within the cells. They can't be exported. So the whole you've got this radioactive isotope now that's then emitting the positrons. OK, so these positrons then collide within the electrons in the soft tissues, and they generate photons as a form of energy.
And this is then picked up by the cameras that absorb it and then transfer that into electrical signals that create your image. OK, so that's a PET scan. But then you can combine that with a CT scan, and it can then provide an anatomical location of where that activity is. So it's an even better way of showing you where the activity is.
So I think you mentioned a lot of the points there. Maybe just a bit more detail of, you know, of the radioisotope that's used, the process in which you generate the images reliant on the, you know, the generation of the photons from the breakdown of the radiation that hits the electrons within the soft tissues. And that's how you get the signal and then the overlap of the city with the PET scan image because you get a PET scan.
But this is to so you're combining the two anatomical location for the pathology. So that maybe you've got an overall understanding there. Maybe just brush up on a bit more detail about the exact radioisotope and you go on to the next part. You then went on the clinical indications, so you mention that, you know, from indication point of view. So there is a malignancy, both benign and malignant tumors, parasitic infections, inflammatory arthritis and things like Paget's disease.
So anything that has high activity circulation, so it's great for showing those, but it doesn't always differentiate between those conditions because, you know, so it's not. It's sensitive, but it's not always specific, so, you know, it's showing there's activity, but you've got to put it as part of an overall clinical picture of what you're why you've arranged that investigation for that particular patient.
What you're querying, et cetera, that is that sort of. Is that clear? Yeah thank you. Any questions? OK so we can move to the third candidate. What do you make of this one then? So this is the AP and lateral radiograph of three-year-old child chose a anterolateral bowing of the leg.
This is a little bowing of the leg, as evidenced by the apex of the deformity being anterior. And lateral, it is associated with neurofibromatosis almost 50% of the time, this maybe as need to look for, assess the child in terms of looking for neurofibromatosis markers, kafeel spots anything in the AIIS. Any family history or any obvious neurofibromatosis along any of the nerves.
In terms of bowing of the legs. It may be anterolateral as in this associated with neurofibromatosis with a high risk of pseudoviruses. If it fractures, then there could be a middle bowing, which is associated with the fibula. And there could be postural medial bowing, which essentially self correct most of the time, but needs to be monitored for any limb length discrepancy as the child grows and could be having calkin your well guess, which also usually correct in terms of management for sorry.
Yeah, good carry on. In terms of management, I would want to protect this child with a brace while it is board to prevent any fractures. And he said it is painless. So but he'd need to be protected, protected because once it fractures, there's a very high risk of the pseudoviruses, non-union and difficulty to achieve union once it fracture.
So it has to be protected with the brace to prevent that. If if it presents with the fracture, then it's a very complicated scenario, it will need an MDT approach. I would discuss with the specialist with the principles of those management would involve a combination of osteotomy stabilization and grafting combination of those three, and it might need to be done in a staged manner.
OK, before I move on to the answers, I'll just ask you a couple of questions. So what type of fixation would you use? Would you use a plate and screws? You know it would have to be incrementally? OK all right. And is there any can have one more word that you might need to consider in this case should they go on to develop versus.
Osteotomy Yeah. If that fails. I'm OK. All right, let's move on. So this is the answer. So you were correct. This is an AP lateral radiograph, right? Lower limbs, mature patient.
It is a lateral bowing. And you pick that up correctly. You did mention the mdc-t approach, and these are the types, which you mentioned correctly. So the poster remedial one is the physiological one, which usually self correct the anterior medial. One is the one associated with Femi fibula Emilia. And again, you monitor it. You might need to reconstructive surgery, and it's got associations with things like ball and socket, ankle joint and things like that.
And then the anterolateral one is the one that you often get in the exam because it's the one that's associated with neurofibromatosis. And you correct 50% have got neurofibromatosis, but only 10% of neurofibromatosis patients have this disorder. Total contact cast into medullary nail. You're correct, you don't use a plate and screws. There's a very high risk of failure. You can use external fixation bone graft, as you said.
