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Intermediate Clinical Cases for Orthopaedic Exams
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Intermediate Clinical Cases for Orthopaedic Exams
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Upload Date:
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Language: EN.
Segment:0 .
Right, Hello.
If if I asked the participants to unmute themselves and keep the videos on, you are now in the intermediate case, lower limb. Me and Joe will be asking the questions AJ and Mohammed, who wants to go first. I can go first, yeah, right, Mohammed. I'll share my screen. Tell me once you can see it and your time will start now. Can you see it?
Yes all right. You've got you've got a young lady. 22 years old, miss beck, who is a college student. She was running down the stairs when her knees buckled underneath her and she almost fell, but she held on to the Banister. She's now coming to you with pain and swelling of her right knee. You can tell me what you want to ask in the history, and I'll tell you the findings.
OK, I will. I would ask when this happened and was there any pain? Did the swelling happen immediately? Or it was swollen later on? Was she able to walk? And what did she do? What treatment she gets at that time? Right? so she fell on the stairs or she her knee buckled underneath her two days ago.
The knee swelled a couple of hours later, and she was able to put weight on it. She didn't actually fall to the ground, but it was just the knee giving way. OK so I would also like to know that whether she had any locking or you said that it's giving way. And did the painkillers improve the pain or not? And is?
Right, what do you mean by locking? Knocking, what was she able to straighten the knee? Oh, she's not able to put it fully straight for the last two days should not be able to put the knee fully straight, fully straight. I would also like to know any allergic history, any medical problems, any medications and what does she do?
She's a college student and she's not allergic to any medications. She doesn't have any previous history of high blood pressure, diabetes and don't know surgeries before. OK, I would like to examine the patient. Right you're finished with the history. OK this is the clinical photograph of the patient, from the front, from the side and with her sitting, can you describe what you see on the photograph?
So this is the clinical picture, which shows a swelling, significant swelling of the right knee as compared to the other side. I cannot appreciate any bruising. There there are some scar at the anterior aspect of the knee joint. On one picture, she she's able to flex the knee to almost 90 degree. In this picture, there is.
It is almost extended completely. Yet these are the my findings. All right, so once you go on to examine, how are you going to do that. So that sequentially? So I would like to see her standing straight and I will look and say, yeah, I will look second freshly from the behind attitude of the attitude of the limb.
Then I will ask her to walk if she's able to walk or not. And look at her gait, [inaudible], then I will ask her to lay down on the bed and then I will ask her to straight leg raised to check for the extensor mechanism if she's able to do it or not. You can do that and you can do that, and then I will ask her to flex as much as she can. Any questions that you want to do?
I would like to do the I would like to check the ligaments and medial and lateral ligament by varus and test for the collateral ligament. I will first check at the 30 degree flexion valgus test and five minutes. Zero degree, and then I will check for the various test at 30 degree first and then add the zero degree, then I would check for the ACL and PCL.
I would like to check for the ACL. I will do the Lageman test how to view the test. Can you describe for me I will flex the knee, but almost 30 degree and I will put my left thigh underneath the thigh of the patient and do and while pressing from my left hand onto the thigh and pulling the DBs forward. And then I will do the anterior cruciate.
And what do you say? What are you looking for when using your Blackman test? Would you say this test is positive or negative? This this is positive. What why why do you say it's positive that the tibia site anteriorly with the movements, would that not be normal for her? Could be I would do the patient examination as well. Would you like to compare?
Yes, I would like to compare. Right, so you've got that positive litmus test, as you say. What further examination or what further tests would you like to do to confirm or compliment your examination? I would do the anterior cruciate as well as I would like to do the pivot shift, but it's usually painful I would. It's more visible when the patient is anesthetized, but I would like to do the pivot shift test as well to confirm the ACL injury and rupture.
And would shift test, I do the fully extended knee and internally rotate the knee joint. And then and putting a vulgar stress, I will flex the knee when if there is an ACL rupture, the knee is internally rotated. And that as I'm flexing the lateral condyle. Push pulls back due to the iliotibial track.
Right, OK. So, yes, you're right, I wasn't able to do that test when she was fully awake, so I had to put her in theater. And this is her like a pivot shift. What other tests would you like to do? Uh, I would also check for the external and internal rotation ACL, sorry, anterior drawers test with the internally rotating and externally stating to see, Uh, the other ligaments as well because other ligaments can also be ruptured as well.
So posterior ACL with the posterior element, posterial medial and posterolateral component. So what would your advice be? Up for the sorry, can I? How what would you advise this patient? What are you thinking of? I think this lady may have an ACL rupture. She may have meniscal injury as well because sometimes the lateral meniscus is also related to it.
