Cadmore media player playing video Flashcards for Short Cases for Orthopaedic Exams
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
Flashcards for Short Cases for Orthopaedic Exams
Description:
Flashcards for Short Cases for Orthopaedic Exams
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e0369748-2224-4af3-bbeb-a5af9de9b77c/videoscrubberimages/Scrubber_1.jpg
Duration:
T01H00M14S
Embed URL:
https://stream.cadmore.media/player/e0369748-2224-4af3-bbeb-a5af9de9b77c
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e0369748-2224-4af3-bbeb-a5af9de9b77c/Flashcards for short cases for Orthopaedic Exams.mp4?sv=2019-02-02&sr=c&sig=478zLhqgOHHjWVHzd46mBwtrY8AYMflHWV9NIxuhZro%3D&st=2024-11-23T12%3A14%3A14Z&se=2024-11-23T14%3A19%3A14Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Everybody My name is Amjad. I am one of the mentors in the FRCS mentor group. Our talk today is about starting a structured approach to fresh, short cases.
And I actually kind of modulated this in a way that it's very FRC focused regarding the short cases because there are a lot of difficulty and we found that the difficulty is mainly around the short cases in the exam. I have Usman, he's my colleague there, and he's one of the senior mentors in this group. And I have Mustafa who is modulating the session, and we will start the talk shortly.
I would just encourage you, if you have any question to raise the question, raise your hand or you can write the question in the chat box and a bit of housekeeping. It's actually crucial. And this is an approach I did. This exam is about three times and this approach, I developed this approach through going to a lot of courses through a lot of teaching sessions.
I benefit a lot from this group, actually from the mentoring group, and there is a lot take in this. So my approach to this is a very kind of different way. I don't think this is the only way of doing this, but it's a good way to summarize things and to get the maximum benefit out of this. So I am based in Dublin, in Ireland and actually I work in a hospital outside Ireland, about 20 minutes from Ireland, from Dublin.
It's called Navin hospital and it's a small hospital. It's like we do. Most of the elective orthopedic work is done in that hospital. So regarding the disclosure, I don't have any financial disclosure and these are all my thoughts. I did this presentation and on my behalf and I got these images. There are a couple of images either from France or from multiple sources, from the internet.
I got it for free and I would like to thank Osman, and I would like to thank Mustafa for modulating in this session. So as I mentioned, this is an effort as focused, focused approach to showcases, and I try to do upper limb and lower limb. I found it very it's going to be very lengthy. So I can resize it into the upper limb and then I will do the lower limb later on.
There is no way to skin a cat, but this is my way. It's it might be suitable for some people. It might not. So you need to find your own way and develop it. The most important thing is to remember this is just a game. And the more you play this game and you play by the rule or you bend the rules anyway, you once you play this game and you get good at it, you actually you enjoyed it.
You find this is really fun. Let's do, and let's play this game. And my approach to this is no one to be very quick. Time is not your friend. There is no time wasting in this short cases. The short cases will come at 5 minutes, and if you count it by the time you, you get the examiner to get you to see the patient. It's actually about 50 seconds or 1 minute.
It's gone. So you have four minutes, so you have to be extremely quick. And it's actually they used to do it as spotters, but now they change it as there is a robot. Like there is no robot, actually. But there is kind of can introduce yourself quickly and then go. It's a spot diagnosis. So the key here is to get the diagnosis, give the diagnosis early.
If it's a do between say, this is a tube train, if it is, can see trigger finger, you say this is a trigger finger, you can see Kessler suture say it's OK for us to it. So once you say that they ignore this, you are almost you are on the path like five, 6 and then sometimes. You might need to have a system, so having a system to enable you to reach that diagnosis, and I will go through this into in this presentation.
Once you read the diagnosis, you change it to Aviva. And that's the magic of doing this much to change it to survive. You are. You are. You are going to be winning here. So the Viva, you are going to be talking about the clinical scenario and you are talking about then the management, all people.
You will know that you notice that all people who have it. This change to avivah, they are really happy. And then you can win the round by throwing the evidence. And this is where you get the 7th and the higher marks. OK so this is the way of doing this. So I feel the analogy I use is that like, this is like a magic show and people look at the kids are really kind of very fascinated with this magical.
But once they know the trick, everything is finished. So the magic show is over. So it's once you spot something, you Zoom your light, for example, you find a rupture of the distal biceps. You find that that's it. Zoom your Zoom. You finish the examination very quickly and say, say it. This is a case of distal biceps rupture. Or if you find this rupture, OK, say it straight away, ok?
If you find the medial nerve, whether it's a proximal or distal medial nerve palsy, you say it and then you Zoom your diagnosis, say you finish your diagnosis and then the examiner. If there is another diagnosis, the examiner will tell you will take you through that diagnosis. And this is how you do it. So let's get started. So sorry.
Don't look miserable. This is you need to be looking smart. You smile. You ready for action and look around for clues. The clues are always, always there. They are hidden. Sometimes they hide it. They hide the clues for a reason. They just want you to look for the clues.
The clues might be splint might be like, very obvious or might be very, very subtle, but you have to look for the clues you need to know your anatomy very thoroughly. This is a new mercy game. If you don't know your anatomy, you are, you're not going to win here. If you find the case of feet, you need to think a spine. So all most cases of especially Kevin's foot, you need to seek spine.
Old cases of if you find clubfoot or any foot deformity, I would be thinking of spine. If if you have another case of feet, you need to and there is a deformity there, you need to think of the hand and rheumatoid hand. You will know rheumatoid hand straightaway. You will not know rheumatoid foot if it hit you in the face. So it's very easy to get to look around and see if there is a rheumatoid hand, and that will be easier for you.
Anticipate the short cases you need to anticipate or where is this coming from? Well, like where is I going to buzzwords? So cases like neurofibromatosis, what are the buzzwords for you need to be thinking of? Once you say they say neurofibromatosis, there is a niche criteria I need to know. I need to rattle that niche criteria quickly. So there is a lot of takes into these short cases.
And the trick is to get more and more practice. That's how you get the slick on it, offer explanation and to avoid prompting. So if you see something you see like, for example, this is ulnar claw glowing. OK, well, once you see it flowing in, you say, OK, this is glowing because of the involvement of the lesion, the ulnar nerve paradox for ulnar claw and you need to mention ulnar nerve products because ulnar nerve products, the more distant the lesion, the more severe the deformity.
And this is, this is important because the examiner will be at ease there, so this guy knows what he's talking about and leave it as a very clear, crystal clear concept in your mind. Opposite to what we think. Nerve injury is a more proximal the lesion, the more severe the deformity, or the more severe the injury. But in the unlock paradox, it's the opposite. OK when revising the big conditions.
Think of what I need to know and what I need to ask about. And this can make a list. I think there is a presentation in this group by my previous mentors. There is one by example you find it in the YouTube, and it was a list of the condition that you will see in the short cases. So I want I want to kind of go there. The key is to practice, practice, practice.
It's like a marathon. If you don't practice, it will you're not going to win this marathon. OK, so you need to practice. You need to practice with your like a colleague, practice with you. The best thing. If you can find a consultant who is interested in teaching, that will be the best thing.
And the best thing I found when I was doing my exams is that I went to a morningList for my consultant. One of the consultant was very keen and I went into the morning, so all the cases were there. Already, there are signs there. So these are real patients. So I went through four or five cases quickly. So the examiner was very good or the my consultant was very good and he helped me a lot.
But sometimes I can't find it. I will do it myself. I do it either. In the clinic I, I set the clock for 4 minutes and then I practice on the patient. I say, listen, this is I'm going to do my exams, so I'm just going to stick with this time here, ok? Practice is the key here, and that's how you are going to be looking at sleep by practicing with your wife is your practicing with your friend, you're building.
Everybody thinks that you are going to forget this is the thing in my mind. I always make sure that I'm not going to forget. I get the stone. If you see a scar and the joint is not moving, you have to think of fusion, whether it's a shoulder, whether it's a knee or there is a hip or whatever you think. If there is a scar and the joint is not moving, this is fusion and let's prove otherwise.
The picture on the right is polio. Polio, I kind of was always thinking of polio, and in the polio there is a clinical presentation that you need. Sensation will be like the limb has a deformity, but the sensation is normal. So it's a motor deformity. And this is where you need to pick it quickly. So then the case will change to survive.
And once you change it to avivah, this is you are winning. It's a quick and your. You're going to get the high marks. Now you think that you need to be aware of. The days that the short cases are straightforward are gone. Not sometimes there are things that you give you do between, but they have carpal tunnel.
They gave you. Do between or near pathology or tendon rupture, and that's actually it happened to me in the exam my case was due between. And it has EPR rupture. And the other one was one of the guys got it is was do between I actually sorry in a previous exam, I got to between with high median nerve with proximal median nerve injury.
So you need to be wary of when you, especially if the do between is very subtle. So you don't have the full use of the full flexion deformity if the do between is subtle. Think of a double pathology or something else. CMC joint with carpal tunnel and we know that there is an association of 48% So once you see CMT say, listen, this is I'm going to say this is 48 percent, 48% about this have involvement of carpal tunnel.