And you know, if you fail to get union, the last resort is amputation. And because their children, generally, you can fit them with an oasis and they do quite well. But that is the last resort and we do a lot of other things first. So well done for me, that was a very good answer. And you got all the points, but extra. What dimension was an amputation?
Yes Yeah. Yeah we just like to put that in at the end because it is a possible outcome. It's probably a lot rarer these days, but we have to put it in there because it's a big, you know, it's rare, but it's an important complication. OK, so next clinical, you may get spine. I had horrible spine. In my opinion.
Clinical side is my long case for my lung case. So how did you go with this young girl? So this is a clinical photograph showing this young lady's back. And also, it shows on the left hand side. And Jonathan said it shows Adam's forward ending this on the left hand side. They can see us a third circle lumbar curve was to the right and then pump on the right hand side.
So I will begin by taking history from the patient about the progression, so there is a progression. Is it painful or not? Does she have any signs of spinal problems like pins and needles and both legs weakness or bladder problems and any gait problems? Also, I would take history about when did not start and family history, about any similar conditions in the family or any needs places.
And also about, I think, any lumps elsewhere. OK, so the school nurse noticed it about six months ago. She doesn't have any pain. She's a bit fatigued at the end of the day, no neurological symptoms. She started mwaniki six months before. And there's no family history of any other problems, so tell me how you're going to examine this girl.
So Alexandra first examines the gait. So I was asked to walk and see if she has any sort of gait, including any. Lower limb problems, long blades discrepancies can cause a compensatory curve. Then I will examine her standing, so looking from the back, I have already had a look. Get a closer look to see if there's any evidence of spinal dystrophies that like bone, was hairy.
But she's also in skin discoloration is completely. Then it would look from the side for the curves of the spines of the forces of the spine and of the lumbar spine. And then looking from the front the shoulder levels to. So it looks like the left shoulder is a little bit lower than the right. And I don't see much of it.
Also, there is a bit of pelvic complexity. So the left pelvis is a little bit higher than the Elvis. But I would like to block this to if there is any discrepancy identified by the knee levels too. If not, I will get the patient to lie down. Perform a full examination of the first sensation.
Also pull up the reflexes and tell me how you do the abdominal reflexes so that I divide the opportunity to four quadrants and I begin striking from lateral to the midline and seems like this moves towards my toes, my scratch. All right. So her neurological examination is normal.
Yes so what would you like to do next? I'll get a full standing X-ray for the whole spine. AP lateral, open muscular and lateral also get supine bending views to the right hand to the left. So I will be looking at the standing static views of the stunning views. I'm sorry, I will look up to the severity by measuring the cops angle and on the bending views, I will look for the credibility of the deformity.
Ok? and I guess I think that's come up to our five minutes. But so. So the history you're correct. Pain, neurological symptoms. Age of menarche. Why is the age of menarche important? Because the following year, he has the quickest or fastest rate of progression.
Or that's why if the patient is within a year or before, I would suspect that the disturbance will progress over. If it was a million years past, the contribution will be lower. And yes, the point of monarchy is that I agree with you it can progress quite rapidly, but usually the growth plates so you reach skeletal maturity round about the time round, about 18 months after the onset of menarche in women.
You can use that as one marker of skeletal age. The other thing you could talk about was. Signs to see when they're going to fuse. Because you know, when you're in, you're still growing. You've got a growth spurt, then the curve is going to progress quite rapidly. So that's why you need to have some idea of when they're going to fuse. So we know that girls generally are around about 14 years old, whereas boys are 16.
But the Heinicke and the rises and signs on the public sector will give you some idea in assessing their skeletal maturity. Adams forward bending tests look for prominence, structure, deformity. Yet you describe that to me. I know it's described as a rib hump. I was taught that saying hump in the hump in front of adolescent girls can make them quite paranoid.
