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Intermediate Clinical Cases for Postgraduate Orthopaedic Exams
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Intermediate Clinical Cases for Postgraduate Orthopaedic Exams
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Upload Date:
2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
We started the Intermediate Lower limb case here is so welcome to each of you, Melissa, and [inaudible] who wants to go first. That to me to go, come on, need a volunteer, all right, so share the screen. Once you can see it, let me know so we can start your timer. Yeah, timer on.
OK, so you've got Miss BH, who is a 22-year-old college student. She was going down the stairs a couple of days ago when her knee buckled underneath her. She didn't fall to the ground but managed to hold onto the banister, and she's now coming to you, complaining of pain and swelling. Tell me what you want to ask about in the history, and I'll tell you what the findings are.
OK, so I want to know when it happened and whether she when she landed or you said she didn't fall. So I'd want to know how she's been walking since then as she's been limping. Yeah, it's painful. So she's been limping. Yeah and where exactly is her pain? The pain is mainly on the inner side of the knee. OK and has she experienced any clicking?
Uh, no, nothing, nothing so far. Any locking or giving way of her knee. What do you mean by locking? So has she found that her knee is stuck in a position and she can't easily move it? You mean, like bend or straighten, either locked in extension or locked in flexion? Has she experienced any symptom? Right, you're absolutely right.
She's not been able to put it fully straight. It does not want to go fully straight. OK, fine. And has she had any prior injuries to her knees? Yes, exactly. She did remember that she was playing basketball two months ago when her right knee was on the right foot was fixed on the ground. She twisted to the left to get the ball from somebody else, and she felt a pop and fell to the ground.
OK and since then, for the last two months, she's been able to mobilize on this knee. It took a little bit of time, so she initially put some ice on it and she was able to put to it a little bit painful, but not that much. OK and I'd also want to know, apart from basketball, does she have any other hobbies or any other sport that she plays? Basketball is her main sport.
OK is she otherwise? Well, any medical conditions? No other medical conditions. Any regular medication? No, nothing. She's had a couple of painkillers for the first injury and for this last injury as well. And the only other thing I'd want to exclude is, is there any history of malaria or eating disorders, anything like that at all?
OK So so in summary, this is a 22-year-old lady who has a history of a knee injury two days ago when running down a flight of stairs. It sounds like the primary injury was two months prior to that, when she landed onto a fixed foot and twisted it whilst playing basketball. She has symptoms of pain and locking with a fixed flexion, which is unable to fully extend, and she plays basketball and is otherwise fit and well.
Yeah, exactly. So what would you want to do examine her? Yes, I would like to proceed with her. Can you comment on what you see on the pictures and then tell me, what steps do you want to do further? They are unexamined on inspection lists. These are clinical photographs of a knee. I can see the right knee appears swollen in comparison to the left.
I also note that on standing, she is holding it in slight flexion compared to the other side. I can't see any obvious patella deformity or patella seem to be at the same level of these photos as she is standing. I would like to proceed by asking her to walk. I'd like to examine her gait to see if she's limping, if she's able to extend her foot, just limping a little bit. It looks like I'm [inaudible].
OK? I'd also like to inspect from the back to see if there's any findings, any swelling or bruising to the back of her knee. Nothing to mention. Same type of swelling. Same size. All right. I then ask her to sit on the examination couch and start by palpitating to assess if there's an effusion.
So I do this by milk milking down the thigh and then sweeping from medial to lateral and seeing if I can see a medial bulge, which would indicate an effusion. Would you expect that to be positive here? No, I wouldn't. If if this is an articular, injury may not be. Right, so. I wouldn't expect in the future, necessarily in this order.
But what about this swelling? And so you can have a swelling because of injury around the knee. So sorry. So in this, I would expect her to have an effusion because she has had an injury in her knee, so I mean, I can see it visually anyway, but I'd also examined for it. Right, OK. Then I'd want to assess a joint tenderness or medial or lateral joint tenderness.
I want to see if, she said. Thank you. So I want to say straight leg raise. And then while she does that, I'd also assessed at the same time if she really extending as well as how far she can flex, she's extending to the same extent that you can see on this picture on the X-ray. And she can flex up to 90, as you can see here on this picture as well.
OK I then move on to assess stability of the knee, so I'd want to assess valgus and various stability by stressing the need both there and in the same value of fashion. I'd also want to perform a draw. I do this by asking her, do you want to test the Ferguson varus instability in? So usually I would lift the leg and I'd have it, well, extended as she can.
And in that position, I placed focus on various stress and see if there's any opening of the joint or if there's anything right. Nothing in full extension. OK? I'd also then assess it inflection to see if there's any difference compared to extension. What degree of extent of flexion do you mean? About 30 degrees.
So you can do it at zero, 30 and 90? Right? no, there is no this. There is no joint opening in either varus or valgus, but when you press the knee and varus, it's a bit big. Embarrasses you. OK, but then go on to perform in an anterior drawer test. I do this by flexing the knee, usually sitting on the end of her foot after consenting her for that.
And then placing an anterior force on the tibia, block subluxation against the femur. And also I can do Lachman's and pivot shift. All of these will assess for an ACL injury. The anterior drawer is not very conclusive. You cannot get any information from that, and this is her lack. Can you describe what you want to do? But so with the Lachman test, I stabilize the thigh with one hand and grasp the tibia over the tibial generosity with the other hand and anteriorly, translate the tibia against the femur and there's various want to assess for a firm endpoint and then also the degree.
Of movement, so this is a positive Lachman's test, which is indicative of an ACL injury in her case, I'd also want to compare it to the other side just to make sure it's not normal for her. And then I'd complete my ACL examination with the pivot shift test. How do you do that? There is a pivot shift. I have the patient's leg extended.
I internally rotate it. I place a bogus force on the knee and then I flex the knee. And what I'm looking for is for the tibia to reduce as I flex the knee. Right so you need an intact MCL and material that can you always get the pivot shift during the examination in the clinic? No, it's best done in a relaxed patient in theater. Right, OK.
And that's what it looks like. So anything else that's important to you to assess now what's going on in your mind? OK so I'm thinking this is an ACL injury. I'd also want to assess the meniscus at this stage. I already know she has a fixed flexion injury, but I want to assess both the risk, also the PCL for completeness. Right, so differential diagnosis, ACL.
OK, I agree. Anything else is deal with the potential lateral meniscal injury. It could also be a multiligament injury involving other structures in the knee, such as the PCL. No how do you assess the PCL? PCL, usually I'd look for a posterior sag from the side with both the knees flexed. You can also do a posterior drawer for that.
Yeah, there is no there is no posterior sag. So what further investigations do you want to obtain? So what investigations do you want to get? OK, so I'd like to get an MRI scan, assuming we've already had radiographs, then I want to get an MRI scan to further assess her injury. I'd then go on to counsel the patient. OK, so these are surgical MRI scans showing I can see on here.
There's I can't see an intact ACL. I can see the PCL is in continuity. I can see fluid both behind the patella and I can also see what looks like a meniscal tear with extrusion, potentially. But I'd want to see more slices and a coronal view to better delivered by extrusion. And so you can.