So the examiners would be at ease and you are going to be winning here because the examiner knows that this guy knows the stuff and he's happy to crack with you trigger finger carpal tunnel, rheumatoid hands with tendon ruptures and an elbow always in the elbow. You have to examine the ulnar nerve and the ulnar nerve usually is you check for it, even just for subluxation, or they check the full ulnar nerve you are offered this time.
Time constraint is very short, so you need to. If you mention it, that's a box ticked. So this is how you there are a few catches and we will know how to deal with these catches. The first one is droplets you. You can easily miss it. Drop, epi or rupture. Easily missed, easily missed. And they love it so that the hint or the clue might be a splint might be or might be a scar or might.
So these are the scars that sometimes the scars in white people heals very well, and you might miss that scar. And so sometimes the scar is for tendon transfer. So there is weakness, but you can't see a funny movement, so you need to be wary of that drop foot. You can easily miss it. My these are the things that you need to be aware of and think, keep it.
Keep them in the back of the mind. I'm kind of fascinated by the concept of 360. You need to look around, look around because look, everything is in that look OK. The deformity might be very obvious. You can see in front of you that its leg length discrepancy, you can see it from the next room or that shoe that you raised might be seen from the next room, but it might be a stick. It might be a crutch.
And the crutch in the effort says for some reason, the crutch they leave it behind the door, they leave it behind the door just for or just for you to look around, ok? Now it can go. Actually, also the source is in that picture was I got it in my efforts and it was for a charcoal joint and I got a charcoal joint in the ankle and sorry in the foot, and I was the first thing they have a scar.
And so they have a dressing over that scar. And they didn't allow me to touch anything. So I said, OK, I'm just going to look around for clues. And I looked I spotted that orthotics and then the discussion actually was about orthotics and that I think that was the case that I passed. So you never know where the discussion going to go, but be ready for everything there is. You see that there is eventually in an inhaler.
That can be a clue that this patient might be not fit for surgery. So these are the clues that you need to be aware of. I always have a problem when they ask me questions. They say, OK, come on. Doctor asked us three questions ask one question. And this is where it gets hairy. We get very challenging. I prepare this question to challenge most of the cases.
And I direct patients or I direct the examiners towards to answer direct answer. Sometimes they can go around in circles. Some of the patients, they like to do that. But I just pinned them towards what is the problem? When did it start? How does it affect you? And what treatment did you have any medical problems and what are your expectations?
So this is always keep them to this question in your mind. If you are asked about a few things about, they say three questions. I say, what's the problem? How does it affect you? And what's your expectation? When did it start? Because you need to kind of differentiate between whether this is congenital or acquired, and that's very important for your treatment.
Treatment algorithm. This we are going to start with few cases. I think the hand was one of the difficult because I did mass to mass. I will explain this mass you need a pillow. There is a screening. I'm going to explain all of this. So any hand cases, if you are faced with a hard case, get a pillow that will really go down very easily.
Get a pillow and that will the examiners will know that your stuff. OK, remember, always get a pillow and cases get a pillow mass. So for the mass, you need to look for muscle wasting attitude, whether it's flexion, attitude, extension, attitude, clawing, buckling, all this attitude of hope and then look for scars. Every star has a story, every star has a story, and once I found it, they will always ask you about what do you think this is?
What is what do you so doctor? What do you think this scar is so? I found it. This is the most challenging, so you need to be open minded about the scars you can describe the scar you can get around it by saying this is a mature surgical scar. Most probably for blah blah blah. OK, but don't commit yourself because the scar can be for something different.
Yes, the scar. Every scar has a story. Keep it in your mind, splint. I usually I cheat, and I think I was. This was, I think, permitting. Like you can, you have a permission to do some cheating there? Ok? ask actively.
I will ask the patient, where do you wear instruments? Although the people they say in short cases, you are not allowed to ask a question actually in office. Yes, you can. You can ask, but don't make it as a habit because they will the examiners. They examine you for three cases and they will kind of they will kind of pick on this. So this guy is cheating all.
But think about it. OK, now I start my examination by doing the screening. So the screening is very important and I think. The way I do this in screening is I think I found that I can pick most of the hard cases by doing the screening. So open that if there is any do between or any clothing or any nerve injury, tendon injury closing and that will see him again if there is nerve injury, tendon injury or an any, any deformity will reveal itself straight away and very slowly, very important to do it slowly.
Now, close and open, you have to do it slowly because trigger finger might be very subtle, might be very subtle. And you just once you say, say like this and you find this finger is locked and that's where you, this is where you the case might be trigger finger if you miss it with that screening without the screen. That's that's it. That's game over.
You want it's very hard to recover from it. OK, now I used to get the thumbs up to get for a better policies, previous, and see if there is any weakness around Dr. blessedness. And I flex the thumb for FTP. OK, then the same thing. And though some of the heart, so do it on the palm of the hand. And then of the hand closed and opened the same. Again, we didn't see any scars, any here.
If that's the case is the case is, for example, rheumatoid. You look for these scars, which are subtle. The case is, for example, ulnar nerve. You look for guttering and all the other cases that you can pick easily on the bottom of the hand. So again, close and open. And then the last one will be come up. And that's for EPL rupture. You get caught if you don't do something up and then you look for the elbow for rheumatoid nodules.
I found that this is a screening. It screening technique is very important in picking almost 90% of the cases. However, sometimes go screening and you can't find any finding. So what the fuck is going on? Sorry for my language, but if you don't know you did the screening and you can't find anything. Think of sensation, ok? Sensation is your friend.
So I start straightaway looking for sensation. I've divided this. I know that there is 100 ways of doing the sensation, but this is very particular for the efforts you need to divide the nerve interproximal and distal. Ulnar nerve, you need to divide them approximately this, especially in the upper limit, ok? Apart from the radial nerve, but I'd be very particular. Where are you checking the ulnar nerve?
Very particular because the examiner will be looking. Where is your finger? Where is your sense sensation and compare it to the other side? That's the way to do it for the FARC. Yes OK, so this still check it for it's called the autonomous zone autonomous zone. OK, so this still in the index finger and proximal for the thinner around the thenar muscles.
OK and you check and compare with other hand, if the other hand, if you think that the other hand, is involved, you check it in more proximal but be. Don't touch the patient without permission to even the forehead or in any proximal area without permission. So you need it. You need to know how to play the game in a very polite and controlled controlled manner. So this is all about anatomy.
It's all about the anatomy. So where is the eye? Will know what is the proximal part of the millionaire come from and what is the distal parts come from? And what's nerve supply for that? And what's the nerve supply for this department? The ulnar nerve. And as I was mentioning earlier on, you need to the autonomous zone, its little finger and the dorsal cutaneous branch of the ulnar nerve.
So I found that if you say that this is from the dorsal ulnar nerve and you say like this, the examiner might not be very interested. But if you say this is a branch, come off about 5 centimeters proximal to the wrist joint. Ah, this man knows the anatomy and knows very well where that nerve is going to happen or it's going to be injured, so you need to know. And then the radial nerve, as we mentioned before.
So these are the zones that the autonomous zone that you need to be aware of in the emphasis now, then the motor. I found it there is a lot of motor innervation in the hands and you can pick any muscle. The muscle that I found that definitely need to know is that four million nerve. You need to pulses at brevis. And that's the way to this is very, very, very particular way of examining the muscle.
OK so I will notice that the examiner will just kind of very focused looking at you. How are you examining that muscle so finger on the resistance and finger on the muscle, muscle belly as well. So to check for the power? And then you say it. You don't say, oh, it's OK. No oh, Dr. Wallace's previous five out of five.
The power is 5 out of five. And that's how you, you, you classify it. OK so then the PhDs and you need for this. This is a technique you need to stabilize the other fingers and then check. So this picture is not correct. The way I do it, I put resistance as well. And yes, and then check it Kessler resistance and then say five out of 504 out of five or so.
Sorry and then ulnar nerve. The ulnar nerve is very common, and the examination of the ulnar nerve might be a bit complex, but very make it very simple. Once you do the sensation, the motor is there mainly to muscles. This still, I would say the first dorsal interossei is the most important muscle and you see it straight away. Here, if there is wasting, you see the cutting of the doctor in sight, but you see it and you check the power.
Then for the proximal lesion, you will check for the FTP of the ulnar nerve. You can check for the FCU. But that's my way of getting this over and over again. So you can get slick and you can have a reason that you go on that system for the radial nerve. You can check usually EPL or the triceps. There are loads of muscles we can check for the metacarpal for EDC.
You can check for the extensive carbohydrate radials or longest or brevis. The difference is that longest can give you radial deviation there. OK and very important to differentiate between the radial nerve proper and the posterior intereses nerve. So it's mainly these are anatomy. These are always anatomy.
And then even after all these. You finished and you will come to a road junction now you need to commit yourself. You need to find a diagnosis if you don't know. Till now, go to surgical save, ok? Like, there are loads of things that if you go to congenital problem, if you go through any plastic so you don't know there is either a tumor or there is a congenital deformity of the hand.