I was an adolescent girl once. I don't think it would have made me paranoid, so I always make it a point of saying we prominence rather than hump. Having said that, I was in an exam and I said rib prominence, and the examiner said this girl knows what it is to call it a hump. So, you know, I think it's nicer to say prominence. But you know, if you say hump, you know, I think people know you described in a then that was fine indications for MRI.
There would be those things. I think in general, we tend to MRI scans anyway because everybody is everybody expects an MRI scan and everybody's a little bit scared. But we generally do. I think radiographs now I was taught that an AP radiograph gives less radiation to the breast tissue, but there's only certain areas that do it. It's not a generalized thing.
And I think as long as you're asking for the view and the bending X-rays to assess them because you're going to look for the Cobb angle, then that should be OK. You could mention AP, but as I said, not everywhere does them and then the principles of treatment. So, you know, this is a clinical exam, so you may not get to this, but you've got your choice of observation, bracing and surgery.
If you're going to observe, you need to be able to say how often you're going to review them. We used to review them every six months to see if they progress. Then we went to 12 bracing. What you need to know about bracing is the need to wear it. 23 hours a day. And if you're an adolescent girl and it's the middle of the summer, you are not necessarily going to be compliant with that brace.
So just be aware of that pressure area things. It's horrible, but it may be a better option for some. If they've only got, you know, a few months before they become seriously mature, then you may get away with the brace because the option is surgery and surgery to your spine is not really a pleasant thing to go through for anyone, either. So you could in this vibe, get to talking about how you would measure a cabango.
My experience of having spine in the exams of the clinical situations is that it's just about assessment and ruling out any major neurological problem. But if you've got it in vyver, you could be asked to calculate common goals and things like that. OK yeah, just going to give you a minute just to formulate your thoughts about this 45-year-old man with the groin pain.
OK do you want to? Tell me what you think of these images and what might be going on with this, so they do enough of the pelvis to show that there's increased exclusives on the left here, although I couldn't see any collapse of or any distortion of the LED light side on the left looks OK. And in the image below, the T2 weighted image of the MRI shows that there is area of May of sclerosis and the area of the sublicense on board from the one on the left side.
All right. Tell me about the MRI. So on the MRI on the left side, I could see that on the similar superior open muscular aspect of the female head, there is decreased signal intensity. And apart from that, most probably there is a sorry there is a line going there showing subconscious collapse.
Maybe the sign is there on the left side left it. And on the vote on the latest, there is a decrease in intensity on the CPI aspect, but there is no Christian there. OK, so so what do you think a diagnosis might be here? My diagnosis is a question of causes of the femoral head by lately more on the left side than light. What are the risk factors for developing a vein that you might be aware of?
So the risk factor, like if it could be one of the most common is post-traumatic, apart from the idiopathic and the is. Apart from that, other risk factors involved in the radiation or alcoholic, if the patient is a smoker and any sickle cell disease or any high level state any. Then if the patient is a diver, then we could think of chicest disease as well.
And apart from that, any other immunosuppressive immunosuppressant conditions like ongoing chemotherapy or radiation? That's fine. So what do you know? So the pathogenesis of arvn, you know what? What's the thought of what's been, what's going on? Why does it happen? So there's like a one off.
So there are different theories, but one of the theories like intravascular coagulation that is the arteries supplying the female head are affected. Then the other one is like venous tess's and the other one is like fat micro impolitely, the micro blood flow to the female head. That's fine. So tell me a little bit, do any how you might be able to classify it?
So in terms of classification, the dates are let's staging in with the stage 0 is like there is nothing on the changes on the female, on the left as well as MRI. The changes we see on the histology and then in stage one is the changes could be seen on the MRI only. Stage two there is sclerosis and fragmentation of the femoral head. It is divided into stage 2 and 2 2b.