I would like to investigate it in the form of MRI scan to confirm my diagnosis and and then makes you think of meniscal injury. Up is 20% to 30% that are related to lateral meniscal tears as well ACL rupture also related to that, you mean nothing in this case, which points out to meniscal injury. Sorry, do you mean that there is nothing in this case which points out that meniscal injury?
How can you confirm that clinically? First, we can do the Matmaris test to confirm that not conforming because sometimes it can be not confirmatory, but we can do the memory test for that, right? This is the MRI that you requested. Can you describe the findings on this in these cuts? So this is a tie to rated weighted MRI scan, which shows some increase.
There's some fluid in the knee joint. It shows intact PCL on one of the view and it shows a. On the medial side, another five minutes. It I think I kind of see the meniscal shadow on the left side of the image with which part of the meniscus and the body of the meniscus is not very much visible, but I think there is the meniscus is there is some.
Shadow at the anterior and posterior aspect of the femur, right? So this is the next pictures going into the trochlea. Can you see anything there? I can just see the effusion, and I'm not able to see the shadow of ACL.
Right, does that confirm your diagnosis? It's right. So your diagnosed so far is an ACL injury. Anything else? ACL injury with significant infusion. And I think there is this displaced meniscus as well, but I'm not very sure about that, right?
The X-ray reports say there's a [inaudible] tear of the medial meniscus. How would you go on to manage that now? So I will explain the findings to the lady, OK. And yeah, and this she is young and I would tell her that the meniscus has gone inside and we need to reduce it. Otherwise our locking will not improve.
So I will offer her a knee arthroscopy plus minus proceed. If it is, whether it is repairable or it's, we may have to excise it. So we will have a shared decision. I will also explain the risk factor involved and the benefit is the operation doctor. So it is. Sorry, I can't hear you. It is it is urgent because she will not be able to flex the knee if there is a hand here.
And also there is a possibility that we may repair it as well. Right to want to do anything with the acl? AI would. I would not, because it's been shown that evidence shows that if we do the repair in early timing, it may lead to ultrahigh process. My first aim would be to sort out the meniscus and then come back later.
OK, so we stop there. What? how do you think this discussion went? I want to comment. I think I move forward and I was able to make the diagnosis. I was able to request the proper investigation and do the test. Maybe I have to be able to assess the MRI scan more better.
OK let's put it at steps one for history. Taking your history for this particular incident is fine. But what? Why do you think her knee buckled underneath her when she was going down the stairs? You already identified that there was a history of giving way. It doesn't automatically give way. If you were asking any further, I would have given you a history of an injury two months ago where she had an immediate swelling, as you said, and put an ice pack.
And since then she has had repeated giving away because this ACL on the MRI does not show, that does not seem a recent injury. It's an old adage. So why is she not able to put her knee fully straight? Because of the meniscal, it's locked. Yeah, so the meniscus is causing the locking in this case, this is why it is an, I wouldn't say, urgent operation, but it has to be done.
You never asked me about what hobbies does she do or what sports does she do? She plays basketball professionally. She wants to join the National team. So we need to find the implications of the injury of the patient herself and any previous injuries for the meniscus. You need to identify the sight of tenderness and the fact that she's looked and the scans have shown you are not exactly T2.
They are fat suppression. And they exactly they definitely show the locked knee with the meniscus. And you're right, you need to repair that. I wouldn't say I want to exercise it in a 22 years old lady with a big chunk displaced into the trochlea. And remember that a meniscus in repairable meniscal tear is an absolute indication for ACL reconstruction because otherwise you will re injure your meniscus later on.
Thank you. I'll leave Joe to go through the next case. Thank you very much. Yeah is it me or is it? AJ it's so one case for each. You're watching your guy. How are you doing? Yeah, not bad.
You're going for junior. Very slow in preparation, anyway. OK, good. So you have a six-year-old boy who came to you as a newcomer and you immigrant from middle Asia and his GPs asking you to examine him because he's not happy with his appearance. So tell me about what can you see? This is the child in front of you is six years old, asked me, so don't ask me, but what do you want to know from the history first?
So on the picture first I can see no, no, no history first. Yeah, Yeah. Three I would like to know from that mom. I presume the parents are present that sense. Yeah, mom is there. Yeah I'll introduce myself and say, Hi mom, I'm one of the orthopaedic consultant. I'm not mom. I I'm.
I ask me, what do you want to ask, mom? So I'll ask, when did you notice this appearance? So basically, he was slightly short once he was born, but as he grew up, you know, he still showed shorter than his, his colleagues in the preschool. OK and I would like to know about his, Uh, birth history. Was there any prenatal issue, prenatal issue?