You don't know it goes through a surgical sleeve. Go back to be safe and get a differential diagnosis. And then you can say they will take you through one digression and the one direction they will give you towards one direction and they will ask you then further. And that's where you need a diagnosis in a systematic way. I'm going to go through quick examples. As you mentioned here.
They have compression is very, very, very common. These are examples for the short cases. This is for you guys to practice on it, practice on it. OK, let's do the median nerve. That's OK. Remember mass muscle wasting altitude and then splints and scars, scars, splints. So muscle wasting attitude starts pulling muscle Western attitude, scarred spin.
And then you go for sensation. You go for motor and then provocative tests like for a test. And you can very important to do. The way of doing tests is from distal to proximal. This is the way I've seen it courses, and this is the way being taught in by the guys who have put in for the exam, like Faisal Ali and Ben Askren. So this is the way to do it.
Hands do between rheumatoid CMC, EPL snack and slap elbow. And these are the list here. I don't need to go through each one of them, but you can find it and it would be in the YouTube. Very important to do hand function. Hand function is crucial for the hand examination. I'm not sure this picture is accurate or, you know, everybody has his own nomination for the hand function.
It's important to have it clear if there are 5, four sets. There are five hand function groups. Three are precision grip and two are power groups. Get this concept clear in your mind and get it right. OK so the precision grip, like a tape to tape or you can say any. Some people say, say tripod key. OK, so the key, the lateral tension is key.
And then there is some people they say the coin is a tripod, so there is difficulty. So key Penn on a coin. This is the way to say and then and who grip and power grip where you hold the power? These are the five. I don't know. It's very like if you're going to go to the always take a key, a coin and a pen, and it's easy.
You don't need to. Some people, they say in the short cases, will I take a measure? Will I take actually don't take a measure because you are going to dig a grave for yourself. Do not take a measure yet. Maybe you can take a touch pen and it might be a nice thing to take a touch pen because that pen will be a touch pen and it will be a very good to if you get a ganglion.
And you can get transfer illumination, that's a bonus, but it won't save you from getting the principle right. OK, the concept right, you need to describe you. You can't jump from the very beginning to transfer information, so you need to be thinking clearly there. OK, nerve compression. These are anatomy, anatomy and physiology like either anatomy. They're going to.
You need to. Once you get a nerve, they're going to ask you anatomy and they're going to ask you where this nerve is compressed to give you this picture. OK, so it's either. And there are sites of compression. You just go and read it and learn it by heart because this is very important. There are five, 5 and I think six needles compression sites.
You have to learn it by heart. I don't care which way you do it. Just learn it and get it out there, ok? And then it will be nerve conduction study. The nerve conduction study is, is. Physiology are a basic science scenario, but it can come into showcases and I've seen people get nerve coming into the nerve conduction study.
The final answer once you find the nerve like median nerve or ulnar nerve is about the tendon transfer. There are principal of tendon transfer. You need to know all this principle. I have a nice way of changing it instead of the as supple as synergistic and all these S's. You can change it to donor factor recipient factor. And then just let me remember donor factor and recipient factor and the patient himself, like the patient, should be motivated and able to do the rehabilitation.
So don't factor the risk factors. And then so the donor factor, you can say that these are the should be synergistic and all the assets and the joint should be simple and just single and same line full on all these kind of things. The recipient should be clear of infection. And then the patient should be able to understand the rehab and compliant.
Now this is where we come to the flashcards. OK, so we come to the flashcards. And all cases, case by case, we have five minutes. So 1 minute is gone. Hello, how are you and stuff like that? And then thank you. Goodbye OK, so you need to be. It's 4 and 1/2 or 4 and 1/2 minutes or so you need to. From the very beginning, there is a spill, you need to be ready for, ok?
For all the cases, you have this spill. OK, so this is a hand. I can see that there is a deflection attitude of the right hand consistent with two between contracture, ok? There is a court that is puckering. There is all this say as much as you can and keep talking and do not stop until you get to the feet and feel that you are satisfied that you describe the deformity and then you can go.
Some people, they say, here you go for a screening, I would actually go for it straightaway if I see the do between remember, earlier on. It's like a show, a magic show. Zoom in between. I'm going to Zoom towards this, this two between. I'm going to go for car hunting. So I see whether there is a commercial record. That's important because it will indicate the is their faces.
There is a digital record and this is all important. I will straightaway ask the patient, OK, do you have it anywhere else? This is you're allowed to ask this because this is part of the examination and it's very important to see. They didn't rule out the senses because it will. The mannequin would be different. OK, Now f-14s examination, you need to flex.
You show that you flex your flex the tip to assess the extension of the flex. The flexibility to assess the extension of metacarpal Allen gel joint and flex the metacarpal for longer to assess the extension or the flexion deformity of the PIP joint. And if you don't do it in that way, you're not. You're not, you're not getting the full mark there. You can say whatever it might be hard sometimes with the deformity, but you need to show them that you are flexing the carpometacarpal joint assets approximately 10-fold and you are flexing the proximal and definitely your two a cup of neurovascular, neurovascular status, digital Allen test.
And there is a way I cannot do it on my own. There is a way to do the digital Allen test. And then as I mentioned here, as for the scissors, do the functional assessment. So if you have time you went through this, you can say, listen, I would like to do quick screening for other pathology because they will say, no, we want you to go focus on this, then this is a case you need to.
At that stage, it would be 1 and 1/2 minute. You need to say this is the machine and then change it to vulva. So the do between you need to talk about family history, you need to know about genetic defects and you need to talk about all the other scenarios there in between and the money is in the management. The money is in the management. So as long as you get it, the management you get, the management you are your past, OK, and then you can talk about the evidence and this is where you get the 7 and 8.
Now for the CMC, arthritis is very there is a speed there shouldering hybridization of metacarpal and joint. Why is Ofer explanation to increase the spine, to increase the spine? OK, so they say because the thumb is the metacarpophalangeal is adapted. So in order to increase the spine they will abduct, so is a hyperextended the metcalf-lindenburger joint.
So because the metacarpal is a sort of a deducted. So they do this, ok? And then I mentioned, once you see this, you got your pillow saying this give the diagnosis straight away. Go for your screening, grind in tests. Do not do grinding test in this case, because everybody and actually it's nicer if you say I would not do the grinding test because it's painful in this.
So that would show that, you know, you have empathy and you are very smart. The same, you stick to the look, feel, move and then you can do your functional assessment, remember? 47% has carpal tunnel, so it's really nice to say it. They would say, oh, OK, OK. But if you don't say it, oh, what do you do and assess anything else you will ask you, then you will start to be.
You will not know it and you. You'll start questioning yourself. Did I miss anything? Did I miss anything? It's merely they know this. They're looking for this. And then you go 4 for the if you change it to another straightaway, you change it. So you are talking about this paper you are talking about.
So exactly, I would not go I would go from operating a non operative treatment, which is a cup of tea, steroid injection and then a splint. And then I'll go straight away to Travis. I am not going to go for anything else because the evidence is out there. Ok? and it's nice to talk about the evidence in this case, actually.
Now the catch, I got caught in this and actually it was not this. Obviously, it was very subtle and and actually, I got prompted, not in this exam, in previous exam and where I flunked, but I got caught in this because it was so subtle. And then I had to the examiner prompt me a couple of times and then eventually I found it so that screening that is screening for the hand is crucial to spot this case.
OK, so once you screen it and do it slowly, open it slowly and you'll find the difficulty, the catch. And that's then you zoom, your zoom, your examination. We find that, OK, this is the trigger finger. The management is so easy. It's so easy. Look, then you do the function assessment. So remember, when you are reciting with your friend, when you are revising with your colleagues or with anybody, do this.
Number one flexion attitude of the finger. I'm going to do the screening. This is trigger finger, look, feel, move and then assess the nodule, digital ulnar nerve and online test and do the functional assessment. And these are the things that we needed. So eight aid station in your mind in about four, sorry, in about two minutes. You need to do this.
This is how slick you need to do this. You need to do it every single minute. And you need to think of it. Need to think of it all the time. Now this is a very common case in the exam. The ulnar nerve ulnar nerve and your need, as I mentioned before, need to talk about ulnar nerve products. So I'm going to give the diagnosis and then sensory motor and then provocative from and test.
You need to explain in from us because the FTP is so did not have to be. The adductor pollicis is not functioning. The patient is recruiting the FTP. Ta So you can see the fingers, the thumb is, it's flexing. So because after you ask the patient to use a doctor policies, but they cannot because the doctor policies is not functioning because a doctor policy is supplied by the ulnar nerve.
So to compensate to offer this explanation offered this explanation. Don't wait for the examiner. You say, why is doing this ok? Offer it. That's how you prevent prompting. Prompting is bad. Prompting is a killer. Prompting will cause you less.
And you can see somebody sent into the group. There is a way of marking the marking sheet. The more you get prompting, the more you lose marks. OK it's anatomy question and then nerve conduction study. Sorry, no rheumatoid hand actually rheumatoid is easy, and it's really, really it's like a gift. I know the way I find it is just it's about rheumatoid arthritis treatment.