There is the decrease sign present where there's a collapse and then in the stage three days for the fragmentation of the femoral head. Then in stage four legs complete outside on the femoral as well as on the acetabular side. So what? What's the significance of the present sign? So the Christian sign signifies that there is irreversible collapse of the female head.
And then it has it been like guiding our towards our management because if the Christian sign is present, then we have to go towards the replacement rather than doing any of the procedures like you touching, touching upon management now. OK, so how so how would you what would you consider to do for this, for this child, for you in terms of management, like on the left hand side, there is a potential for collapse already present.
So we could go for. Let's say that on the left side, it's not quite collapsed, it's maybe pre slap stage. Uh, so then there is the option of what's called. Are drilling through the cortex, our quad core decompression is about to get decompression. And what you consider before you do that because that's invasive, isn't it? Yeah so it comes like initially before I could go for like non-operated treatments such as this, like clinically examine and assess.
This is like how much is functional and daily activities are limited. If it's clinically not limited and the pain is not severe, then we can postpone any surgery as far as quality time as far as we can. OK apart from that, there is like options of starting bisphosphonate, but I'm not sure how much effective they are. OK, so that's an option, isn't it?
So that is not that might prevent collapse. OK you mentioned a core decompression. Yeah as opposed to compression could be done before the collapse of femoral head taken place. You can drill up to the bone to relieve the incautious pressure and stimulate the healing response. OK, fine. And what about if you've reached the collapsed stage now? What are you going to do sort of stage three?
So there's like if you want to delay the replacement, stay like this, what other procedure in which we can do this vascular rock the I can't remember the name, which was, let's say, is advanced to arthritis now. So what? Well, story in terms of advance authorities, then the decision five, isn't he? Yeah so he would need a replacement.
He's 45. So I would go for the uncommitted. Totally replacement for him. Yeah OK. What what sort of paring surface for this age group? So, yeah, in terms of bearing very surface, it would be I would try to use. best would be, I think, metal on metal polythene claw palsy in this age group.
45 years. I'm not sure. Yeah 45 years. We don't use that. OK great, right? Better get through to think through the answers. So you start off well. So, you know, you did the diagnosis. You mentioned the changes on the radiographs quickly mention it's a T2 coronal MRI.
OK? and you can see this sort of double line sign. And this is all consistent with avascular necrosis. So classification you rattle through this quite well. I think you covered that quite well, which which is good. I don't think I had a major issues with what you said about that one. Largely, the management is guided by that, isn't it, so you've got sort of a split up and your had sort of pre collapse collapse in 08.
So, you know, the first sort of two stages. You thinking about pre collapse, it still can still salvage something here. Protected weight bearing consider bisphosphonates core decompression. I mentioned some people drill up and put stem cell injection as well up there. Some people use fabulous drug grafts as well. There's the tantalum rods as well.
You might have seen those some people use that as well. That's a consideration. And then once you go into the stage three, you kind of, you know, you've got some collapse now you've got the Crescent sign you thinking possibly the rotation osteotomy can be considered, you know, to offload that and put it onto the weight of different parts of the femoral head. And then once you get into the stages of 4 to six, it's just basically different stages of it.
And then you're talking about salvage at this point, there's nothing really else you can offer this guy apart from either continue as he is or bite the bullet and go down a replacement route. So you've got to make sure that about the enger data to the young guy. Don't mention all metal on poly, OK? You know you got to be thinking ceramic bearing and really ceramic on poly actually works quite well.
You can say ceramic on ceramic, but the angle does suggest that ceramic and poly do better. And you can argue ceramic and ceramic has got risk factors. You know, it's more expensive, it's squeaking, it's brittleness and fracture and things like that which you don't necessarily get with ceramic on poly. So and you can use on cement as you might think. While the local biology might not be great because he's had this condition that's not been proven you can use on cement it in these cases.
OK, so good. So overall, you've got the knowledge, just Polish up, then you'd be fine.
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