No, there was no prenatal issue. Perinatal or during birth. Was there any difficulty or no? She had a normal plan C.-section, he didn't need any resuscitation or anything like that postnatal and any postnatal issue. You said that there was not any. No, no. OK and I would like to ask about his developmental milestone.
When did he stop start head holding and sitting and standing walking? The whole thing was about four months old. He started to sit at around eight months. He started to stand up around like 14 months, something like that. Ok? she can't, actually. But it was definitely after his first birthday when he started to stand up.
OK and I would like to know about these language milestones as well, whether he has learned speaking as you know, he learned speaking quite well. I, he doesn't know how to. He doesn't know a lot of english, but he talks in his native language. OK and Uh, and any difficulty this is stage in terms of have they noticed any walking, any difficulty in walking or any abnormal walking?
Yeah, he walks funny. Funny, OK. And does he complain any pain or any discomfort? No, he doesn't. He's not that of a runner, and he doesn't play around with his Mates quite often, and his mom noticed that, Uh, any difficulty in changing his nappy or. Order when they made him or change his clothes, do they find difficulty in moving his children, her first child.
So she didn't have any experience with other children? But basically, yeah, it was slightly difficult to change his nappies. I've noticed any abnormal fold in his thigh or like an increased crease or no, no. They don't know that. And in the upper limb, he can move normally. Or is there any restriction of any movement?
No, well, yeah, it's like the limitation of free range of movement, but he can do whatever he wants with his has not noticed any skin, any discoloration or any spots in the skin. No, why do you want to ask about that? I want to know if there's any neurofibromatosis or OK. No, it doesn't have anything to like to know about any of these.
Well, she didn't know. Yeah yeah, OK. And the mom, mom, dad, anybody had any, any kind of deformity? Well, that will be your history time. OK Yeah. Is that correct, doctor? Yeah, exactly. So, OK, now tell me about your examination. What do you want to examine in this child?
How would you like to examine this child as if he is in front of you? OK, so I would like to expose him and respecting his dignity. I would like to see from the front and the side and the back. What can you see? This is the child I can see. He is. It's just it seems to be.
I get the excavantum on his sternum seems to be a bit more in as compared to normal, and he seems to be a bit of a shortage stretcher. And his head seems to be big, and I cannot confirm on the picture whether he has got any upper limb deformity [inaudible] with this varus or not, and its joint seems to be slightly enlarged as compared to if I look at the wrist joint on these side. Sorry his wrist joint is, yeah, it's slightly distal radius at the level of distal radius for this joint seems to be slightly enlarged.
So I would like to after and I would like to check from the back side his spine, whether they are aligned or not. Is it aligned or not? Yes, it's fine, it's fine, whether there is straight or is there any qualitative deformity? Well, what do you see from the side? Can you see any deformity from the side? It seems to be a more, more [inaudible] lumbar spine from the side.
OK a normal, and I would like to check the position of both hips. Is there any? This is this is look from the front. What can you see about his shoulder level? Shoulder level is left shoulder seems to be a bit lower than the right one. OK so, yes, the lower limbs, what do you want to know from the lower limbs or just want to know is the both aces the patella and the medial are the same level or different level and.
Well, yeah, yeah, they're the same look. It simply relocate, then I'd like to sit the patient and check his spine and shoulder level again. But the day, would you do anything before sitting, the patient, sorry check the walking is how is walking, checking so his gait? He's swinging right and left. It's swinging right and left, OK, so I'm suspecting that possibly it's AI would like to check to proceed and do the tendon test if he can understand to stand on the one leg and check his pelvis aces from the front or the buttocks level from the backside.
And so how would you do this to a six-year-old child? So six-year, if he can understand I came to. Well, he can understand, Yes. But how would you do it? OK, I'll demonstrate him first say that. Can you stand on one leg? I'll support his both hand to check the pressure. He's standing on the floor.
The [inaudible] either on the floor, I can kneel down or I can stand him on the couch so that we are on the same level. I can stand and support him from falling. Ok? and then check the simultaneously on the left side and then right side to see which side is positive or which side, I'm like. For example, if he's standing on the left side, but OK, what would you expect?
So, too, as he's swinging gait on the both side, I'm suspecting possibly the both side stand, the test is positive. OK, so how would you give a straight to the six-year-old child, the Lindbergh test, while you are kneeling on the floor? So I kneel on the floor and support his boat hands to make to give him confidence that they can stand on the one leg.
Ok? and then how would you demonstrate to him since I have exposed him respecting his dignity? I'll keep my bow ties on his ASIS from the front and check whether the pelvis is dropping or not. Yes, I know. But how would you? OK, tell me I'm the six-year-old boy. Tell me the instructions.