You don't touch this patient. You do not touch. Try not to touch this patient. And that's a trick if you try to. Ah, you're fired. You are gone. Ok? it's all about description. There is a spiel you need to say it with is bilaterally symmetrical deformity of the hand consistent with rheumatoid arthritis.
And that's the way I say it all the time. The bilateral symmetrical deformity of both hands or both upper or lower level, more consistent with rheumatoid arthritis. Start describing from proximal to distal, proximal to distal. OK, and then you can do your screen straight away. Go to the functional segment straight away. Go to the functional cells. And if you don't have anything to say, go to.
I'd say, listen, that's my coin, my key. My pen rheumatoid is sorted that you pass. Rheumatoid arthritis, OK, but it's nice to have that spiel ok? Causes of drop finger. These are the catches causes of dry fingers. There are four causes multiple pathology. What are the causes? How are you going to do it?
I'm not going to say to you guys, you're going to find it and search it and you'll find it. What are the causes for dropping it? So these are the bullet points that you need to go with. OK you start describing the deformity. Do not. Don't think that you are going to examine the touch. This patient OK to not touch this patient because the skin is paper thin.
The examiners are kind of nervous. There are a picture of if you Google rheumatoid disgust, you find like about 12 scars either for replacement or for fusion for like. If you find it, longitudinal scars are for fusion. If it translates to scars, usually it's hard for replacement fusion of the wrist, but there are scars that you're going to be very vigilant for kind of pointing this scar.
You have to look for them. Now the difficult one, the all. My God. Oh, OK. I don't know what's going on. It's actually it's actually a gift and they want to see you have a system. They want to see that you are going to stick to look, feel, move and then if you don't know what's going on.
Just under the phone, which is so severe that you just say, listen, I'm going to do an assessment. And then I'm going to go back to my surgical teeth. This is most likely a congenital deformity of. So the picture is, is either radial Klopp hand or this is what you can discard. It's a Viper. So change it to a. And that's how you approach it.
And this is the lower picture is perfection pieces. One example one was operated on, the other one wasn't, and he had dysmorphic faces and neck as well. So I got pretty face down. But then I kind of somehow my mind clicked and I just went into some kind of syndromic anomaly. I don't know what it is, but I'm going to do the function assessment and I'm going to discuss this in with my pediatric colleagues, and I'm going to involve my geneticist as well.
This needs to be investigated and it needs to be the specialized center where I've got the expertise and the resources to deal with this. So if so, you think, my god, just keep calm. Describe what you see, the deformity, what you see and just be frank, tell them it's a syndrome. I'm not aware of it, but this is one way to go about it. And that's it.
That's what they want to hear. Exactly you have a system and stick to the functional system. Change it all over. Yes, let's go talk about why the are differential diagnosis, and that's how you approach this. This actually is the same as hand, but usually in the wrist. I change the rhythm of my examination. I'm going to look, move and then feel, guess that's a personal preference and the same for the elbow.
OK so but you need to be conscious of that. The wrist has three zones radial, ulnar and central. And this is how you differentiate between the problem in the wrist. And this is a question of anatomy and pathology. OK you can get cane disease. You can get a slap snack on this arthritis or anything. Yes, you need to divide it. Where is it?
And this is how you approach it with a range of motion examination and that you can screen with that, ok? And that will bring you down to where is the problem? Elbow again, quick and easy. And I actually like, I like. And you know what? In the exam. There is a lot of elbows. There is a lot of elbow examination and especially arthritis, rheumatoid arthritis.
I got my rheumatoid arthritis in not this exam in the previous exam. And it was actually it was sorry. It was my lung case. But some people, they examine it as a shortness and elbow is very important. Do not forget the ulnar nerve in any elbow examination. Do not forget it because you are doomed to failure if you forget the ulnar nerve.
It's really important. Keep it in your mind. This is how you put your flash card is just carry on until you comment on it, from the front, from the side, from the back and then look, move and then feel move. Yeah, put your hand like spread your hand, so extend it flexion. Do it actively and passively.
Very important to do it passively as well. So because yeah, you say, OK, let's see it active and then OK, can we can? Can we improve it? Watch for the patient, for the pain. OK, then assess the stability and neurovascular and then the joint above and below. These are the usual routines you get. I'm sorry, I'm interrupting you again.
But with the elbow, you guys can get a flail elbow. You can get a chronic radial head that was excised, which you cannot feel the osteoarthritis and rheumatoid in the elbow. These are very common. I also, if you are stuck for time, just ask the patient, can you reach your mouth? Can you reach your bump? And can you?
That's that's a quick way of the quick way. I've seen it in courses, and I found it really very handy and I found this is very helpful to get. So as I mentioned earlier on. Spread out your elbow and then active and passive and supine. And this is actually the picture or the. The photo on the left is actually for the examination of ulnar nerve, but you need to check for subluxation of the ulnar nerve as well to move it if it's a plus or not.
And the examiner wants to see that all the time because in the shoulder you went from distal to proximal. I'm sorry, this is the easy way of doing this presentation. Shoulder if you go to the short case, the first thing notice it is the age, OK, the age of the patient, because small, younger, younger patients are. Definitely instability. More than likely instability.
All the patients are arthritis or rotator cuff, and the bone in between are impingement. So we know that and this is all everybody. This is for emphasis. Three groups younger patient instability. The minute you say instability, you need to mention weight and score and do it and make sure that no, it's very, very easy to forget. Patterns cause the minute you see a young, a young patient, you're more than likely you are going to get instability.
Make sure in your back the back of the mind. There is better and score. We're going to ask about that score, and you have patterns already in your mind there. Ok? all the other patient, probably you are talking about in this study. We are talking about rotator cuff or arthritis of the shoulder. So and strangely enough, we got a case in our exam.
Actually, I got it in my exam. It was actually frozen shoulder. So anything can come up, you know, frozen shoulder, reduced external rotation, and that was a Warning sign. So if you have this, you have to keep in mind middle age, do in score and then the brachial plexus examination, which is, I think, very good. This examination is a gift as well. OK it's people are nervous about the Brexit process, but I think it's pure anatomy session.
It's a pure anatomy session. And then once you do, there is a video in YouTube how to draw blood in 10 seconds? OK no, that video. Go to YouTube and find it and know it. Draw your Blackness in 10 seconds and before your exam. I did this session, particularly for guys who are going in at the end of this month. You need to know the Brexit process in 10 seconds.
You need to see where is this coming from? Where is the route and where is it? There is a very nice way of examining. I used to examine the Brexit process in 1 and 1/2 when we used to do it 3 minutes and then we at the end we will lower it down to 1 and 1/2 minutes, 1 and 1/2 minutes. You finish the Brexit process and that's it. And the way I use it, the abbreviation of hamas, it's hitch is for Horner's syndrome and for muscle wasting a for attitude.
As for scars, as for splints the same way I used for all the cases. For that, it was mass here. It's Hamas response syndrome. OK this is the way, I guess, when I see something look like Brexit blogs. OK, how does it go then mass? I'm sorry. Muscle wasting attitude, feeling and scars.
And then you go for the sensation, according to dermatologist. So the dermatomes are very clearly written in Asia, and you need in the Asia Asia paper, you will. You will see there are dots. OK, so these dots are where you check the sensation. So you can't say, oh, this is here in this here, C5 on this. No, you go with a dot in Asia. So you see here in the lateral Latin is.
You don't check it here. I know that people, they take it here. No link it in the latter, the latter epicondyle of the humerus and then for C6, C7, C8 and one. So these are points that you are shooting on those points. So you don't have around and then motor the motor milestones are very particular. If you go to the Asia score, sorry Asia sheet, you will find these are very clearly written.
And these are the muscle testing. You are going to do it according to Asia score. So your main aim in the recall process is to find the level. OK, and then you can go take the discussion later. Actually, Brexit is really good because you start in high, you starting like scoring once you know this is brexit, you probably had 5 and 6 or six actually knowing the Brexit talks.
And then you can go for what type of Brexit Brexit is it high? So the upper or lower brexit, Brexit or total Brexit like so. But see, now there are an unusual pattern, and this is the one that comes into this so unusual pattern. You need to think of parts and Ike Turner or some Brexit plexus with partial treatment with tendon transfer or something like that. So unusual pattern in the breaker process, although you can see the deformity can see everything, but there is unusual pattern.
So think either this is part of an Turner syndrome or some tendon transfer? These references are I found it in kind of no particular order, but this is I prefer disorder. When asked, which is a very good book. OK you need to read it. You need to read it at least once again. It's a good book and it's a good reference and everything is there.
It's a big book. I found it really hard, but try to get hold of this. Ok? mercifully, has a very fully and forecasting. This is the book has a very good examination and have very good kind of selection of cases. There is another book by Sharma. I don't think it's AI don't know, it's OK by demonstrations and stuff like that, but I think fully and banaszak, which are the best in the market.
So far. I think this thing to take from this amount you share, my book is that he has given you a list of clinical cases and he has narrowed it down to a few examination that you can do, which are specific for that clinical case. Like if you get ahead its values, what things you are going to do? What if you get egawa test the five things you are going to do.