Sorry, so that might, in fact, if I can retract that, that might be a double steal sign on the right, but I'm not very clear. I'd want to just look through a few more slices, to be sure. And you can sometimes see that in the bucket handle there. Right? OK. This is another slice.
OK, so I can clearly see an ACL injury complete rupture of the ACL. But again, I can see how can you say that I can't see any progress and continuity of the ACL at all. You'd normally see that going from anterior to posterior, almost in the other direction to the PCL, which you can't see, right? So what are you going to offer this patient?
I'm going to discuss with her two courses possible courses of action. One is physiotherapy, which is a prerequisite anyway because she doesn't have full range of movement. So I would first start with preoperative physiotherapy and explain the importance of regaining a full range of movement there. Thereafter, her option. There are a certain percentage of patients who do go on to have a reasonably functioning knee with that treatment, but the majority of young active patients will require operative intervention in the form of an ACL reconstruction.
And so I will counsel her about this. I'll explain that there are risks associated with it, including infection pain, stiffness, arthritis down the line, risk of rerupture, risk of ongoing instability. You're not going to tackle that at all. Sorry, you're not going to tackle this pathology at all. What did you mention on the mri? She had the bucket handle tear as well?
Yes so just Yes. No, I wouldn't leave that because that will also cause her ongoing symptoms. There's two options of managing this, either depending on the severity of her symptoms. You can either address it immediately with the ACL tear or if because she's got a flexion deformity. If we're not going to do an ACL immediately, we can assess address the bucket handle tear first.
OK right, I think this is fair enough for now. Take a breath, sit down, sit back and think, how do you think this station went? Um, I think the initial bit was OK in terms of identifying the pathology, talking through the examination and the history. I think I was a little bit. I wasn't very fluent with the management in that I jumped back and forth a little bit.
And I did initially forget the bucket handle part of it, so I could have been a bit more decisive about that. Right? you've got a very good insight. You've identified I would have given you six or seven, even for the history and the clinical examination you've asked about the site of the pain, the site of tenderness, what you missed in the history was swelling. You never asked me about swelling on your side.
No yeah, OK. But then does it make any difference? How soon did the swelling come up after the injury? Because it. What I would have told you that it has happened in a couple of hours on the first case and on the second case. And if it's happened very soon, then the meniscus is a peripheral meniscal tear because these are the ones that bleed and it's probably one that needs repairing.
The other thing is, you've quite rightly identified the flexion deformity and mentioned about the patella with the patella in a patient who's given way. What you're interested on is whether it's partial or alter. It's whether it's lateral realized as well, because it could have been a patella subluxation or recurrent dislocation when you were talking about the effusion. What I was aiming for is sweep test would give you the small or the minimal effusion.
But with such a large effusion that you can see in her case, sweep test would be negative, but you will be able to detect either fluctuation or patella tap. These are the signs for a bigger size of effusion. The killer is your is your treatment with a failed tear because you forgot completely forgot that a locked knee with a bucket handle 22 years old lady plays basketball, and if you've asked about her sports level, she's playing for her University.
So she's a very sporty lady, young and she needs to go back to sport. So this bucket needs to go back in its place. You can't take it out altogether, especially if it's a large one with a peripheral wide breadth of Reds. So it's a meniscus repair and meniscus repair is an absolute education for ACL reconstruction. OK, thank you.
Joe thank you. That's right. If you can stop, Joe, thank you very much, Melissa. Hi and your time starts now. You have been asked by the GP that this young lad, six years old, come from mid Asia countries and he is not happy with his appearance and he came to you with mom. So tell me, what are the questions you want to ask to to mom?
So I'd like to ask mom about a prenatal history if there was any problems in the pregnancy, any infections or premature birth. I'd like to know about the no. There was no there was no any prenatal history issues, any problems in the birth or in the post-operative post as a. She had a planned cesarean section and the child was a healthy boy, and he didn't need to stay in the hospital at all.
OK, I'd like to know if the child has met their normal developmental milestones. So sitting walking? Yes, although she thinks that he was, you know, slightly delayed compared to his cousins. OK, I would like to know if there's any, any other children at home and if they have any similar problems at all. Yes, there is.
His older, older sister had similar condition. And anything that in the parents side, any known problems with any diagnosis of height or structural deformity in the parents that they know of. Yeah, the mother said that her family is brilliant as usual. Ok? it's the father's problem, ok? His grand, his grandfather and himself was short or short.
OK, I would like to know if the child a little bit about the child's schooling if they go to a mainstream school or any different type of schooling. No, it's good schooling. Although he's not playing as usual as the other children, is not interacting in the PE and, you know, activity wise, but he's intellectual. Is good. OK and I'd like to know a bit more about why he's not interacting.
Is it pain or is it more of a fatigue or what sort of stopping him playing so much with the other children? Well, yeah, he he's not that, you know, as active as the other children, and he's not of the same physical capabilities. OK I'd like to know just a little bit more about the child as well if they've ever had any problems with their neck or their spine diagnosed or have any other past medical history.
Didn't she say that the medical, the medical care back home was really not good, and they said that this happens? You might have something from his father's side, and that's it. OK and he's not known of any breathing problems when he was a baby that the mom tells me about nothing. No, no. He didn't have any problems with his breathing, though.
OK I'd like to know. It doesn't seem like they've had any treatment. So far, but I'd like to know if the child's on any medications, I assume. Probably not. No but he was, you know, she was sticking him to the, you know, the optician to check his eyes. Oh, OK. And did that find anything at the optician?
I know, but she thinks that he is he might be wearing. need to wear eyeglasses like his father as well. OK I would like to know just to know the dad or the child is known to be sort of quite stretchy or bendy at all. No, no. You should say that he's more stiffer than usual. You know, people. Yeah and just like I feel from the mum, if things have changed rapidly or if this is sort of more of a he's always been like this and it's just that they're now seeking.
Yeah, she's saying that she slowly, slowly getting worse. So you're getting worse, OK? And just to show this, there's not been any that that's OK. What? that concludes your history time we need to go to. Sorry to interrupt, but you have to go to examination. So tell me about how would you approach this child? So our [inaudible] child with a top to toe examination, so initially asking the child to walk around the clinic walking, would you like to comment on the pictures?
So looking at these pictures, I can see a picture of the front and the side of this child. It looks like he's got a sagittal plane deformity. He looks like he's short in height with. It's difficult to tell if this is where the shortening is actually coming from because his shorts are covering quite a lot of his lower limb. But it looks like it's a symmetrical, symmetrical shortening with potential.
So in terms of, I think it's probably a level rise, a little shortening. It looks like his arm is shorter than his forearm, but I can't obviously see his thumb. So, so I to like defines the segment. What is symmetrical? Is there a symmetrical shortening and non symmetrical shortening? So I just meant that on both sides.
I was just sort of oh, OK, right? So OK. So no, no hypertrophy. OK all right. OK So then I would like to fully examine the child, so expose them down to their underwear. Looking at the spine, looking, if there's any signs of any spine, any problems with the spine, you can see.
So it looks like he does have a set of scoliosis. Looking at these clinical photographs, I'd like to explore that further. I would look for any signs of scrape isms or any hairy patches or any, no hairy patches, and I would like them to do a Forward Bend test to see if this further accentuates any deformity. He can. He can.