OK So can you I'll show you how to stand. Can you do this for me? But you're standing in front of me? Yeah, Yeah. Tell me first. OK I think the [inaudible] that concludes your examination. Can we go to investigations, what investigations do you want? So I would like to get a whole spine AP in lateral view.
And also the pelvis X-ray. So they said the p of this point, which shows there's a right sided it's a double cover, right sided, no scoliosis and, Uh, double curved. So where is the second curve? It seems to be very, very, very subtle lumbar curve and quite prominent. So curve it or a compensatory lumbar.
I think it's probably a compensatory curve. What of curve is this what is your classification, what classification are you describing here? It's the it's the King's classification King's. I skinks classification, it's a terrific toric lumber or lumber, or there is no Kings in America. It was an American guy. What is he called?
That's fine. What are the types because you say double curve? Yeah so I the single thoracic curve or the double curved correct lumbar curve? OK what type? What was he describing? Was he describing what type of physical uses here? It's like any scoliosis or a specific type of scoliosis. It's got the right side, the lower.
What are the types of skin uses in general? It's structural or non structural. Like it, it's a neuromuscular issue. So what type of scoliosis is that? Is this an adolescent type of scoliosis, idiopathic scoliosis or congenital scoliosis or a syndrome? It's early onset. There are different types of early onset adolescent or the neuromuscular, so I think it's early early onset scoliosis.
And what do you mean by early onset scoliosis and congenital as well? So it seems to be 2 minutes left? OK, thank you very much, AJ I will stop here. OK, calm down. Take a deep breath. Ok? let's start by the history. OK so when you start with the history, with the pediatric, I'm asking this question.
I know this is a tough case, ok? But lately, especially in the last exam, they have incorporated loads of pediatric cases in it and more complicated than this straightforward case, actually. OK, so first. The in the history you asked about the short stature, yeah, that's good developmental milestones, good prenatal, natal and post-natal, that's good.
You didn't ask me anything about the family history. All right, which is so much important in this case. OK you didn't ask me, is there any associated problems like problems with vision problems with the hearing? Why am I asking this? Because this is collagen. What? what, what? What's your diagnosis now after seeing all these things? They both hips.
They are not developed properly. It may be spinal epithelial dysplasia. Yes so what is spinal fusion. And what type of collision is affected? It's a type 1. I think that to type two, type 2. So type two, it affects the prefaces and affects the. Connective tissue, mainly in the retina and in the cochlea. So they have hearing loss and visual deficit.
OK, so this should be asked, right? OK you quite ask about skin for skin discoloration to exclude other problems, but you were like you were haphazard. You were asking these questions. You didn't have a quite specific and systematic questionnaire for the history of a pediatric dysplasia condition. Then on examination, you told me about short stature, but you didn't tell me, is it proportionate?
Is it disproportionate? OK, you didn't tell me, is it, you know, mainly in the proximal, in the middle or in the distal segments? And then you didn't tell me, actually, I had to prompt you to ask you whether or not the sugar levels are in the same level. I had to prompt you to tell me about the smaller doses. And then when you were more concentrated on the discrepancy rather than the gate, which is so much important, this case is OK.
I had to ask you, what will you do before sitting the patient down? OK, and then turn them back in. The six-year-old is, I don't know, my personal thing. It's very difficult. I don't I can't demonstrate it. A six-year-old can't be like this. OK, you can try OK, but not in the, you know, in the heat of the exam and these things. And you have to stand him on the high thing.
And you hold both hands and to be able to demonstrate it in front of. Well, I don't know. Personally, I didn't do it before, but you know, like, yeah, OK, so I'm then. Examine him, examine the spine, you know, mobility, you didn't examine the spine movement, hip range of movement implants discrepancy. OK he can be short in both limbs, which is this case, but above the trochanteric area.
So [inaudible] get all these things has to come up in the examination you're dealing with is then said, Yeah. And then in the x rays, yeah, this is an X-ray. It's called linkage classification. Did I ask you about that? Because you straight away. This is a double curve thoracolumbar. Scoliosis?
Wow. All right. OK, even the spine surgeons would be like, you know, a little bit shaky before hitting, you know, a leg kick classification terminology straight away. OK I'm not saying that it might. It might be good. Bad, but come on. This is syndromic type scoliosis link
He was describing other adolescent scoliosis. This is. This is not OK. You can say that there is a right side. The thoracic curve with a small lumbar curve know left side is compensatory lumbar curve you can start describing rather than going into the classification, which is not applied to congenital condition.
So right, OK, so not a syndromic type of scoliosis. Then the we didn't go into management, actually. OK this is an eye opener. OK, go. Review all the dysplasia. All right. This I had the same case in one of the courses. OK it's always difficult with the first station, so don't feel.