So when you are making your flashcards, that's what sanjit has been telling you all for the last hour is that you concentrate on those four or five things and you do them in an orderly fashion and be very slick with them. And you just kind of zone in on that thing. And that's where you get the marks. OK, guys, I have to stop here and thank you very much for listening.
If there is any burning questions, you can either raise your hand or you can. We just will continue to. All right, thank you very much. That was a very nice presentation, you did very well. And I think you have covered all the topics and you've given us a very good record in.
This must.
Segment:0 .
Everybody My name is Amjad. I am one of the mentors in the FRCS mentor group. Our talk today is about starting a structured approach to fresh, short cases.
And I actually kind of modulated this in a way that it's very FRC focused regarding the short cases because there are a lot of difficulty and we found that the difficulty is mainly around the short cases in the exam. I have Usman, he's my colleague there, and he's one of the senior mentors in this group. And I have Mustafa who is modulating the session, and we will start the talk shortly.
I would just encourage you, if you have any question to raise the question, raise your hand or you can write the question in the chat box and a bit of housekeeping. It's actually crucial. And this is an approach I did. This exam is about three times and this approach, I developed this approach through going to a lot of courses through a lot of teaching sessions.
I benefit a lot from this group, actually from the mentoring group, and there is a lot take in this. So my approach to this is a very kind of different way. I don't think this is the only way of doing this, but it's a good way to summarize things and to get the maximum benefit out of this. So I am based in Dublin, in Ireland and actually I work in a hospital outside Ireland, about 20 minutes from Ireland, from Dublin.
It's called Navin hospital and it's a small hospital. It's like we do. Most of the elective orthopedic work is done in that hospital. So regarding the disclosure, I don't have any financial disclosure and these are all my thoughts. I did this presentation and on my behalf and I got these images. There are a couple of images either from France or from multiple sources, from the internet.
I got it for free and I would like to thank Osman, and I would like to thank Mustafa for modulating in this session. So as I mentioned, this is an effort as focused, focused approach to showcases, and I try to do upper limb and lower limb. I found it very it's going to be very lengthy. So I can resize it into the upper limb and then I will do the lower limb later on.
There is no way to skin a cat, but this is my way. It's it might be suitable for some people. It might not. So you need to find your own way and develop it. The most important thing is to remember this is just a game. And the more you play this game and you play by the rule or you bend the rules anyway, you once you play this game and you get good at it, you actually you enjoyed it.
You find this is really fun. Let's do, and let's play this game. And my approach to this is no one to be very quick. Time is not your friend. There is no time wasting in this short cases. The short cases will come at 5 minutes, and if you count it by the time you, you get the examiner to get you to see the patient. It's actually about 50 seconds or 1 minute.
It's gone. So you have four minutes, so you have to be extremely quick. And it's actually they used to do it as spotters, but now they change it as there is a robot. Like there is no robot, actually. But there is kind of can introduce yourself quickly and then go. It's a spot diagnosis. So the key here is to get the diagnosis, give the diagnosis early.
If it's a do between say, this is a tube train, if it is, can see trigger finger, you say this is a trigger finger, you can see Kessler suture say it's OK for us to it. So once you say that they ignore this, you are almost you are on the path like five, 6 and then sometimes. You might need to have a system, so having a system to enable you to reach that diagnosis, and I will go through this into in this presentation.
Once you read the diagnosis, you change it to Aviva. And that's the magic of doing this much to change it to survive. You are. You are. You are going to be winning here. So the Viva, you are going to be talking about the clinical scenario and you are talking about then the management, all people.
You will know that you notice that all people who have it. This change to avivah, they are really happy. And then you can win the round by throwing the evidence. And this is where you get the 7th and the higher marks. OK so this is the way of doing this. So I feel the analogy I use is that like, this is like a magic show and people look at the kids are really kind of very fascinated with this magical.
But once they know the trick, everything is finished. So the magic show is over. So it's once you spot something, you Zoom your light, for example, you find a rupture of the distal biceps. You find that that's it. Zoom your Zoom. You finish the examination very quickly and say, say it. This is a case of distal biceps rupture. Or if you find this rupture, OK, say it straight away, ok?
If you find the medial nerve, whether it's a proximal or distal medial nerve palsy, you say it and then you Zoom your diagnosis, say you finish your diagnosis and then the examiner. If there is another diagnosis, the examiner will tell you will take you through that diagnosis. And this is how you do it. So let's get started. So sorry.
Don't look miserable. This is you need to be looking smart. You smile. You ready for action and look around for clues. The clues are always, always there. They are hidden. Sometimes they hide it. They hide the clues for a reason. They just want you to look for the clues.
The clues might be splint might be like, very obvious or might be very, very subtle, but you have to look for the clues you need to know your anatomy very thoroughly. This is a new mercy game. If you don't know your anatomy, you are, you're not going to win here. If you find the case of feet, you need to think a spine. So all most cases of especially Kevin's foot, you need to seek spine.
Old cases of if you find clubfoot or any foot deformity, I would be thinking of spine. If if you have another case of feet, you need to and there is a deformity there, you need to think of the hand and rheumatoid hand. You will know rheumatoid hand straightaway. You will not know rheumatoid foot if it hit you in the face. So it's very easy to get to look around and see if there is a rheumatoid hand, and that will be easier for you.
Anticipate the short cases you need to anticipate or where is this coming from? Well, like where is I going to buzzwords? So cases like neurofibromatosis, what are the buzzwords for you need to be thinking of? Once you say they say neurofibromatosis, there is a niche criteria I need to know. I need to rattle that niche criteria quickly. So there is a lot of takes into these short cases.
And the trick is to get more and more practice. That's how you get the slick on it, offer explanation and to avoid prompting. So if you see something you see like, for example, this is ulnar claw glowing. OK, well, once you see it flowing in, you say, OK, this is glowing because of the involvement of the lesion, the ulnar nerve paradox for ulnar claw and you need to mention ulnar nerve products because ulnar nerve products, the more distant the lesion, the more severe the deformity.
And this is, this is important because the examiner will be at ease there, so this guy knows what he's talking about and leave it as a very clear, crystal clear concept in your mind. Opposite to what we think. Nerve injury is a more proximal the lesion, the more severe the deformity, or the more severe the injury. But in the unlock paradox, it's the opposite. OK when revising the big conditions.
Think of what I need to know and what I need to ask about. And this can make a list. I think there is a presentation in this group by my previous mentors. There is one by example you find it in the YouTube, and it was a list of the condition that you will see in the short cases. So I want I want to kind of go there. The key is to practice, practice, practice.
It's like a marathon. If you don't practice, it will you're not going to win this marathon. OK, so you need to practice. You need to practice with your like a colleague, practice with you. The best thing. If you can find a consultant who is interested in teaching, that will be the best thing.
And the best thing I found when I was doing my exams is that I went to a morningList for my consultant. One of the consultant was very keen and I went into the morning, so all the cases were there. Already, there are signs there. So these are real patients. So I went through four or five cases quickly. So the examiner was very good or the my consultant was very good and he helped me a lot.
But sometimes I can't find it. I will do it myself. I do it either. In the clinic I, I set the clock for 4 minutes and then I practice on the patient. I say, listen, this is I'm going to do my exams, so I'm just going to stick with this time here, ok? Practice is the key here, and that's how you are going to be looking at sleep by practicing with your wife is your practicing with your friend, you're building.
Everybody thinks that you are going to forget this is the thing in my mind. I always make sure that I'm not going to forget. I get the stone. If you see a scar and the joint is not moving, you have to think of fusion, whether it's a shoulder, whether it's a knee or there is a hip or whatever you think. If there is a scar and the joint is not moving, this is fusion and let's prove otherwise.
The picture on the right is polio. Polio, I kind of was always thinking of polio, and in the polio there is a clinical presentation that you need. Sensation will be like the limb has a deformity, but the sensation is normal. So it's a motor deformity. And this is where you need to pick it quickly. So then the case will change to survive.
And once you change it to avivah, this is you are winning. It's a quick and your. You're going to get the high marks. Now you think that you need to be aware of. The days that the short cases are straightforward are gone. Not sometimes there are things that you give you do between, but they have carpal tunnel.
They gave you. Do between or near pathology or tendon rupture, and that's actually it happened to me in the exam my case was due between. And it has EPR rupture. And the other one was one of the guys got it is was do between I actually sorry in a previous exam, I got to between with high median nerve with proximal median nerve injury.
So you need to be wary of when you, especially if the do between is very subtle. So you don't have the full use of the full flexion deformity if the do between is subtle. Think of a double pathology or something else. CMC joint with carpal tunnel and we know that there is an association of 48% So once you see CMT say, listen, this is I'm going to say this is 48 percent, 48% about this have involvement of carpal tunnel.
So the examiners would be at ease and you are going to be winning here because the examiner knows that this guy knows the stuff and he's happy to crack with you trigger finger carpal tunnel, rheumatoid hands with tendon ruptures and an elbow always in the elbow. You have to examine the ulnar nerve and the ulnar nerve usually is you check for it, even just for subluxation, or they check the full ulnar nerve you are offered this time.