Yeah, he can Forward Bend and there is a slight, a slight [inaudible] But when he flexes forward, yeah, OK. So I'd like to note down the side of that. And then I would like it's on the right side. OK and I would like to examine him, examine his cervical spine movements. I would like to examine his hips if there's any signs of any scarring.
Why would you want to examine his cervical spine? So in a child with a dysplasia, they can have problems with their cervical spine. So some atlantoaxial subluxation wouldn't really be picked up too much on examination, but it would just be a proper examination. And then I would like to go on to examine the abdomen, just make sure I can feel no abdominal masses (abdominal masses?) and then going down to the hips to see the range of movement here.
If this is painful and want to know if it's limited in abduction or abduction, or flexible and limited in abduction, abduction, ok? And then looking at this, so there is no abduction, no abduction. OK, so that might suggest a problem such as a foot of the hip or a dislocation. And then I would like to get down to examine the knees, see that they fixed flexion deformity and the range of movement and flexion, extension, and ligamentous laxity.
OK, would you walk the child? Yes yes, I would. OK so the child is swinging right, right and left. So you right and left, OK, so that's I guess so I'd like them to attempt this child to do it. Lindbergh's test. It can be difficult in this age group, but I would try and get them just to stand by me and listen. And then after examining him, what would you like to know when he lie flat on the bed?
I would want to know I would want to do attempting a Thomas test to see if he's got any fixed flexion deformity. I'd also like galeotti test to see if where his leg length discrepancy or its femoral, it's above the knee above the knee. OK would you do anything further? I can. I can do.
I can draw with my hands Bryants triangle to see if this is more of a Supra-Malleoar problem, or whether it's equal on both sides, but they're very small. Very small. OK, OK, OK, good, so what investigations would you like to do? So my investigators with I would like to do a radiographs of the patient's spine to further the spine and the hips and the hips.
So looking at the radiograph of the spine, AP radiograph, I can see that there is a right sided curve. And looking at the radiographs of the hips are minimized that can see bilateral hip changes with loss of the suffocation or loss of the femoral head. My concern is this potentially is secondary to a type picture.
It's not been treated. It looks like they are LDH. Oh, picture and not. Not necessarily, because the hip is not necessarily, but I think there has been a change in the hips. So would you lose the ossification center at six years old? No you would expect not to see it at all. So this isn't a picture.
I'm sorry. There is a change. There is almost a loss of the bilateral femoral head, potentially to a variety of different reasons. This could be secondary to AVN or a purpose or secondary to further is. So what type of spectrum of diseases we are talking here about? So in terms of the child, I think the child has a dysplasia.
Dysplasia is birth or even included in skeletal dysplasia, they are not, but a child could also still have them, but it would be unlucky and unusual in both sides again. So the hip change is looking at his hip change may be more in keeping with something like an MED multiple physeal dysplasia, so. What do you say about the spine? So then it would be more of a said so. So we are talking about said, all right, so hips back to hips.
How would you manage this child? OK so I imagine as a child by talking to the child and to the parents about in terms of their aims of treatment, how much it's really affecting him in terms of how much is functional demands. We know he's not really playing so much at school in terms of the spine. The options for treatment. You know, I could measure angles and further delineate the level of deformity of the spine.
But the options are bracing, which is not always that effective. Or it would be thinking about why it's not effective, although it is a low degree of stability. So it can be effective. It helps support the spine and helps to prevent progression progression. But it doesn't correct the deformity, and it sounds that he seems like he's already got deformity, which most likely may regress.
What do you think the Cobb angle is? So the Cobb angle is a mild, moderate, severe, I don't want the degree I would say this is probably more of a moderate Cobb angle. That's right. Is that more or the pathology is the more concerning thing? I think the hip pathology is more concerning is as this is likely to progress, and I would want to treat this as part of an MDT approach with the pediatricians and the physiotherapists.
Wanted to get this? OK thank you, Melissa. Thank you. That's it. Take a deep breath and rest now, right? OK, we'd be moved soon. Yeah, first. First thing you did well, I'm know, I'm happy with your answers.
It is a shocker. And recently, they started to put pediatric complicated pediatric cases, you know, things that never been in the normal, you know, old pattern of. And this was in one of my courses I did during the preparation. So that's why I brought it up, but in real patient. So in the history type, I am happy with the history. Although you missed quite a few questions like any I meant to try to prompt you by the eye test, OK, because if it's said it's an eye and hearing problems.
OK, so that's from the history examination. Yes, you know, a little bit bumpy, but have a sequence of what do you want to ask and what do you want to go further? The hips are the more concerning thing because this is coxa vara, the Greek angle. Yeah and you said it actually after the time. OK So will it count?
A, I guess so this is your lower limb intermediate. Who were the first? Is it Benjamin and Assef, is that right? Yeah, yeah, I can, I can go ahead. Right? and let me just show you what my. Sorry can you see this screen?
Yes, we can. So this is a 57-year-old lady. She's presented to your clinic with a referral letter from the GP and the GP letter says that he's been seeing this lady for some time with bilateral knee pain. It's got worse over a period of years. He's tried analgesia, he's injected and he's a couple of times, and he says the pain is just getting worse and he wants your orthopedic opinion.
So you've got 5 minutes for the history, first of all. So what do you want to know? So I need to know the age of the patient and his level of activity and how long this is there any surgery done on this side and how long the pain is there and how it is affecting the his daily activities. And I would like to know generally his overall mobility as well.
And precisely, I will ask him to tell me where exactly is the pain and how much is the pain on visual analog score? And is there any radiation of pain approximately or distally? I will look in and out of the box, particularly the spine and the hip, as well as the distal part I would look for. I will ask him, is he having any other pain? Is he having any previous surgery done and was he pain free after the surgery or not?
I would also like to know if he have any fever now, and he's generally fit and well. I would like to know the other past medical history, particularly diabetes mellitus, immunocompromised peripheral vascular disease and. I want to know what is his expectations. In addition to that, I just want to gather that easy. So give you some information. So she said, she said it's not.
So it's a 57-year-old lady. She has had pain on and off actually now for quite a long time, probably about 30 years. And she did have surgery when she was in her early 20s. She can't remember exactly what she said. She was having problems with any problems with her knees, with an old surgeon who retired, and there's no records. But she did have some surgery on both of her knees in her early 20s.
It's got worse over 30 years. She was managing fine, but over the past two or three years, she's really deteriorated and that's why she's taking more analgesia. She's taking cocodemol eight tablets a day, so she maximized that she's had a few steroid injections. And in terms of her mobility, she's still walking independently. But if she walks for a long distance, if she goes outdoors, she has to use a stick past medical history.
She's got hypertension. No other significant past medical history. So I need to know that before you know, pain from the spine or the hip, as you mentioned, no pain from anywhere else. OK, so this is a good thing. Actually, the only involved is the right knee. I want to know that before this surgery was having any long standing issue or no like a dislocation of the patella or any other issues is there any history of particularly if she had surgery when she was in her early 20s.
And she had exactly the surgery was at the heart? Remember, she can't remember, she said there a long time ago. No, I can't remember. I don't think so. OK and because we are lacking the information here, so I will proceed with the examination. OK do you want to summarize the history? Yeah so she's a 57-year-old lady who is having pain in the right knee from last 30 years or so.