Segment:0 .
Right, Hello.
If if I asked the participants to unmute themselves and keep the videos on, you are now in the intermediate case, lower limb. Me and Joe will be asking the questions AJ and Mohammed, who wants to go first. I can go first, yeah, right, Mohammed. I'll share my screen. Tell me once you can see it and your time will start now. Can you see it?
Yes all right. You've got you've got a young lady. 22 years old, miss beck, who is a college student. She was running down the stairs when her knees buckled underneath her and she almost fell, but she held on to the Banister. She's now coming to you with pain and swelling of her right knee. You can tell me what you want to ask in the history, and I'll tell you the findings.
OK, I will. I would ask when this happened and was there any pain? Did the swelling happen immediately? Or it was swollen later on? Was she able to walk? And what did she do? What treatment she gets at that time? Right? so she fell on the stairs or she her knee buckled underneath her two days ago.
The knee swelled a couple of hours later, and she was able to put weight on it. She didn't actually fall to the ground, but it was just the knee giving way. OK so I would also like to know that whether she had any locking or you said that it's giving way. And did the painkillers improve the pain or not? And is?
Right, what do you mean by locking? Knocking, what was she able to straighten the knee? Oh, she's not able to put it fully straight for the last two days should not be able to put the knee fully straight, fully straight. I would also like to know any allergic history, any medical problems, any medications and what does she do?
She's a college student and she's not allergic to any medications. She doesn't have any previous history of high blood pressure, diabetes and don't know surgeries before. OK, I would like to examine the patient. Right you're finished with the history. OK this is the clinical photograph of the patient, from the front, from the side and with her sitting, can you describe what you see on the photograph?
So this is the clinical picture, which shows a swelling, significant swelling of the right knee as compared to the other side. I cannot appreciate any bruising. There there are some scar at the anterior aspect of the knee joint. On one picture, she she's able to flex the knee to almost 90 degree. In this picture, there is.
It is almost extended completely. Yet these are the my findings. All right, so once you go on to examine, how are you going to do that. So that sequentially? So I would like to see her standing straight and I will look and say, yeah, I will look second freshly from the behind attitude of the attitude of the limb.
Then I will ask her to walk if she's able to walk or not. And look at her gait, [inaudible], then I will ask her to lay down on the bed and then I will ask her to straight leg raised to check for the extensor mechanism if she's able to do it or not. You can do that and you can do that, and then I will ask her to flex as much as she can. Any questions that you want to do?
I would like to do the I would like to check the ligaments and medial and lateral ligament by varus and test for the collateral ligament. I will first check at the 30 degree flexion valgus test and five minutes. Zero degree, and then I will check for the various test at 30 degree first and then add the zero degree, then I would check for the ACL and PCL.
I would like to check for the ACL. I will do the Lageman test how to view the test. Can you describe for me I will flex the knee, but almost 30 degree and I will put my left thigh underneath the thigh of the patient and do and while pressing from my left hand onto the thigh and pulling the DBs forward. And then I will do the anterior cruciate.
And what do you say? What are you looking for when using your Blackman test? Would you say this test is positive or negative? This this is positive. What why why do you say it's positive that the tibia site anteriorly with the movements, would that not be normal for her? Could be I would do the patient examination as well. Would you like to compare?
Yes, I would like to compare. Right, so you've got that positive litmus test, as you say. What further examination or what further tests would you like to do to confirm or compliment your examination? I would do the anterior cruciate as well as I would like to do the pivot shift, but it's usually painful I would. It's more visible when the patient is anesthetized, but I would like to do the pivot shift test as well to confirm the ACL injury and rupture.
And would shift test, I do the fully extended knee and internally rotate the knee joint. And then and putting a vulgar stress, I will flex the knee when if there is an ACL rupture, the knee is internally rotated. And that as I'm flexing the lateral condyle. Push pulls back due to the iliotibial track.
Right, OK. So, yes, you're right, I wasn't able to do that test when she was fully awake, so I had to put her in theater. And this is her like a pivot shift. What other tests would you like to do? Uh, I would also check for the external and internal rotation ACL, sorry, anterior drawers test with the internally rotating and externally stating to see, Uh, the other ligaments as well because other ligaments can also be ruptured as well.
So posterior ACL with the posterior element, posterial medial and posterolateral component. So what would your advice be? Up for the sorry, can I? How what would you advise this patient? What are you thinking of? I think this lady may have an ACL rupture. She may have meniscal injury as well because sometimes the lateral meniscus is also related to it.