Time constraint is very short, so you need to. If you mention it, that's a box ticked. So this is how you there are a few catches and we will know how to deal with these catches. The first one is droplets you. You can easily miss it. Drop, epi or rupture. Easily missed, easily missed. And they love it so that the hint or the clue might be a splint might be or might be a scar or might.
So these are the scars that sometimes the scars in white people heals very well, and you might miss that scar. And so sometimes the scar is for tendon transfer. So there is weakness, but you can't see a funny movement, so you need to be wary of that drop foot. You can easily miss it. My these are the things that you need to be aware of and think, keep it.
Keep them in the back of the mind. I'm kind of fascinated by the concept of 360. You need to look around, look around because look, everything is in that look OK. The deformity might be very obvious. You can see in front of you that its leg length discrepancy, you can see it from the next room or that shoe that you raised might be seen from the next room, but it might be a stick. It might be a crutch.
And the crutch in the effort says for some reason, the crutch they leave it behind the door, they leave it behind the door just for or just for you to look around, ok? Now it can go. Actually, also the source is in that picture was I got it in my efforts and it was for a charcoal joint and I got a charcoal joint in the ankle and sorry in the foot, and I was the first thing they have a scar.
And so they have a dressing over that scar. And they didn't allow me to touch anything. So I said, OK, I'm just going to look around for clues. And I looked I spotted that orthotics and then the discussion actually was about orthotics and that I think that was the case that I passed. So you never know where the discussion going to go, but be ready for everything there is. You see that there is eventually in an inhaler.
That can be a clue that this patient might be not fit for surgery. So these are the clues that you need to be aware of. I always have a problem when they ask me questions. They say, OK, come on. Doctor asked us three questions ask one question. And this is where it gets hairy. We get very challenging. I prepare this question to challenge most of the cases.
And I direct patients or I direct the examiners towards to answer direct answer. Sometimes they can go around in circles. Some of the patients, they like to do that. But I just pinned them towards what is the problem? When did it start? How does it affect you? And what treatment did you have any medical problems and what are your expectations?
So this is always keep them to this question in your mind. If you are asked about a few things about, they say three questions. I say, what's the problem? How does it affect you? And what's your expectation? When did it start? Because you need to kind of differentiate between whether this is congenital or acquired, and that's very important for your treatment.
Treatment algorithm. This we are going to start with few cases. I think the hand was one of the difficult because I did mass to mass. I will explain this mass you need a pillow. There is a screening. I'm going to explain all of this. So any hand cases, if you are faced with a hard case, get a pillow that will really go down very easily.
Get a pillow and that will the examiners will know that your stuff. OK, remember, always get a pillow and cases get a pillow mass. So for the mass, you need to look for muscle wasting attitude, whether it's flexion, attitude, extension, attitude, clawing, buckling, all this attitude of hope and then look for scars. Every star has a story, every star has a story, and once I found it, they will always ask you about what do you think this is?
What is what do you so doctor? What do you think this scar is so? I found it. This is the most challenging, so you need to be open minded about the scars you can describe the scar you can get around it by saying this is a mature surgical scar. Most probably for blah blah blah. OK, but don't commit yourself because the scar can be for something different.
Yes, the scar. Every scar has a story. Keep it in your mind, splint. I usually I cheat, and I think I was. This was, I think, permitting. Like you can, you have a permission to do some cheating there? Ok? ask actively.
I will ask the patient, where do you wear instruments? Although the people they say in short cases, you are not allowed to ask a question actually in office. Yes, you can. You can ask, but don't make it as a habit because they will the examiners. They examine you for three cases and they will kind of they will kind of pick on this. So this guy is cheating all.
But think about it. OK, now I start my examination by doing the screening. So the screening is very important and I think. The way I do this in screening is I think I found that I can pick most of the hard cases by doing the screening. So open that if there is any do between or any clothing or any nerve injury, tendon injury closing and that will see him again if there is nerve injury, tendon injury or an any, any deformity will reveal itself straight away and very slowly, very important to do it slowly.
Now, close and open, you have to do it slowly because trigger finger might be very subtle, might be very subtle. And you just once you say, say like this and you find this finger is locked and that's where you, this is where you the case might be trigger finger if you miss it with that screening without the screen. That's that's it. That's game over.
You want it's very hard to recover from it. OK, now I used to get the thumbs up to get for a better policies, previous, and see if there is any weakness around Dr. blessedness. And I flex the thumb for FTP. OK, then the same thing. And though some of the heart, so do it on the palm of the hand. And then of the hand closed and opened the same. Again, we didn't see any scars, any here.
If that's the case is the case is, for example, rheumatoid. You look for these scars, which are subtle. The case is, for example, ulnar nerve. You look for guttering and all the other cases that you can pick easily on the bottom of the hand. So again, close and open. And then the last one will be come up. And that's for EPL rupture. You get caught if you don't do something up and then you look for the elbow for rheumatoid nodules.
I found that this is a screening. It screening technique is very important in picking almost 90% of the cases. However, sometimes go screening and you can't find any finding. So what the fuck is going on? Sorry for my language, but if you don't know you did the screening and you can't find anything. Think of sensation, ok? Sensation is your friend.
So I start straightaway looking for sensation. I've divided this. I know that there is 100 ways of doing the sensation, but this is very particular for the efforts you need to divide the nerve interproximal and distal. Ulnar nerve, you need to divide them approximately this, especially in the upper limit, ok? Apart from the radial nerve, but I'd be very particular. Where are you checking the ulnar nerve?
Very particular because the examiner will be looking. Where is your finger? Where is your sense sensation and compare it to the other side? That's the way to do it for the FARC. Yes OK, so this still check it for it's called the autonomous zone autonomous zone. OK, so this still in the index finger and proximal for the thinner around the thenar muscles.
OK and you check and compare with other hand, if the other hand, if you think that the other hand, is involved, you check it in more proximal but be. Don't touch the patient without permission to even the forehead or in any proximal area without permission. So you need it. You need to know how to play the game in a very polite and controlled controlled manner. So this is all about anatomy.
It's all about the anatomy. So where is the eye? Will know what is the proximal part of the millionaire come from and what is the distal parts come from? And what's nerve supply for that? And what's the nerve supply for this department? The ulnar nerve. And as I was mentioning earlier on, you need to the autonomous zone, its little finger and the dorsal cutaneous branch of the ulnar nerve.
So I found that if you say that this is from the dorsal ulnar nerve and you say like this, the examiner might not be very interested. But if you say this is a branch, come off about 5 centimeters proximal to the wrist joint. Ah, this man knows the anatomy and knows very well where that nerve is going to happen or it's going to be injured, so you need to know. And then the radial nerve, as we mentioned before.
So these are the zones that the autonomous zone that you need to be aware of in the emphasis now, then the motor. I found it there is a lot of motor innervation in the hands and you can pick any muscle. The muscle that I found that definitely need to know is that four million nerve. You need to pulses at brevis. And that's the way to this is very, very, very particular way of examining the muscle.
OK so I will notice that the examiner will just kind of very focused looking at you. How are you examining that muscle so finger on the resistance and finger on the muscle, muscle belly as well. So to check for the power? And then you say it. You don't say, oh, it's OK. No oh, Dr. Wallace's previous five out of five.
The power is 5 out of five. And that's how you, you, you classify it. OK so then the PhDs and you need for this. This is a technique you need to stabilize the other fingers and then check. So this picture is not correct. The way I do it, I put resistance as well. And yes, and then check it Kessler resistance and then say five out of 504 out of five or so.
Sorry and then ulnar nerve. The ulnar nerve is very common, and the examination of the ulnar nerve might be a bit complex, but very make it very simple. Once you do the sensation, the motor is there mainly to muscles. This still, I would say the first dorsal interossei is the most important muscle and you see it straight away. Here, if there is wasting, you see the cutting of the doctor in sight, but you see it and you check the power.
Then for the proximal lesion, you will check for the FTP of the ulnar nerve. You can check for the FCU. But that's my way of getting this over and over again. So you can get slick and you can have a reason that you go on that system for the radial nerve. You can check usually EPL or the triceps. There are loads of muscles we can check for the metacarpal for EDC.
You can check for the extensive carbohydrate radials or longest or brevis. The difference is that longest can give you radial deviation there. OK and very important to differentiate between the radial nerve proper and the posterior intereses nerve. So it's mainly these are anatomy. These are always anatomy.
And then even after all these. You finished and you will come to a road junction now you need to commit yourself. You need to find a diagnosis if you don't know. Till now, go to surgical save, ok? Like, there are loads of things that if you go to congenital problem, if you go through any plastic so you don't know there is either a tumor or there is a congenital deformity of the hand.
You don't know it goes through a surgical sleeve. Go back to be safe and get a differential diagnosis. And then you can say they will take you through one digression and the one direction they will give you towards one direction and they will ask you then further. And that's where you need a diagnosis in a systematic way. I'm going to go through quick examples. As you mentioned here.
They have compression is very, very, very common. These are examples for the short cases. This is for you guys to practice on it, practice on it. OK, let's do the median nerve. That's OK. Remember mass muscle wasting altitude and then splints and scars, scars, splints. So muscle wasting attitude starts pulling muscle Western attitude, scarred spin.