She cannot remember what exactly happened at that time, but there is a clear history of surgery, which was done in. The surgeon is retired now. Since that time, she has pain and it is affecting her daily activities and otherwise she is fit and well apart from a high blood pressure. Yeah, OK, fine. So you move on to the examination.
So you see her knees, and this is what you see. So just describe what you can see. So these are the clinical photographs of a knee I can see there is a prominence on the anterior aspect of the knee with the previous scar. Mark dimpling as well, but a bit of dimpling there. The attitude of the limb base in slight flexion. If you can see the scar both sides any, what do you think? Might she have had what kind of operation?
So there are two options. I can't figure it out. It's me on the medial side or on the lateral side. So can you guide me? Is it think it's on the lateral side? It's on the lateral side, so it could be lateral parallel release. It could be some infection at that time. So, OK, just move on.
So in terms of examination, what do you want to do in terms of how would you examine this knee? So I will ask her to stand up and see, is it? Is there any fixed flexion deformity? I would like to see the hip as what is the attitude of the limb? And then I will ask her to walk and see how she walks. Is there any antalgic gait or any specific sort of gait? I will look back in the popliteal fossa as well to see that there is no other scar mark there.
And then I will ask her to sit on the edge of the couch and ask her to kick out the knee to see that how much she has got the movement and I can at the same time, I can look at the quadricep. Is it intact or not? And I will ask her to do the perform the sit on the couch. I will again see that there is no leg left discrepancy and I will position both the sides and measure, but initially happened and then two leg length discrepancy focusing on the knee.
Basically, I want to know, is it passively correctable or not correctable and how much is the flexion from this point onwards? And I will do the I will do the palpation to see where exactly is the pain? What is the temperature? Is there any? So just to move on. So in terms of her gait, she does have a slightly antalgic gait.
It's worse on the right compared to the left. She has a slight valgus alignment of her knee. All right, and her range of motion is actually quite good. She can fully extend the knee and she can flex to 100 degrees. In terms of the pain, she says. Both in the history and from this examination is global. It's not focused on one side of. The whole knee is quite painful.
Ok? I have asked her already that she has any pain, any other joints, so I'm concerned about arthritis as well. So is she taking any medicine for rheumatoid arthritis or not? No, she's not. I will see because she has a wielgus deformity, I would like to know that the medial structures they are competent are not, particularly with the medial collateral ligament.
And again, as I mentioned previously, how are you going to test that? So I will try to see that. Is it correctable or not? Is it a fixed? Well, are it's correctable. And then I will go for X-ray of the knee. OK, so if it is correctable, does that mean that the collaterals are insufficient or sufficient or how is that helping you?
So I will apply the valgas stress test and see, is it competent or not? It is a Frank. mean, I have to see the endpoint as well, if it's a point. She does have an end point. Yeah, so the collaterals are intact. OK, so you want some x-rays? What x-rays would you like? I would like to get AP and lateral and skyline view as well.
That's not the best quality X-ray. So apologies for that. But this is the right knee that we want to focus on. So what can you see there on the ap? It's a weight bearing X-ray. All right. So this is AP both of AP two slightly different on the left hand side. Yeah, it does focus on the right side.
The right side there is good joint space. So the right knee is a left of the picture, sorry, right? Yeah, on the left. So there is increase osteopenia in the medial tibial plateau area. OK and there is increased signals in the distal femur increase ketosis in the five minutes.
Sorry there is a bit of you looking at this, this knee, aren't you? So I can see there is a valgus deformity. Yeah and there is a bit of subluxation on the medial side, medial femoral condyle. And in this case, I'm concerned about the lateral femoral condyle, bone loss and also the competence of ACL and PCL, I would examine, but it would be very difficult to see.
Yeah, I agree. The bloods of this patient said he wanted to see a lateral as well. Yeah, definitely. OK so on the latter view, the patella is absent and there is no posterior subluxation of the femur, it looked like the PCL seems all right. So it's a complex situation. Yes, and I will.
I need to know what is her expectations and I will involve my because it's a sort of complex case. It's not a simple one. Yeah, I will take the advice from my revision surgeon because if we have to do anything surgically, it will be a complex primary and PCL stabilizing knees needed rather than jumping for anything. But we need to know what is. So her expectations are that she's at the end of her tether.
She's in a lot of pain and she wants a definitive solution. From here, it looks like she has exhausted all the non operative management. Yes, I will go for. I mean, I will speak to my [inaudible] So you've discussed that in the MDT. So what are you going to offer the full blood count? Yeah I will do the CT to look at the lateral efficiency, and I will refer him to the. So let's say you're in a specialist centre, you are the specialists. The complexity here is the approach. I will go for medial para-patellar approach. I know that some people go for lateral approach, if it will be difficult case, really. So maybe there is contraction of the quadriceps and exposure would be difficult. We have to do a lot of medial releases and I will not use the White side.
I will use the White side line, I will not use the posterior referencing in this case, because it can lead to internal rotation of the femoral conduit and I will go for posterior stabilizing knee replacement. In addition to that, before proceeding to this stage, I need the wrap to be there. I need that I have all the materials. If the medial collateral ligament is not competent, maybe we have to go for varus valgus, stabilize knee so that I have all the ladders going all the way to the hinge needs to be the principle of a PS knee said, a posterior stabilize knee.
Why would you use that? How does that work? Because in the posterior stabilizing knee, we have a Cam and the Cam mechanism big and a Cam mechanism. And most of these patients are both PCL deficient in that case, when as we flex, the Cam engages the peg and it gives posterior stability to the knee joint two more minutes feedback.
Fine OK, we'll stop there. So what do you think? How do you think you did? Yeah, reaching to the absence of patella was difficult. Yeah, it is. Yeah so I did the exam two weeks ago. This was my case. An example. Yeah so this is the exact case I got.
So yeah, it's an interesting case. It's not a straightforward one. So it's quite difficult. So I think you did really well. I think you were systematic. I think your history is very good. Your you have a spiel and I think sometimes it's advantageous to just keep talking, but also listen to the examiner. So I said to you when we got to the management, I just said to what do you want to do?
Which is exhausted all options and I appreciate you want to go through the ladder and you saying, but just I asked you a direct question and you want to just score the points. So just listen to the question that I'm questioning. But yeah, the scar is quite difficult. It's not one that you see that often. I just got this off the internet, so I actually had a transverse scar over the front of the patella.
So this is maybe a bit misleading. So I apologize for that. But you understood the principles of a bogus knee and you know, the approaches and what kind of releases and the issues with rotation. I think you probably need to do more lateral releases. said medial releases, I think you need to do more lateral releases and about the contractor part is that but you know, it's a slow fix them.
Yeah, this is the convex side, the medial is and the concave side is the lateral side, which need release. Yeah, Yeah. So you need to do more lateral releases. And yeah, you're right. I think most people would still use their medial patella as that's what you used to, but you can use lateral as well. You can see here on the apex, we actually, if you look closely, there's no patella on this one.
Yeah, Yeah. So that was the other clue, but it's difficult to spot. I didn't spot it in the exam as well until I saw this x ray, but overall that was good. I think the next conversation would have been talking about what type of knee NJR data and why you would use a certain type of knee. But overall, I think. You did very well.
Very good. Definitely a pass. Good pass.
Segment:0 .
We started the Intermediate Lower limb case here is so welcome to each of you, Melissa, and [inaudible] who wants to go first. That to me to go, come on, need a volunteer, all right, so share the screen. Once you can see it, let me know so we can start your timer. Yeah, timer on.
OK, so you've got Miss BH, who is a 22-year-old college student. She was going down the stairs a couple of days ago when her knee buckled underneath her. She didn't fall to the ground but managed to hold onto the banister, and she's now coming to you, complaining of pain and swelling. Tell me what you want to ask about in the history, and I'll tell you what the findings are.
OK, so I want to know when it happened and whether she when she landed or you said she didn't fall. So I'd want to know how she's been walking since then as she's been limping. Yeah, it's painful. So she's been limping. Yeah and where exactly is her pain? The pain is mainly on the inner side of the knee. OK and has she experienced any clicking?
Uh, no, nothing, nothing so far. Any locking or giving way of her knee. What do you mean by locking? So has she found that her knee is stuck in a position and she can't easily move it? You mean, like bend or straighten, either locked in extension or locked in flexion? Has she experienced any symptom? Right, you're absolutely right.
She's not been able to put it fully straight. It does not want to go fully straight. OK, fine. And has she had any prior injuries to her knees? Yes, exactly. She did remember that she was playing basketball two months ago when her right knee was on the right foot was fixed on the ground. She twisted to the left to get the ball from somebody else, and she felt a pop and fell to the ground.
OK and since then, for the last two months, she's been able to mobilize on this knee. It took a little bit of time, so she initially put some ice on it and she was able to put to it a little bit painful, but not that much. OK and I'd also want to know, apart from basketball, does she have any other hobbies or any other sport that she plays? Basketball is her main sport.
OK is she otherwise? Well, any medical conditions? No other medical conditions. Any regular medication? No, nothing. She's had a couple of painkillers for the first injury and for this last injury as well. And the only other thing I'd want to exclude is, is there any history of malaria or eating disorders, anything like that at all?
OK So so in summary, this is a 22-year-old lady who has a history of a knee injury two days ago when running down a flight of stairs. It sounds like the primary injury was two months prior to that, when she landed onto a fixed foot and twisted it whilst playing basketball. She has symptoms of pain and locking with a fixed flexion, which is unable to fully extend, and she plays basketball and is otherwise fit and well.
Yeah, exactly. So what would you want to do examine her? Yes, I would like to proceed with her. Can you comment on what you see on the pictures and then tell me, what steps do you want to do further? They are unexamined on inspection lists. These are clinical photographs of a knee. I can see the right knee appears swollen in comparison to the left.
I also note that on standing, she is holding it in slight flexion compared to the other side. I can't see any obvious patella deformity or patella seem to be at the same level of these photos as she is standing. I would like to proceed by asking her to walk. I'd like to examine her gait to see if she's limping, if she's able to extend her foot, just limping a little bit. It looks like I'm [inaudible].
OK? I'd also like to inspect from the back to see if there's any findings, any swelling or bruising to the back of her knee. Nothing to mention. Same type of swelling. Same size. All right. I then ask her to sit on the examination couch and start by palpitating to assess if there's an effusion.
So I do this by milk milking down the thigh and then sweeping from medial to lateral and seeing if I can see a medial bulge, which would indicate an effusion. Would you expect that to be positive here? No, I wouldn't. If if this is an articular, injury may not be. Right, so. I wouldn't expect in the future, necessarily in this order.
But what about this swelling? And so you can have a swelling because of injury around the knee. So sorry. So in this, I would expect her to have an effusion because she has had an injury in her knee, so I mean, I can see it visually anyway, but I'd also examined for it. Right, OK. Then I'd want to assess a joint tenderness or medial or lateral joint tenderness.
I want to see if, she said. Thank you. So I want to say straight leg raise. And then while she does that, I'd also assessed at the same time if she really extending as well as how far she can flex, she's extending to the same extent that you can see on this picture on the X-ray. And she can flex up to 90, as you can see here on this picture as well.
OK I then move on to assess stability of the knee, so I'd want to assess valgus and various stability by stressing the need both there and in the same value of fashion. I'd also want to perform a draw. I do this by asking her, do you want to test the Ferguson varus instability in? So usually I would lift the leg and I'd have it, well, extended as she can.
And in that position, I placed focus on various stress and see if there's any opening of the joint or if there's anything right. Nothing in full extension. OK? I'd also then assess it inflection to see if there's any difference compared to extension. What degree of extent of flexion do you mean? About 30 degrees.
So you can do it at zero, 30 and 90? Right? no, there is no this. There is no joint opening in either varus or valgus, but when you press the knee and varus, it's a bit big. Embarrasses you. OK, but then go on to perform in an anterior drawer test. I do this by flexing the knee, usually sitting on the end of her foot after consenting her for that.
And then placing an anterior force on the tibia, block subluxation against the femur. And also I can do Lachman's and pivot shift. All of these will assess for an ACL injury. The anterior drawer is not very conclusive. You cannot get any information from that, and this is her lack. Can you describe what you want to do? But so with the Lachman test, I stabilize the thigh with one hand and grasp the tibia over the tibial generosity with the other hand and anteriorly, translate the tibia against the femur and there's various want to assess for a firm endpoint and then also the degree.
Of movement, so this is a positive Lachman's test, which is indicative of an ACL injury in her case, I'd also want to compare it to the other side just to make sure it's not normal for her. And then I'd complete my ACL examination with the pivot shift test. How do you do that? There is a pivot shift. I have the patient's leg extended.
I internally rotate it. I place a bogus force on the knee and then I flex the knee. And what I'm looking for is for the tibia to reduce as I flex the knee. Right so you need an intact MCL and material that can you always get the pivot shift during the examination in the clinic? No, it's best done in a relaxed patient in theater. Right, OK.
And that's what it looks like. So anything else that's important to you to assess now what's going on in your mind? OK so I'm thinking this is an ACL injury. I'd also want to assess the meniscus at this stage. I already know she has a fixed flexion injury, but I want to assess both the risk, also the PCL for completeness. Right, so differential diagnosis, ACL.
OK, I agree. Anything else is deal with the potential lateral meniscal injury. It could also be a multiligament injury involving other structures in the knee, such as the PCL. No how do you assess the PCL? PCL, usually I'd look for a posterior sag from the side with both the knees flexed. You can also do a posterior drawer for that.
Yeah, there is no there is no posterior sag. So what further investigations do you want to obtain? So what investigations do you want to get? OK, so I'd like to get an MRI scan, assuming we've already had radiographs, then I want to get an MRI scan to further assess her injury. I'd then go on to counsel the patient. OK, so these are surgical MRI scans showing I can see on here.
There's I can't see an intact ACL. I can see the PCL is in continuity. I can see fluid both behind the patella and I can also see what looks like a meniscal tear with extrusion, potentially. But I'd want to see more slices and a coronal view to better delivered by extrusion. And so you can.
Sorry, so that might, in fact, if I can retract that, that might be a double steal sign on the right, but I'm not very clear. I'd want to just look through a few more slices, to be sure. And you can sometimes see that in the bucket handle there. Right? OK. This is another slice.
OK, so I can clearly see an ACL injury complete rupture of the ACL. But again, I can see how can you say that I can't see any progress and continuity of the ACL at all. You'd normally see that going from anterior to posterior, almost in the other direction to the PCL, which you can't see, right? So what are you going to offer this patient?
I'm going to discuss with her two courses possible courses of action. One is physiotherapy, which is a prerequisite anyway because she doesn't have full range of movement. So I would first start with preoperative physiotherapy and explain the importance of regaining a full range of movement there. Thereafter, her option. There are a certain percentage of patients who do go on to have a reasonably functioning knee with that treatment, but the majority of young active patients will require operative intervention in the form of an ACL reconstruction.
And so I will counsel her about this. I'll explain that there are risks associated with it, including infection pain, stiffness, arthritis down the line, risk of rerupture, risk of ongoing instability. You're not going to tackle that at all. Sorry, you're not going to tackle this pathology at all. What did you mention on the mri? She had the bucket handle tear as well?
Yes so just Yes. No, I wouldn't leave that because that will also cause her ongoing symptoms. There's two options of managing this, either depending on the severity of her symptoms. You can either address it immediately with the ACL tear or if because she's got a flexion deformity. If we're not going to do an ACL immediately, we can assess address the bucket handle tear first.
OK right, I think this is fair enough for now. Take a breath, sit down, sit back and think, how do you think this station went? Um, I think the initial bit was OK in terms of identifying the pathology, talking through the examination and the history. I think I was a little bit. I wasn't very fluent with the management in that I jumped back and forth a little bit.
And I did initially forget the bucket handle part of it, so I could have been a bit more decisive about that. Right? you've got a very good insight. You've identified I would have given you six or seven, even for the history and the clinical examination you've asked about the site of the pain, the site of tenderness, what you missed in the history was swelling. You never asked me about swelling on your side.
No yeah, OK. But then does it make any difference? How soon did the swelling come up after the injury? Because it. What I would have told you that it has happened in a couple of hours on the first case and on the second case. And if it's happened very soon, then the meniscus is a peripheral meniscal tear because these are the ones that bleed and it's probably one that needs repairing.
The other thing is, you've quite rightly identified the flexion deformity and mentioned about the patella with the patella in a patient who's given way. What you're interested on is whether it's partial or alter. It's whether it's lateral realized as well, because it could have been a patella subluxation or recurrent dislocation when you were talking about the effusion. What I was aiming for is sweep test would give you the small or the minimal effusion.
But with such a large effusion that you can see in her case, sweep test would be negative, but you will be able to detect either fluctuation or patella tap. These are the signs for a bigger size of effusion. The killer is your is your treatment with a failed tear because you forgot completely forgot that a locked knee with a bucket handle 22 years old lady plays basketball, and if you've asked about her sports level, she's playing for her University.
So she's a very sporty lady, young and she needs to go back to sport. So this bucket needs to go back in its place. You can't take it out altogether, especially if it's a large one with a peripheral wide breadth of Reds. So it's a meniscus repair and meniscus repair is an absolute education for ACL reconstruction. OK, thank you.
Joe thank you. That's right. If you can stop, Joe, thank you very much, Melissa. Hi and your time starts now. You have been asked by the GP that this young lad, six years old, come from mid Asia countries and he is not happy with his appearance and he came to you with mom. So tell me, what are the questions you want to ask to to mom?
So I'd like to ask mom about a prenatal history if there was any problems in the pregnancy, any infections or premature birth. I'd like to know about the no. There was no there was no any prenatal history issues, any problems in the birth or in the post-operative post as a. She had a planned cesarean section and the child was a healthy boy, and he didn't need to stay in the hospital at all.
OK, I'd like to know if the child has met their normal developmental milestones. So sitting walking? Yes, although she thinks that he was, you know, slightly delayed compared to his cousins. OK, I would like to know if there's any, any other children at home and if they have any similar problems at all. Yes, there is.
His older, older sister had similar condition. And anything that in the parents side, any known problems with any diagnosis of height or structural deformity in the parents that they know of. Yeah, the mother said that her family is brilliant as usual. Ok? it's the father's problem, ok? His grand, his grandfather and himself was short or short.
OK, I would like to know if the child a little bit about the child's schooling if they go to a mainstream school or any different type of schooling. No, it's good schooling. Although he's not playing as usual as the other children, is not interacting in the PE and, you know, activity wise, but he's intellectual. Is good. OK and I'd like to know a bit more about why he's not interacting.
Is it pain or is it more of a fatigue or what sort of stopping him playing so much with the other children? Well, yeah, he he's not that, you know, as active as the other children, and he's not of the same physical capabilities. OK I'd like to know just a little bit more about the child as well if they've ever had any problems with their neck or their spine diagnosed or have any other past medical history.
Didn't she say that the medical, the medical care back home was really not good, and they said that this happens? You might have something from his father's side, and that's it. OK and he's not known of any breathing problems when he was a baby that the mom tells me about nothing. No, no. He didn't have any problems with his breathing, though.
OK I'd like to know. It doesn't seem like they've had any treatment. So far, but I'd like to know if the child's on any medications, I assume. Probably not. No but he was, you know, she was sticking him to the, you know, the optician to check his eyes. Oh, OK. And did that find anything at the optician?
I know, but she thinks that he is he might be wearing. need to wear eyeglasses like his father as well. OK I would like to know just to know the dad or the child is known to be sort of quite stretchy or bendy at all. No, no. You should say that he's more stiffer than usual. You know, people. Yeah and just like I feel from the mum, if things have changed rapidly or if this is sort of more of a he's always been like this and it's just that they're now seeking.
Yeah, she's saying that she slowly, slowly getting worse. So you're getting worse, OK? And just to show this, there's not been any that that's OK. What? that concludes your history time we need to go to. Sorry to interrupt, but you have to go to examination. So tell me about how would you approach this child? So our [inaudible] child with a top to toe examination, so initially asking the child to walk around the clinic walking, would you like to comment on the pictures?
So looking at these pictures, I can see a picture of the front and the side of this child. It looks like he's got a sagittal plane deformity. He looks like he's short in height with. It's difficult to tell if this is where the shortening is actually coming from because his shorts are covering quite a lot of his lower limb. But it looks like it's a symmetrical, symmetrical shortening with potential.
So in terms of, I think it's probably a level rise, a little shortening. It looks like his arm is shorter than his forearm, but I can't obviously see his thumb. So, so I to like defines the segment. What is symmetrical? Is there a symmetrical shortening and non symmetrical shortening? So I just meant that on both sides.
I was just sort of oh, OK, right? So OK. So no, no hypertrophy. OK all right. OK So then I would like to fully examine the child, so expose them down to their underwear. Looking at the spine, looking, if there's any signs of any spine, any problems with the spine, you can see.
So it looks like he does have a set of scoliosis. Looking at these clinical photographs, I'd like to explore that further. I would look for any signs of scrape isms or any hairy patches or any, no hairy patches, and I would like them to do a Forward Bend test to see if this further accentuates any deformity. He can. He can.
Yeah, he can Forward Bend and there is a slight, a slight [inaudible] But when he flexes forward, yeah, OK. So I'd like to note down the side of that. And then I would like it's on the right side. OK and I would like to examine him, examine his cervical spine movements. I would like to examine his hips if there's any signs of any scarring.
Why would you want to examine his cervical spine? So in a child with a dysplasia, they can have problems with their cervical spine. So some atlantoaxial subluxation wouldn't really be picked up too much on examination, but it would just be a proper examination. And then I would like to go on to examine the abdomen, just make sure I can feel no abdominal masses (abdominal masses?) and then going down to the hips to see the range of movement here.
If this is painful and want to know if it's limited in abduction or abduction, or flexible and limited in abduction, abduction, ok? And then looking at this, so there is no abduction, no abduction. OK, so that might suggest a problem such as a foot of the hip or a dislocation. And then I would like to get down to examine the knees, see that they fixed flexion deformity and the range of movement and flexion, extension, and ligamentous laxity.
OK, would you walk the child? Yes yes, I would. OK so the child is swinging right, right and left. So you right and left, OK, so that's I guess so I'd like them to attempt this child to do it. Lindbergh's test. It can be difficult in this age group, but I would try and get them just to stand by me and listen. And then after examining him, what would you like to know when he lie flat on the bed?
I would want to know I would want to do attempting a Thomas test to see if he's got any fixed flexion deformity. I'd also like galeotti test to see if where his leg length discrepancy or its femoral, it's above the knee above the knee. OK would you do anything further? I can. I can do.
I can draw with my hands Bryants triangle to see if this is more of a Supra-Malleoar problem, or whether it's equal on both sides, but they're very small. Very small. OK, OK, OK, good, so what investigations would you like to do? So my investigators with I would like to do a radiographs of the patient's spine to further the spine and the hips and the hips.
So looking at the radiograph of the spine, AP radiograph, I can see that there is a right sided curve. And looking at the radiographs of the hips are minimized that can see bilateral hip changes with loss of the suffocation or loss of the femoral head. My concern is this potentially is secondary to a type picture.
It's not been treated. It looks like they are LDH. Oh, picture and not. Not necessarily, because the hip is not necessarily, but I think there has been a change in the hips. So would you lose the ossification center at six years old? No you would expect not to see it at all. So this isn't a picture.
I'm sorry. There is a change. There is almost a loss of the bilateral femoral head, potentially to a variety of different reasons. This could be secondary to AVN or a purpose or secondary to further is. So what type of spectrum of diseases we are talking here about? So in terms of the child, I think the child has a dysplasia.
Dysplasia is birth or even included in skeletal dysplasia, they are not, but a child could also still have them, but it would be unlucky and unusual in both sides again. So the hip change is looking at his hip change may be more in keeping with something like an MED multiple physeal dysplasia, so. What do you say about the spine? So then it would be more of a said so. So we are talking about said, all right, so hips back to hips.
How would you manage this child? OK so I imagine as a child by talking to the child and to the parents about in terms of their aims of treatment, how much it's really affecting him in terms of how much is functional demands. We know he's not really playing so much at school in terms of the spine. The options for treatment. You know, I could measure angles and further delineate the level of deformity of the spine.
But the options are bracing, which is not always that effective. Or it would be thinking about why it's not effective, although it is a low degree of stability. So it can be effective. It helps support the spine and helps to prevent progression progression. But it doesn't correct the deformity, and it sounds that he seems like he's already got deformity, which most likely may regress.
What do you think the Cobb angle is? So the Cobb angle is a mild, moderate, severe, I don't want the degree I would say this is probably more of a moderate Cobb angle. That's right. Is that more or the pathology is the more concerning thing? I think the hip pathology is more concerning is as this is likely to progress, and I would want to treat this as part of an MDT approach with the pediatricians and the physiotherapists.
Wanted to get this? OK thank you, Melissa. Thank you. That's it. Take a deep breath and rest now, right? OK, we'd be moved soon. Yeah, first. First thing you did well, I'm know, I'm happy with your answers.
It is a shocker. And recently, they started to put pediatric complicated pediatric cases, you know, things that never been in the normal, you know, old pattern of. And this was in one of my courses I did during the preparation. So that's why I brought it up, but in real patient. So in the history type, I am happy with the history. Although you missed quite a few questions like any I meant to try to prompt you by the eye test, OK, because if it's said it's an eye and hearing problems.
OK, so that's from the history examination. Yes, you know, a little bit bumpy, but have a sequence of what do you want to ask and what do you want to go further? The hips are the more concerning thing because this is coxa vara, the Greek angle. Yeah and you said it actually after the time. OK So will it count?
A, I guess so this is your lower limb intermediate. Who were the first? Is it Benjamin and Assef, is that right? Yeah, yeah, I can, I can go ahead. Right? and let me just show you what my. Sorry can you see this screen?
Yes, we can. So this is a 57-year-old lady. She's presented to your clinic with a referral letter from the GP and the GP letter says that he's been seeing this lady for some time with bilateral knee pain. It's got worse over a period of years. He's tried analgesia, he's injected and he's a couple of times, and he says the pain is just getting worse and he wants your orthopedic opinion.
So you've got 5 minutes for the history, first of all. So what do you want to know? So I need to know the age of the patient and his level of activity and how long this is there any surgery done on this side and how long the pain is there and how it is affecting the his daily activities. And I would like to know generally his overall mobility as well.
And precisely, I will ask him to tell me where exactly is the pain and how much is the pain on visual analog score? And is there any radiation of pain approximately or distally? I will look in and out of the box, particularly the spine and the hip, as well as the distal part I would look for. I will ask him, is he having any other pain? Is he having any previous surgery done and was he pain free after the surgery or not?
I would also like to know if he have any fever now, and he's generally fit and well. I would like to know the other past medical history, particularly diabetes mellitus, immunocompromised peripheral vascular disease and. I want to know what is his expectations. In addition to that, I just want to gather that easy. So give you some information. So she said, she said it's not.
So it's a 57-year-old lady. She has had pain on and off actually now for quite a long time, probably about 30 years. And she did have surgery when she was in her early 20s. She can't remember exactly what she said. She was having problems with any problems with her knees, with an old surgeon who retired, and there's no records. But she did have some surgery on both of her knees in her early 20s.
It's got worse over 30 years. She was managing fine, but over the past two or three years, she's really deteriorated and that's why she's taking more analgesia. She's taking cocodemol eight tablets a day, so she maximized that she's had a few steroid injections. And in terms of her mobility, she's still walking independently. But if she walks for a long distance, if she goes outdoors, she has to use a stick past medical history.
She's got hypertension. No other significant past medical history. So I need to know that before you know, pain from the spine or the hip, as you mentioned, no pain from anywhere else. OK, so this is a good thing. Actually, the only involved is the right knee. I want to know that before this surgery was having any long standing issue or no like a dislocation of the patella or any other issues is there any history of particularly if she had surgery when she was in her early 20s.
And she had exactly the surgery was at the heart? Remember, she can't remember, she said there a long time ago. No, I can't remember. I don't think so. OK and because we are lacking the information here, so I will proceed with the examination. OK do you want to summarize the history? Yeah so she's a 57-year-old lady who is having pain in the right knee from last 30 years or so.
She cannot remember what exactly happened at that time, but there is a clear history of surgery, which was done in. The surgeon is retired now. Since that time, she has pain and it is affecting her daily activities and otherwise she is fit and well apart from a high blood pressure. Yeah, OK, fine. So you move on to the examination.
So you see her knees, and this is what you see. So just describe what you can see. So these are the clinical photographs of a knee I can see there is a prominence on the anterior aspect of the knee with the previous scar. Mark dimpling as well, but a bit of dimpling there. The attitude of the limb base in slight flexion. If you can see the scar both sides any, what do you think? Might she have had what kind of operation?
So there are two options. I can't figure it out. It's me on the medial side or on the lateral side. So can you guide me? Is it think it's on the lateral side? It's on the lateral side, so it could be lateral parallel release. It could be some infection at that time. So, OK, just move on.
So in terms of examination, what do you want to do in terms of how would you examine this knee? So I will ask her to stand up and see, is it? Is there any fixed flexion deformity? I would like to see the hip as what is the attitude of the limb? And then I will ask her to walk and see how she walks. Is there any antalgic gait or any specific sort of gait? I will look back in the popliteal fossa as well to see that there is no other scar mark there.
And then I will ask her to sit on the edge of the couch and ask her to kick out the knee to see that how much she has got the movement and I can at the same time, I can look at the quadricep. Is it intact or not? And I will ask her to do the perform the sit on the couch. I will again see that there is no leg left discrepancy and I will position both the sides and measure, but initially happened and then two leg length discrepancy focusing on the knee.
Basically, I want to know, is it passively correctable or not correctable and how much is the flexion from this point onwards? And I will do the I will do the palpation to see where exactly is the pain? What is the temperature? Is there any? So just to move on. So in terms of her gait, she does have a slightly antalgic gait.
It's worse on the right compared to the left. She has a slight valgus alignment of her knee. All right, and her range of motion is actually quite good. She can fully extend the knee and she can flex to 100 degrees. In terms of the pain, she says. Both in the history and from this examination is global. It's not focused on one side of. The whole knee is quite painful.
Ok? I have asked her already that she has any pain, any other joints, so I'm concerned about arthritis as well. So is she taking any medicine for rheumatoid arthritis or not? No, she's not. I will see because she has a wielgus deformity, I would like to know that the medial structures they are competent are not, particularly with the medial collateral ligament.
And again, as I mentioned previously, how are you going to test that? So I will try to see that. Is it correctable or not? Is it a fixed? Well, are it's correctable. And then I will go for X-ray of the knee. OK, so if it is correctable, does that mean that the collaterals are insufficient or sufficient or how is that helping you?
So I will apply the valgas stress test and see, is it competent or not? It is a Frank. mean, I have to see the endpoint as well, if it's a point. She does have an end point. Yeah, so the collaterals are intact. OK, so you want some x-rays? What x-rays would you like? I would like to get AP and lateral and skyline view as well.
That's not the best quality X-ray. So apologies for that. But this is the right knee that we want to focus on. So what can you see there on the ap? It's a weight bearing X-ray. All right. So this is AP both of AP two slightly different on the left hand side. Yeah, it does focus on the right side.
The right side there is good joint space. So the right knee is a left of the picture, sorry, right? Yeah, on the left. So there is increase osteopenia in the medial tibial plateau area. OK and there is increased signals in the distal femur increase ketosis in the five minutes.
Sorry there is a bit of you looking at this, this knee, aren't you? So I can see there is a valgus deformity. Yeah and there is a bit of subluxation on the medial side, medial femoral condyle. And in this case, I'm concerned about the lateral femoral condyle, bone loss and also the competence of ACL and PCL, I would examine, but it would be very difficult to see.
Yeah, I agree. The bloods of this patient said he wanted to see a lateral as well. Yeah, definitely. OK so on the latter view, the patella is absent and there is no posterior subluxation of the femur, it looked like the PCL seems all right. So it's a complex situation. Yes, and I will.
I need to know what is her expectations and I will involve my because it's a sort of complex case. It's not a simple one. Yeah, I will take the advice from my revision surgeon because if we have to do anything surgically, it will be a complex primary and PCL stabilizing knees needed rather than jumping for anything. But we need to know what is. So her expectations are that she's at the end of her tether.
She's in a lot of pain and she wants a definitive solution. From here, it looks like she has exhausted all the non operative management. Yes, I will go for. I mean, I will speak to my [inaudible] So you've discussed that in the MDT. So what are you going to offer the full blood count? Yeah I will do the CT to look at the lateral efficiency, and I will refer him to the. So let's say you're in a specialist centre, you are the specialists. The complexity here is the approach. I will go for medial para-patellar approach. I know that some people go for lateral approach, if it will be difficult case, really. So maybe there is contraction of the quadriceps and exposure would be difficult. We have to do a lot of medial releases and I will not use the White side.
I will use the White side line, I will not use the posterior referencing in this case, because it can lead to internal rotation of the femoral conduit and I will go for posterior stabilizing knee replacement. In addition to that, before proceeding to this stage, I need the wrap to be there. I need that I have all the materials. If the medial collateral ligament is not competent, maybe we have to go for varus valgus, stabilize knee so that I have all the ladders going all the way to the hinge needs to be the principle of a PS knee said, a posterior stabilize knee.
Why would you use that? How does that work? Because in the posterior stabilizing knee, we have a Cam and the Cam mechanism big and a Cam mechanism. And most of these patients are both PCL deficient in that case, when as we flex, the Cam engages the peg and it gives posterior stability to the knee joint two more minutes feedback.
Fine OK, we'll stop there. So what do you think? How do you think you did? Yeah, reaching to the absence of patella was difficult. Yeah, it is. Yeah so I did the exam two weeks ago. This was my case. An example. Yeah so this is the exact case I got.
So yeah, it's an interesting case. It's not a straightforward one. So it's quite difficult. So I think you did really well. I think you were systematic. I think your history is very good. Your you have a spiel and I think sometimes it's advantageous to just keep talking, but also listen to the examiner. So I said to you when we got to the management, I just said to what do you want to do?
Which is exhausted all options and I appreciate you want to go through the ladder and you saying, but just I asked you a direct question and you want to just score the points. So just listen to the question that I'm questioning. But yeah, the scar is quite difficult. It's not one that you see that often. I just got this off the internet, so I actually had a transverse scar over the front of the patella.
So this is maybe a bit misleading. So I apologize for that. But you understood the principles of a bogus knee and you know, the approaches and what kind of releases and the issues with rotation. I think you probably need to do more lateral releases. said medial releases, I think you need to do more lateral releases and about the contractor part is that but you know, it's a slow fix them.
Yeah, this is the convex side, the medial is and the concave side is the lateral side, which need release. Yeah, Yeah. So you need to do more lateral releases. And yeah, you're right. I think most people would still use their medial patella as that's what you used to, but you can use lateral as well. You can see here on the apex, we actually, if you look closely, there's no patella on this one.
Yeah, Yeah. So that was the other clue, but it's difficult to spot. I didn't spot it in the exam as well until I saw this x ray, but overall that was good. I think the next conversation would have been talking about what type of knee NJR data and why you would use a certain type of knee. But overall, I think. You did very well.
Very good. Definitely a pass. Good pass.
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