I would like to investigate it in the form of MRI scan to confirm my diagnosis and and then makes you think of meniscal injury. Up is 20% to 30% that are related to lateral meniscal tears as well ACL rupture also related to that, you mean nothing in this case, which points out to meniscal injury. Sorry, do you mean that there is nothing in this case which points out that meniscal injury?
How can you confirm that clinically? First, we can do the Matmaris test to confirm that not conforming because sometimes it can be not confirmatory, but we can do the memory test for that, right? This is the MRI that you requested. Can you describe the findings on this in these cuts? So this is a tie to rated weighted MRI scan, which shows some increase.
There's some fluid in the knee joint. It shows intact PCL on one of the view and it shows a. On the medial side, another five minutes. It I think I kind of see the meniscal shadow on the left side of the image with which part of the meniscus and the body of the meniscus is not very much visible, but I think there is the meniscus is there is some.
Shadow at the anterior and posterior aspect of the femur, right? So this is the next pictures going into the trochlea. Can you see anything there? I can just see the effusion, and I'm not able to see the shadow of ACL.
Right, does that confirm your diagnosis? It's right. So your diagnosed so far is an ACL injury. Anything else? ACL injury with significant infusion. And I think there is this displaced meniscus as well, but I'm not very sure about that, right?
The X-ray reports say there's a [inaudible] tear of the medial meniscus. How would you go on to manage that now? So I will explain the findings to the lady, OK. And yeah, and this she is young and I would tell her that the meniscus has gone inside and we need to reduce it. Otherwise our locking will not improve.
So I will offer her a knee arthroscopy plus minus proceed. If it is, whether it is repairable or it's, we may have to excise it. So we will have a shared decision. I will also explain the risk factor involved and the benefit is the operation doctor. So it is. Sorry, I can't hear you. It is it is urgent because she will not be able to flex the knee if there is a hand here.
And also there is a possibility that we may repair it as well. Right to want to do anything with the acl? AI would. I would not, because it's been shown that evidence shows that if we do the repair in early timing, it may lead to ultrahigh process. My first aim would be to sort out the meniscus and then come back later.
OK, so we stop there. What? how do you think this discussion went? I want to comment. I think I move forward and I was able to make the diagnosis. I was able to request the proper investigation and do the test. Maybe I have to be able to assess the MRI scan more better.
OK let's put it at steps one for history. Taking your history for this particular incident is fine. But what? Why do you think her knee buckled underneath her when she was going down the stairs? You already identified that there was a history of giving way. It doesn't automatically give way. If you were asking any further, I would have given you a history of an injury two months ago where she had an immediate swelling, as you said, and put an ice pack.
And since then she has had repeated giving away because this ACL on the MRI does not show, that does not seem a recent injury. It's an old adage. So why is she not able to put her knee fully straight? Because of the meniscal, it's locked. Yeah, so the meniscus is causing the locking in this case, this is why it is an, I wouldn't say, urgent operation, but it has to be done.
You never asked me about what hobbies does she do or what sports does she do? She plays basketball professionally. She wants to join the National team. So we need to find the implications of the injury of the patient herself and any previous injuries for the meniscus. You need to identify the sight of tenderness and the fact that she's looked and the scans have shown you are not exactly T2.
They are fat suppression. And they exactly they definitely show the locked knee with the meniscus. And you're right, you need to repair that. I wouldn't say I want to exercise it in a 22 years old lady with a big chunk displaced into the trochlea. And remember that a meniscus in repairable meniscal tear is an absolute indication for ACL reconstruction because otherwise you will re injure your meniscus later on.
Thank you. I'll leave Joe to go through the next case. Thank you very much. Yeah is it me or is it? AJ it's so one case for each. You're watching your guy. How are you doing? Yeah, not bad.
You're going for junior. Very slow in preparation, anyway. OK, good. So you have a six-year-old boy who came to you as a newcomer and you immigrant from middle Asia and his GPs asking you to examine him because he's not happy with his appearance. So tell me about what can you see? This is the child in front of you is six years old, asked me, so don't ask me, but what do you want to know from the history first?
So on the picture first I can see no, no, no history first. Yeah, Yeah. Three I would like to know from that mom. I presume the parents are present that sense. Yeah, mom is there. Yeah I'll introduce myself and say, Hi mom, I'm one of the orthopaedic consultant. I'm not mom. I I'm.
I ask me, what do you want to ask, mom? So I'll ask, when did you notice this appearance? So basically, he was slightly short once he was born, but as he grew up, you know, he still showed shorter than his, his colleagues in the preschool. OK and I would like to know about his, Uh, birth history. Was there any prenatal issue, prenatal issue?
No, there was no prenatal issue. Perinatal or during birth. Was there any difficulty or no? She had a normal plan C.-section, he didn't need any resuscitation or anything like that postnatal and any postnatal issue. You said that there was not any. No, no. OK and I would like to ask about his developmental milestone.
When did he stop start head holding and sitting and standing walking? The whole thing was about four months old. He started to sit at around eight months. He started to stand up around like 14 months, something like that. Ok? she can't, actually. But it was definitely after his first birthday when he started to stand up.
OK and I would like to know about these language milestones as well, whether he has learned speaking as you know, he learned speaking quite well. I, he doesn't know how to. He doesn't know a lot of english, but he talks in his native language. OK and Uh, and any difficulty this is stage in terms of have they noticed any walking, any difficulty in walking or any abnormal walking?
Yeah, he walks funny. Funny, OK. And does he complain any pain or any discomfort? No, he doesn't. He's not that of a runner, and he doesn't play around with his Mates quite often, and his mom noticed that, Uh, any difficulty in changing his nappy or. Order when they made him or change his clothes, do they find difficulty in moving his children, her first child.
So she didn't have any experience with other children? But basically, yeah, it was slightly difficult to change his nappies. I've noticed any abnormal fold in his thigh or like an increased crease or no, no. They don't know that. And in the upper limb, he can move normally. Or is there any restriction of any movement?
No, well, yeah, it's like the limitation of free range of movement, but he can do whatever he wants with his has not noticed any skin, any discoloration or any spots in the skin. No, why do you want to ask about that? I want to know if there's any neurofibromatosis or OK. No, it doesn't have anything to like to know about any of these.
Well, she didn't know. Yeah yeah, OK. And the mom, mom, dad, anybody had any, any kind of deformity? Well, that will be your history time. OK Yeah. Is that correct, doctor? Yeah, exactly. So, OK, now tell me about your examination. What do you want to examine in this child?
How would you like to examine this child as if he is in front of you? OK, so I would like to expose him and respecting his dignity. I would like to see from the front and the side and the back. What can you see? This is the child I can see. He is. It's just it seems to be.
I get the excavantum on his sternum seems to be a bit more in as compared to normal, and he seems to be a bit of a shortage stretcher. And his head seems to be big, and I cannot confirm on the picture whether he has got any upper limb deformity [inaudible] with this varus or not, and its joint seems to be slightly enlarged as compared to if I look at the wrist joint on these side. Sorry his wrist joint is, yeah, it's slightly distal radius at the level of distal radius for this joint seems to be slightly enlarged.
So I would like to after and I would like to check from the back side his spine, whether they are aligned or not. Is it aligned or not? Yes, it's fine, it's fine, whether there is straight or is there any qualitative deformity? Well, what do you see from the side? Can you see any deformity from the side? It seems to be a more, more [inaudible] lumbar spine from the side.
OK a normal, and I would like to check the position of both hips. Is there any? This is this is look from the front. What can you see about his shoulder level? Shoulder level is left shoulder seems to be a bit lower than the right one. OK so, yes, the lower limbs, what do you want to know from the lower limbs or just want to know is the both aces the patella and the medial are the same level or different level and.
Well, yeah, yeah, they're the same look. It simply relocate, then I'd like to sit the patient and check his spine and shoulder level again. But the day, would you do anything before sitting, the patient, sorry check the walking is how is walking, checking so his gait? He's swinging right and left. It's swinging right and left, OK, so I'm suspecting that possibly it's AI would like to check to proceed and do the tendon test if he can understand to stand on the one leg and check his pelvis aces from the front or the buttocks level from the backside.
And so how would you do this to a six-year-old child? So six-year, if he can understand I came to. Well, he can understand, Yes. But how would you do it? OK, I'll demonstrate him first say that. Can you stand on one leg? I'll support his both hand to check the pressure. He's standing on the floor.
The [inaudible] either on the floor, I can kneel down or I can stand him on the couch so that we are on the same level. I can stand and support him from falling. Ok? and then check the simultaneously on the left side and then right side to see which side is positive or which side, I'm like. For example, if he's standing on the left side, but OK, what would you expect?
So, too, as he's swinging gait on the both side, I'm suspecting possibly the both side stand, the test is positive. OK, so how would you give a straight to the six-year-old child, the Lindbergh test, while you are kneeling on the floor? So I kneel on the floor and support his boat hands to make to give him confidence that they can stand on the one leg.
Ok? and then how would you demonstrate to him since I have exposed him respecting his dignity? I'll keep my bow ties on his ASIS from the front and check whether the pelvis is dropping or not. Yes, I know. But how would you? OK, tell me I'm the six-year-old boy. Tell me the instructions.
OK So can you I'll show you how to stand. Can you do this for me? But you're standing in front of me? Yeah, Yeah. Tell me first. OK I think the [inaudible] that concludes your examination. Can we go to investigations, what investigations do you want? So I would like to get a whole spine AP in lateral view.
And also the pelvis X-ray. So they said the p of this point, which shows there's a right sided it's a double cover, right sided, no scoliosis and, Uh, double curved. So where is the second curve? It seems to be very, very, very subtle lumbar curve and quite prominent. So curve it or a compensatory lumbar.
I think it's probably a compensatory curve. What of curve is this what is your classification, what classification are you describing here? It's the it's the King's classification King's. I skinks classification, it's a terrific toric lumber or lumber, or there is no Kings in America. It was an American guy. What is he called?
That's fine. What are the types because you say double curve? Yeah so I the single thoracic curve or the double curved correct lumbar curve? OK what type? What was he describing? Was he describing what type of physical uses here? It's like any scoliosis or a specific type of scoliosis. It's got the right side, the lower.
What are the types of skin uses in general? It's structural or non structural. Like it, it's a neuromuscular issue. So what type of scoliosis is that? Is this an adolescent type of scoliosis, idiopathic scoliosis or congenital scoliosis or a syndrome? It's early onset. There are different types of early onset adolescent or the neuromuscular, so I think it's early early onset scoliosis.
And what do you mean by early onset scoliosis and congenital as well? So it seems to be 2 minutes left? OK, thank you very much, AJ I will stop here. OK, calm down. Take a deep breath. Ok? let's start by the history. OK so when you start with the history, with the pediatric, I'm asking this question.
I know this is a tough case, ok? But lately, especially in the last exam, they have incorporated loads of pediatric cases in it and more complicated than this straightforward case, actually. OK, so first. The in the history you asked about the short stature, yeah, that's good developmental milestones, good prenatal, natal and post-natal, that's good.
You didn't ask me anything about the family history. All right, which is so much important in this case. OK you didn't ask me, is there any associated problems like problems with vision problems with the hearing? Why am I asking this? Because this is collagen. What? what, what? What's your diagnosis now after seeing all these things? They both hips.
They are not developed properly. It may be spinal epithelial dysplasia. Yes so what is spinal fusion. And what type of collision is affected? It's a type 1. I think that to type two, type 2. So type two, it affects the prefaces and affects the. Connective tissue, mainly in the retina and in the cochlea. So they have hearing loss and visual deficit.
OK, so this should be asked, right? OK you quite ask about skin for skin discoloration to exclude other problems, but you were like you were haphazard. You were asking these questions. You didn't have a quite specific and systematic questionnaire for the history of a pediatric dysplasia condition. Then on examination, you told me about short stature, but you didn't tell me, is it proportionate?
Is it disproportionate? OK, you didn't tell me, is it, you know, mainly in the proximal, in the middle or in the distal segments? And then you didn't tell me, actually, I had to prompt you to ask you whether or not the sugar levels are in the same level. I had to prompt you to tell me about the smaller doses. And then when you were more concentrated on the discrepancy rather than the gate, which is so much important, this case is OK.
I had to ask you, what will you do before sitting the patient down? OK, and then turn them back in. The six-year-old is, I don't know, my personal thing. It's very difficult. I don't I can't demonstrate it. A six-year-old can't be like this. OK, you can try OK, but not in the, you know, in the heat of the exam and these things. And you have to stand him on the high thing.
And you hold both hands and to be able to demonstrate it in front of. Well, I don't know. Personally, I didn't do it before, but you know, like, yeah, OK, so I'm then. Examine him, examine the spine, you know, mobility, you didn't examine the spine movement, hip range of movement implants discrepancy. OK he can be short in both limbs, which is this case, but above the trochanteric area.
So [inaudible] get all these things has to come up in the examination you're dealing with is then said, Yeah. And then in the x rays, yeah, this is an X-ray. It's called linkage classification. Did I ask you about that? Because you straight away. This is a double curve thoracolumbar. Scoliosis?
Wow. All right. OK, even the spine surgeons would be like, you know, a little bit shaky before hitting, you know, a leg kick classification terminology straight away. OK I'm not saying that it might. It might be good. Bad, but come on. This is syndromic type scoliosis link
He was describing other adolescent scoliosis. This is. This is not OK. You can say that there is a right side. The thoracic curve with a small lumbar curve know left side is compensatory lumbar curve you can start describing rather than going into the classification, which is not applied to congenital condition.
So right, OK, so not a syndromic type of scoliosis. Then the we didn't go into management, actually. OK this is an eye opener. OK, go. Review all the dysplasia. All right. This I had the same case in one of the courses. OK it's always difficult with the first station, so don't feel.
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