And then you go for sensation. You go for motor and then provocative tests like for a test. And you can very important to do. The way of doing tests is from distal to proximal. This is the way I've seen it courses, and this is the way being taught in by the guys who have put in for the exam, like Faisal Ali and Ben Askren. So this is the way to do it.
Hands do between rheumatoid CMC, EPL snack and slap elbow. And these are the list here. I don't need to go through each one of them, but you can find it and it would be in the YouTube. Very important to do hand function. Hand function is crucial for the hand examination. I'm not sure this picture is accurate or, you know, everybody has his own nomination for the hand function.
It's important to have it clear if there are 5, four sets. There are five hand function groups. Three are precision grip and two are power groups. Get this concept clear in your mind and get it right. OK so the precision grip, like a tape to tape or you can say any. Some people say, say tripod key. OK, so the key, the lateral tension is key.
And then there is some people they say the coin is a tripod, so there is difficulty. So key Penn on a coin. This is the way to say and then and who grip and power grip where you hold the power? These are the five. I don't know. It's very like if you're going to go to the always take a key, a coin and a pen, and it's easy.
You don't need to. Some people, they say in the short cases, will I take a measure? Will I take actually don't take a measure because you are going to dig a grave for yourself. Do not take a measure yet. Maybe you can take a touch pen and it might be a nice thing to take a touch pen because that pen will be a touch pen and it will be a very good to if you get a ganglion.
And you can get transfer illumination, that's a bonus, but it won't save you from getting the principle right. OK, the concept right, you need to describe you. You can't jump from the very beginning to transfer information, so you need to be thinking clearly there. OK, nerve compression. These are anatomy, anatomy and physiology like either anatomy. They're going to.
You need to. Once you get a nerve, they're going to ask you anatomy and they're going to ask you where this nerve is compressed to give you this picture. OK, so it's either. And there are sites of compression. You just go and read it and learn it by heart because this is very important. There are five, 5 and I think six needles compression sites.
You have to learn it by heart. I don't care which way you do it. Just learn it and get it out there, ok? And then it will be nerve conduction study. The nerve conduction study is, is. Physiology are a basic science scenario, but it can come into showcases and I've seen people get nerve coming into the nerve conduction study.
The final answer once you find the nerve like median nerve or ulnar nerve is about the tendon transfer. There are principal of tendon transfer. You need to know all this principle. I have a nice way of changing it instead of the as supple as synergistic and all these S's. You can change it to donor factor recipient factor. And then just let me remember donor factor and recipient factor and the patient himself, like the patient, should be motivated and able to do the rehabilitation.
So don't factor the risk factors. And then so the donor factor, you can say that these are the should be synergistic and all the assets and the joint should be simple and just single and same line full on all these kind of things. The recipient should be clear of infection. And then the patient should be able to understand the rehab and compliant.
Now this is where we come to the flashcards. OK, so we come to the flashcards. And all cases, case by case, we have five minutes. So 1 minute is gone. Hello, how are you and stuff like that? And then thank you. Goodbye OK, so you need to be. It's 4 and 1/2 or 4 and 1/2 minutes or so you need to. From the very beginning, there is a spill, you need to be ready for, ok?
For all the cases, you have this spill. OK, so this is a hand. I can see that there is a deflection attitude of the right hand consistent with two between contracture, ok? There is a court that is puckering. There is all this say as much as you can and keep talking and do not stop until you get to the feet and feel that you are satisfied that you describe the deformity and then you can go.
Some people, they say, here you go for a screening, I would actually go for it straightaway if I see the do between remember, earlier on. It's like a show, a magic show. Zoom in between. I'm going to Zoom towards this, this two between. I'm going to go for car hunting. So I see whether there is a commercial record. That's important because it will indicate the is their faces.
There is a digital record and this is all important. I will straightaway ask the patient, OK, do you have it anywhere else? This is you're allowed to ask this because this is part of the examination and it's very important to see. They didn't rule out the senses because it will. The mannequin would be different. OK, Now f-14s examination, you need to flex.
You show that you flex your flex the tip to assess the extension of the flex. The flexibility to assess the extension of metacarpal Allen gel joint and flex the metacarpal for longer to assess the extension or the flexion deformity of the PIP joint. And if you don't do it in that way, you're not. You're not, you're not getting the full mark there. You can say whatever it might be hard sometimes with the deformity, but you need to show them that you are flexing the carpometacarpal joint assets approximately 10-fold and you are flexing the proximal and definitely your two a cup of neurovascular, neurovascular status, digital Allen test.
And there is a way I cannot do it on my own. There is a way to do the digital Allen test. And then as I mentioned here, as for the scissors, do the functional assessment. So if you have time you went through this, you can say, listen, I would like to do quick screening for other pathology because they will say, no, we want you to go focus on this, then this is a case you need to.
At that stage, it would be 1 and 1/2 minute. You need to say this is the machine and then change it to vulva. So the do between you need to talk about family history, you need to know about genetic defects and you need to talk about all the other scenarios there in between and the money is in the management. The money is in the management. So as long as you get it, the management you get, the management you are your past, OK, and then you can talk about the evidence and this is where you get the 7 and 8.
Now for the CMC, arthritis is very there is a speed there shouldering hybridization of metacarpal and joint. Why is Ofer explanation to increase the spine, to increase the spine? OK, so they say because the thumb is the metacarpophalangeal is adapted. So in order to increase the spine they will abduct, so is a hyperextended the metcalf-lindenburger joint.
So because the metacarpal is a sort of a deducted. So they do this, ok? And then I mentioned, once you see this, you got your pillow saying this give the diagnosis straight away. Go for your screening, grind in tests. Do not do grinding test in this case, because everybody and actually it's nicer if you say I would not do the grinding test because it's painful in this.
So that would show that, you know, you have empathy and you are very smart. The same, you stick to the look, feel, move and then you can do your functional assessment, remember? 47% has carpal tunnel, so it's really nice to say it. They would say, oh, OK, OK. But if you don't say it, oh, what do you do and assess anything else you will ask you, then you will start to be.
You will not know it and you. You'll start questioning yourself. Did I miss anything? Did I miss anything? It's merely they know this. They're looking for this. And then you go 4 for the if you change it to another straightaway, you change it. So you are talking about this paper you are talking about.
So exactly, I would not go I would go from operating a non operative treatment, which is a cup of tea, steroid injection and then a splint. And then I'll go straight away to Travis. I am not going to go for anything else because the evidence is out there. Ok? and it's nice to talk about the evidence in this case, actually.
Now the catch, I got caught in this and actually it was not this. Obviously, it was very subtle and and actually, I got prompted, not in this exam, in previous exam and where I flunked, but I got caught in this because it was so subtle. And then I had to the examiner prompt me a couple of times and then eventually I found it so that screening that is screening for the hand is crucial to spot this case.
OK, so once you screen it and do it slowly, open it slowly and you'll find the difficulty, the catch. And that's then you zoom, your zoom, your examination. We find that, OK, this is the trigger finger. The management is so easy. It's so easy. Look, then you do the function assessment. So remember, when you are reciting with your friend, when you are revising with your colleagues or with anybody, do this.
Number one flexion attitude of the finger. I'm going to do the screening. This is trigger finger, look, feel, move and then assess the nodule, digital ulnar nerve and online test and do the functional assessment. And these are the things that we needed. So eight aid station in your mind in about four, sorry, in about two minutes. You need to do this.
This is how slick you need to do this. You need to do it every single minute. And you need to think of it. Need to think of it all the time. Now this is a very common case in the exam. The ulnar nerve ulnar nerve and your need, as I mentioned before, need to talk about ulnar nerve products. So I'm going to give the diagnosis and then sensory motor and then provocative from and test.
You need to explain in from us because the FTP is so did not have to be. The adductor pollicis is not functioning. The patient is recruiting the FTP. Ta So you can see the fingers, the thumb is, it's flexing. So because after you ask the patient to use a doctor policies, but they cannot because the doctor policies is not functioning because a doctor policy is supplied by the ulnar nerve.
So to compensate to offer this explanation offered this explanation. Don't wait for the examiner. You say, why is doing this ok? Offer it. That's how you prevent prompting. Prompting is bad. Prompting is a killer. Prompting will cause you less.
And you can see somebody sent into the group. There is a way of marking the marking sheet. The more you get prompting, the more you lose marks. OK it's anatomy question and then nerve conduction study. Sorry, no rheumatoid hand actually rheumatoid is easy, and it's really, really it's like a gift. I know the way I find it is just it's about rheumatoid arthritis treatment.
You don't touch this patient. You do not touch. Try not to touch this patient. And that's a trick if you try to. Ah, you're fired. You are gone. Ok? it's all about description. There is a spiel you need to say it with is bilaterally symmetrical deformity of the hand consistent with rheumatoid arthritis.
And that's the way I say it all the time. The bilateral symmetrical deformity of both hands or both upper or lower level, more consistent with rheumatoid arthritis. Start describing from proximal to distal, proximal to distal. OK, and then you can do your screen straight away. Go to the functional segment straight away. Go to the functional cells. And if you don't have anything to say, go to.
I'd say, listen, that's my coin, my key. My pen rheumatoid is sorted that you pass. Rheumatoid arthritis, OK, but it's nice to have that spiel ok? Causes of drop finger. These are the catches causes of dry fingers. There are four causes multiple pathology. What are the causes? How are you going to do it?
I'm not going to say to you guys, you're going to find it and search it and you'll find it. What are the causes for dropping it? So these are the bullet points that you need to go with. OK you start describing the deformity. Do not. Don't think that you are going to examine the touch. This patient OK to not touch this patient because the skin is paper thin.
The examiners are kind of nervous. There are a picture of if you Google rheumatoid disgust, you find like about 12 scars either for replacement or for fusion for like. If you find it, longitudinal scars are for fusion. If it translates to scars, usually it's hard for replacement fusion of the wrist, but there are scars that you're going to be very vigilant for kind of pointing this scar.
You have to look for them. Now the difficult one, the all. My God. Oh, OK. I don't know what's going on. It's actually it's actually a gift and they want to see you have a system. They want to see that you are going to stick to look, feel, move and then if you don't know what's going on.
Just under the phone, which is so severe that you just say, listen, I'm going to do an assessment. And then I'm going to go back to my surgical teeth. This is most likely a congenital deformity of. So the picture is, is either radial Klopp hand or this is what you can discard. It's a Viper. So change it to a. And that's how you approach it.
And this is the lower picture is perfection pieces. One example one was operated on, the other one wasn't, and he had dysmorphic faces and neck as well. So I got pretty face down. But then I kind of somehow my mind clicked and I just went into some kind of syndromic anomaly. I don't know what it is, but I'm going to do the function assessment and I'm going to discuss this in with my pediatric colleagues, and I'm going to involve my geneticist as well.
This needs to be investigated and it needs to be the specialized center where I've got the expertise and the resources to deal with this. So if so, you think, my god, just keep calm. Describe what you see, the deformity, what you see and just be frank, tell them it's a syndrome. I'm not aware of it, but this is one way to go about it. And that's it.
That's what they want to hear. Exactly you have a system and stick to the functional system. Change it all over. Yes, let's go talk about why the are differential diagnosis, and that's how you approach this. This actually is the same as hand, but usually in the wrist. I change the rhythm of my examination. I'm going to look, move and then feel, guess that's a personal preference and the same for the elbow.
OK so but you need to be conscious of that. The wrist has three zones radial, ulnar and central. And this is how you differentiate between the problem in the wrist. And this is a question of anatomy and pathology. OK you can get cane disease. You can get a slap snack on this arthritis or anything. Yes, you need to divide it. Where is it?
And this is how you approach it with a range of motion examination and that you can screen with that, ok? And that will bring you down to where is the problem? Elbow again, quick and easy. And I actually like, I like. And you know what? In the exam. There is a lot of elbows. There is a lot of elbow examination and especially arthritis, rheumatoid arthritis.
I got my rheumatoid arthritis in not this exam in the previous exam. And it was actually it was sorry. It was my lung case. But some people, they examine it as a shortness and elbow is very important. Do not forget the ulnar nerve in any elbow examination. Do not forget it because you are doomed to failure if you forget the ulnar nerve.
It's really important. Keep it in your mind. This is how you put your flash card is just carry on until you comment on it, from the front, from the side, from the back and then look, move and then feel move. Yeah, put your hand like spread your hand, so extend it flexion. Do it actively and passively.
Very important to do it passively as well. So because yeah, you say, OK, let's see it active and then OK, can we can? Can we improve it? Watch for the patient, for the pain. OK, then assess the stability and neurovascular and then the joint above and below. These are the usual routines you get. I'm sorry, I'm interrupting you again.
But with the elbow, you guys can get a flail elbow. You can get a chronic radial head that was excised, which you cannot feel the osteoarthritis and rheumatoid in the elbow. These are very common. I also, if you are stuck for time, just ask the patient, can you reach your mouth? Can you reach your bump? And can you?
That's that's a quick way of the quick way. I've seen it in courses, and I found it really very handy and I found this is very helpful to get. So as I mentioned earlier on. Spread out your elbow and then active and passive and supine. And this is actually the picture or the. The photo on the left is actually for the examination of ulnar nerve, but you need to check for subluxation of the ulnar nerve as well to move it if it's a plus or not.
And the examiner wants to see that all the time because in the shoulder you went from distal to proximal. I'm sorry, this is the easy way of doing this presentation. Shoulder if you go to the short case, the first thing notice it is the age, OK, the age of the patient, because small, younger, younger patients are. Definitely instability. More than likely instability.
All the patients are arthritis or rotator cuff, and the bone in between are impingement. So we know that and this is all everybody. This is for emphasis. Three groups younger patient instability. The minute you say instability, you need to mention weight and score and do it and make sure that no, it's very, very easy to forget. Patterns cause the minute you see a young, a young patient, you're more than likely you are going to get instability.
Make sure in your back the back of the mind. There is better and score. We're going to ask about that score, and you have patterns already in your mind there. Ok? all the other patient, probably you are talking about in this study. We are talking about rotator cuff or arthritis of the shoulder. So and strangely enough, we got a case in our exam.
Actually, I got it in my exam. It was actually frozen shoulder. So anything can come up, you know, frozen shoulder, reduced external rotation, and that was a Warning sign. So if you have this, you have to keep in mind middle age, do in score and then the brachial plexus examination, which is, I think, very good. This examination is a gift as well. OK it's people are nervous about the Brexit process, but I think it's pure anatomy session.
It's a pure anatomy session. And then once you do, there is a video in YouTube how to draw blood in 10 seconds? OK no, that video. Go to YouTube and find it and know it. Draw your Blackness in 10 seconds and before your exam. I did this session, particularly for guys who are going in at the end of this month. You need to know the Brexit process in 10 seconds.
You need to see where is this coming from? Where is the route and where is it? There is a very nice way of examining. I used to examine the Brexit process in 1 and 1/2 when we used to do it 3 minutes and then we at the end we will lower it down to 1 and 1/2 minutes, 1 and 1/2 minutes. You finish the Brexit process and that's it. And the way I use it, the abbreviation of hamas, it's hitch is for Horner's syndrome and for muscle wasting a for attitude.
As for scars, as for splints the same way I used for all the cases. For that, it was mass here. It's Hamas response syndrome. OK this is the way, I guess, when I see something look like Brexit blogs. OK, how does it go then mass? I'm sorry. Muscle wasting attitude, feeling and scars.
And then you go for the sensation, according to dermatologist. So the dermatomes are very clearly written in Asia, and you need in the Asia Asia paper, you will. You will see there are dots. OK, so these dots are where you check the sensation. So you can't say, oh, this is here in this here, C5 on this. No, you go with a dot in Asia. So you see here in the lateral Latin is.
You don't check it here. I know that people, they take it here. No link it in the latter, the latter epicondyle of the humerus and then for C6, C7, C8 and one. So these are points that you are shooting on those points. So you don't have around and then motor the motor milestones are very particular. If you go to the Asia score, sorry Asia sheet, you will find these are very clearly written.
And these are the muscle testing. You are going to do it according to Asia score. So your main aim in the recall process is to find the level. OK, and then you can go take the discussion later. Actually, Brexit is really good because you start in high, you starting like scoring once you know this is brexit, you probably had 5 and 6 or six actually knowing the Brexit talks.
And then you can go for what type of Brexit Brexit is it high? So the upper or lower brexit, Brexit or total Brexit like so. But see, now there are an unusual pattern, and this is the one that comes into this so unusual pattern. You need to think of parts and Ike Turner or some Brexit plexus with partial treatment with tendon transfer or something like that. So unusual pattern in the breaker process, although you can see the deformity can see everything, but there is unusual pattern.
So think either this is part of an Turner syndrome or some tendon transfer? These references are I found it in kind of no particular order, but this is I prefer disorder. When asked, which is a very good book. OK you need to read it. You need to read it at least once again. It's a good book and it's a good reference and everything is there.
It's a big book. I found it really hard, but try to get hold of this. Ok? mercifully, has a very fully and forecasting. This is the book has a very good examination and have very good kind of selection of cases. There is another book by Sharma. I don't think it's AI don't know, it's OK by demonstrations and stuff like that, but I think fully and banaszak, which are the best in the market.
So far. I think this thing to take from this amount you share, my book is that he has given you a list of clinical cases and he has narrowed it down to a few examination that you can do, which are specific for that clinical case. Like if you get ahead its values, what things you are going to do? What if you get egawa test the five things you are going to do.
So when you are making your flashcards, that's what sanjit has been telling you all for the last hour is that you concentrate on those four or five things and you do them in an orderly fashion and be very slick with them. And you just kind of zone in on that thing. And that's where you get the marks. OK, guys, I have to stop here and thank you very much for listening.
If there is any burning questions, you can either raise your hand or you can. We just will continue to. All right, thank you very much. That was a very nice presentation, you did very well. And I think you have covered all the topics and you've given us a very good record in.
This must.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode