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Hip Examination for Postgraduate Orthopaedic Exams (Part1)
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Hip Examination for Postgraduate Orthopaedic Exams (Part1)
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Segment:0 .
Uh, questions without further ado with his two registrars who are helping him, Zubin and Sunil will introduce Zavala to continue Part two of his hip examination. Thank you very much, one for that very good of you and all the other mentors who joined is David de Gea as well.
Yes, David's here, because with three of us did the history and welcome to the other mentors, so we just move on. Just to recap, last time we stopped at history, Sean made an important point is that today and for the next session for examination, he will try to go to just the basic system of examination of the hip. More importantly, really, it's the way you talk and how we do the examination correctly.
And then if it's going well, then for the future, we can do things like difficult cases or the cases you most likely will get in a short case like or tenodesis impingement, et cetera. But it's no use going onto that or seeing a case of that if you don't have a system in place. OK, so today's is for a system. Just imagine I'm going to give you a scenario once again. We are doing it fresh.
No one else is really doing this interactive type of examination anywhere. So so let's try to be interactive, and let's imagine it's real life. And once again, it's the same patient who you took a history from. So imagine the same candidate last time has taken a history. It's a left hip.
Let's say it is an arthritic hip, and this time I want you to start by coming towards a patient. You've already introduced yourself, but just introduce it one more time. And I want you to tell us how you're going to tell the patient what you want to do. OK, so I want you to say, you know, remove your clothes or whatever, whatever.
Let's see the phrases you use, and then let's take it forward. Imagine now I'm going to move away from the screen and I'll point you towards the patient, and I want you to imagine that it's your intermediate case. So I'll get. Can you see the patient there? Yes, I see him. OK, so now just, yeah, you're coming. I'm there as examiner.
I'm standing somewhere here and Sean is standing on the left of the patient somewhere there. So you've come in and, yeah, go ahead and start talking to the patients and tell me, what are you going to do? And yeah, it's is Mr smith, his name is Mr. smith, and you've already taken a history. So now you tell him, thank you, Mr. smith, I've taken you've given me a history now. Carry on, so please speak.
Yeah OK. First of all, please, could I get a chair to sit beside my patient? Thank you so much. Yeah and then. Hello, Mr Smith. Muhammad Ibrahim. Could I take a history previously under examination with you?
Yeah, sure. And now imagine that you've taken the history, which is very good. And now you said, thank you. Now we're moving on to the examination. Very good. Thank you. OK a routine examination. Yeah, yeah, exactly.
You've taken a history. The problem was the left hip and now you're going to tell him what you want to do so. Yes OK. Just for a reminder, Mohammed, this is an elderly gentleman who's having problems in his left with decreased walking distance and a couple of other comorbidities. You went there last week, I think, this last week, but please go ahead.
History is of it. Yes, and everyone, says a typical 70-year-old old man with arthritic left hip. Just for everyone in the group, this is a good opening line, and what I'm trying to tell you is, please, there's a statement which you can all use and you can use it for foot and ankle or hip and knee and spine.
So I don't want any fumbling or anything you introduce yourself like you have moment. Very nice. And the next thing you say, Mr Schmidt. I need you to remove your trousers. I need to remove your socks and shoes. Leave your underpants on and have a seat, right? And then when and say as you're removing your shoes, please pass me your shoes.
So Abraham and everyone else. This is a statement, which means you will not forget examining shoes, and you will not forget saying what you want them to do. And at the same time, you'll tell him you look around and say, Mr smith, do you have any walking stick? So in other words, in one statement, you've covered everything which you will not miss a removing your trousers, socks and shoes.
Ask me your shoes so you're not going to forget examining the shoes, and you're going to look around and say, Mr smith, do you have a stick? Say all these things together in one statement, and everyone is the best opening line. OK, so the minute the foot becomes in your hands, you will. Can you see the camera now? Yes, Yes.
OK, so I want you to first look at it like this. Yeah and first of all, the first statement will be there's no external heel raise. All right, very clear. The word is external. He'll raise OK. Yep then you're going to put your hand inside. Like this and say and look and say there's no internal Hillary's.
Happy with that moment. Yes, happy. OK, then you're going to put your hand inside and look for what is a communist or ptosis you get in feet will be the medial arch support. You agree. People put a medial support inside so you can put your hand inside and check. There's no medial arch support, right?
Then you're going to turn over the foot like this and say there is no undue wear pattern of one foot over the other, right? Correct and then you're going to say there is no look at it, the frontier. There is no stretch suggestive of a bunion or a bunny in it. Yeah So I repeat again for you the minute that while the patient is changing, you're going to take the shoes and you're going to start external.
Hillary's internal Hillary's medial support, the outer belt, undue wear pattern and stretch of a bunion or Bonnet. And this gives a good opening statement because while the patient is undressing, you are doing this. All right, mama bear with that. This is what you're going to say for everything. Lovely, Sean and David and the others. Is there anything you'd like to add or should we move on? No, but it's something that is very important for the I just reinforcing what you said.
Very important. Proper examination. So proper shoe examination for anything lower limb is critical. It's one of the first things you should do for any part of an oral examination and you look for your anything like walking aids and/or support. All right.
And that's what I was telling you. You know, you're so tense in the exam. You know, you're comfortable with us here, but you can imagine the exam, how tense you'll be. So you're going to forget walking it and you're going to forget shoes. But if you practice this for every lower limb, you'll never forget it. Right So this is the statement you'll make.
And when it comes to the shoes, just a little, I don't know, harp on it. But if there are no negative findings, you don't have to say there's no external heel, but at least you're looking for it. So I don't want you to just pick up the screws. Shoes, ladies do this and put it down. I'm going to look with a purpose, which is like this. Then like that with your hands inside, turn it over.
And then looking like that, you may not have to say it, but at least still looking for it. And that's done now. Thank you. That was very good. You're talking style was very good. Don't change that at all. You are very clear. Yeah, thank you.
Just one. Anyone else just beforehand. Everyone else. Please don't bother with the introduction because you've already met this patient. But for future reference, don't ask the patient can I take a history examination? That's what they're there for in the exam. It's a better introduction is hi, my name is.
Thank you for coming today. I'm going to ask you a few questions, or I'm going to ask you to do a few things. That's it. Don't bother trying. I'm going to do a history examination. They know why you're there. So it just wastes time and makes it feel awkward for you. OK the only way where I agree, let's say thank you very much.
It's just that sometimes implied consent is implied in a manner that's the only reason why. So but you're saying thank you and coming there is good, but I only that statement is only whether implied consent. But the message with both of us are giving is don't make it law. Yeah, Yeah. Yeah, absolutely. And one of our mentors is typing a message, he said, reminding people that sometimes there isn't any shoes because they're wearing hospital slippers still make the effort to say, I'm looking for shoes.
Yeah thank you so much. Yeah lovely. Exactly Thanks for the next person. I'm putting the patient back there. Imagine now he's undressed. You've done your shoes, you've done his walking it, and he's undressed in front of you. What do you want him to do now? He's dead.
You want to stand up? Yeah, please stand up, Mr Smith inside. But in real life, in the stress of it, you probably haven't. Is that correct? Yeah, Yeah. Yeah so so therefore, just to remind you again, the front is front now. Tell them what you want to do. Yeah can you turn around for me, please, to the side?
So I want you to stand like this and say, can you turn around so you can face that wall? You know, I want you to point with your hand and say, that will turn around and face that wall? Yeah so Mr smith, can you turn around and face that wall, please? Yeah, lovely. Very clear. Fantastic now imagine the actor left and he's standing a bit like this and a bit like that.
And just put up your foot a little higher. Yeah, yeah, that's it. Now, now, now, do you agree? That what you had talked about from the front, you should have said from the side, the foot. Can you mention it from the front? No, right? You can. From the side.
OK and now, what do you want them to do? So yeah, so I so there is a good spinal line. Yeah, Yeah. You've talked about that spinal cord where the spinal cord as if you may have mentioned some point. But for everyone in the audience, let's stick to some points for all examinations of the body. All right. So in inspection, let's all agree.
We are going to examine from the front, we'll examine the side and examine from the back. Is that right for every joint? Yeah now from the front and from the back of side, the system will be, which I keep is let's put three headings. The first big heading is swelling and wasting. All right, let's keep that as one second would be scars and sinuses. Third would be deformity.
all right. Where are you, abdullah? Where are you? Yeah, I'm here. Yeah, sorry. Yeah, sorry. So it is deformity and just stick to that. So don't jump from one to the other. So let's say from the front.
Imagine you were standing up this. The first thing you say is you don't expect the hip to see swelling. Is that right? most of the time. So you won't say there is a swelling in the hip, right? But you expect to see some wasting. So you'll see I notice there's left quadriceps wasting, so you're standing up there. Yeah and I say and I don't see it from the front because the examiner knows you're looking at from the front, but there is quadriceps Mason.
Next is a scar. So there's a skull. If it's a classic scar, you describe it as a classic scar. So if this doesn't scar, you say it's been put inside. If it is an ostrich approach, you say it's a posterior approach. If it's for the Delta pectoral in the shoulder, you say, all right, it was a classic. Say that and not for scars, everyone.
I want you to describe it in a particular manner. So we'll say there's a skull, which is a smooth Peterson scar in the anterior aspect of his hip area, which is healed, which is of how many centimeters length approximately. So we say about 10 centimeter length. So we talk about where it is. It's a classical scar or not. How long is it it? And it has healed throughout its length by primary intention.
Happy to use that, Abdullah. Yeah, Yeah. Now imagine and you'll get a scenario in the exam, which our previous mentor who gave the excellent talk on prosthetics, had in his case is you'll get a patient with scars everywhere. So you describe this. Suppose the scar healed in the lower part, not by primary intention.
I want everyone to say this guy is healed by primary intention throughout its length, but the lower end of the scar as healed by secondary intention. But I do not see a sinus or I see a sinus with surrounding redness. Yeah, so you've covered that part, and I notice that there is no hypertrophy in the skull or the scar is not hypertrophic. Yeah so you want to repeat that, Abdullah.
The third is deformity. Now, you know, from the front and my mentors and Chuan, I lost them. But you said that there's limb length discrepancy. All you can make out from the front and the hip is whether the size of one side is lower than the other. You agree with that. Yes Yeah. So why don't you just say that?
And now this is a typical hip examination for the future. The side where the pathology is. So I'm telling you now for Mr smith, the pathology, the left side, which is here, right? Yes you mention whether that side exercise is lower or higher, not the other side, you know. Right because one has to be lower. One has to be higher. So the dip for everything is the pathology side is what you comment on the size.
Imagine this is lower, right? So what are you going to say? I notice. I notice that the ISIS on the left side is lower than the other side. Yeah so if you want to be better. And this will explain why the left is lower than the right? That's one phrase. Another phrase which you can use, and I'll ask the mentors what they prefer.
You can say there's a pelvic tilt, with the left side being lower than the right. You don't make it simple, but whichever phrase you want to use, please write down the phrase practice that phrase, because that's what you're going to say on that day. Happy with that. Up to that. Yes Yeah.
Now you want to move to the left, so we'll be moving in. Can you face the wall, please? Now, I don't mind that always a controversy from all of you. Whether you should ask the patient to turn or whether you should walk around the patient, please do whatever you're comfortable, but stick to 1. Don't do one day and the other day, and please don't change your pattern for old person or young person because you're so stressed and an older person will look young and a young person will look older.
Just stick to one, right? So if you want to make the patient turn, turn all the time and practice facing the wall from the side. Sticking to the same things, Abdullah. You agree that it's going to be no swelling at all because you don't see swelling wasting from the side, right? Yes so don't mention it scar sinuses important. So if there was a scar tissue or plastic electrical use, you'll see that, but there's no scar.
And third, for deformity, you're going to say, exactly, let's start from the top. You're going to say there is an exaggerated lumbar lotuses. There isn't say that there's no exaggerated lumbar doses, and you can say the hip is an attitude of flexion. You agree. Yeah and the knee is an attitude of flexion flexion and the foot is accused of plantar flexion. You can say the ankle is an acquaintance all.
Let's put it straight against. See Sunil making it straight down. So now and imagine you still have the flexion of the hip and knee. Just verbalize this. You're going to say there's a flexion attitude of the head. So there's a flexion attitude of the hip flexion at the knee and the foot is planned to read, yeah, yeah, Yeah. So these are the options and then may turn around and face the wall, please.
So when Mr Smith is facing the wall at once again, you're not going to swelling you. There's going to be no swelling, but you're going to talk about hamstring and gluteal wasting. Is that right? Yes so mentioned it. Say I said, there's no or there is whatever you want, but practice it. There's no gluteal wasting.
There's no hamstring. So there's no obvious gluteal or hamstring wasting. Yeah and don't talk about scars and sinuses because no one really operates from the back, right? So don't mention it. And don't walk towards skin changes and things. You're not going to see that there. And as well as deformity is concerned, you've already mentioned all the deformities right from the front.
So you don't have to mention it again. But don't forget the back and say, I notice when I'm standing, there's no obvious scoliosis. Yes, right? So that's and then so in other words, what I'm trying to tell you is in front, back side, you've continued on the hip, but talked about one joint above and one joint below, right? Yeah, Yeah.
And that's all you do. So, you know, shoulder, it'll be cervical, spine. It's with elbow, it'll be shoulder and wrist. Yeah, so don't go all the way up. So if we're talking about the knee, you don't have to talk about the hip, you don't have to talk about the spine. It's just one joint about one joint below. Happy with that, Abdullah.
Yes Yeah. Very good. Excellent way of talking, Sean and any of the others. Anything you want to add for this part. Don't forget to look at the other hip quickly. Yeah, yeah, Yeah. Very correct. Exactly yeah, I personally, I went for my inspection. I look stuff from the shoulders.
I make sure the shoulders level, I think antero-supero-lateral spines for the pelvis level. And also, as you mentioned, but I just held me like, if the shoulder is not level, I'll be thinking there's something going on with the spine as well. Good point. I agree with everything you have said, but I just want to reinforce the word attitude because so many times when I'm practicing this guy's clinical examination, they watch the patient standing in a particular position and then they say the patient has a fixed flexion.
Thank you, Sean. Thank you for that. That works. That's wrong. Must be the word attitude. Thank you for that, your honor. Good, you pick it up, please. No one at inspiratory level would say the word fixed and the word deformity.
It's just an attitude. Let's stick to that. Thank you, Sean, for that. Good now we'll go on someone else you want. You've done a you've done your gait. You've described it. And now you're going to do the treadmill test. Is that right? Yes, sir.
Fantastic so, Joe, before that, everyone I want you to. I want you to say, I want you to. First of all, be very clear with your instructions. So if you are in a place where the room is very cluttered, please, it's your responsibility. We want to make sure you take charge and we give you marks for being a consultant, so therefore clear the room. All right.
So the patient is not going to jump over chairs, so clear the room. And then the best is to tell the patient clearly walk away from you and then give him instructions. Please turn around and walk towards me. That's the best way. And when you're doing that, the only thing Joe is the minute the patient started walking, you started giving an opinion.
Is that correct, joe? Yes so why do it straight away? The patient walk there he was walking into the wall and you were speaking to me saying here until you get now, that's probably not taking control. The patient may walk out of the examination and hence if you want to see front, back and side see him walk in that manner and just look after him. So tell him, yes, walk towards the walk.
Thank you very much, miss Smith. Turn round. Please walk towards me and then go to the side. So I'll do it like this. The camera. So imagine and you see me here. Yeah Yeah so Mrs. smith, do you mind if you turn around and just walk and walk towards that wall? Thank you very much.
Now, John, come and walk towards me. Yeah, thank you very much and see what I'm doing. I just went to the site. That's right. Thank you very much. Please have a seat. Yeah now and then immediately look at the examiner and say this patient. And does it get right or this patient got up shortly?
Or this patient got up Burkett right? Yes so before we go into the dental test very quickly, there's always a controversy with the policy as to in the clinical examination. My advice to all of you is please don't talk about he's walking with a good foot progression. I'll tell his step off, his good. His stuff is good, please. This clinical examination is only to demonstrate whether you can pick up a clinical gait pattern if they ask you later on what it is.
Please do so. But I'm telling you very clearly after examining hundreds of people in my course, as well as when they are preparing for the exam, is doing everything together. You're talking a lot of nonsense and not saying what you're saying. So let's all agree that we just identify the gait pattern and they'll test you on these other things on Survivor.
So let's start with each one with you, Joe. What is a common? What does that tell you get? If I ask you, tell me about it, you? What does that tell you? It is a shortened stance, a stance phase of the affected. Right so the patient has a short time. That's correct. And can you tell me another?
The next common gait will do it. Gait? Yes. Thank you very much. Can you please tell me what do you understand by a trained gait is that the patient is trying to compensate for week for week abductors by swinging the center of rotation, a center of gravity over the affected limb?
And so what exactly happens in the clinical scenario? You said it is doing the burglars, which is yeah, so Joe, and for everyone the way I would say, this is a common question it could be asking in Survivor and if the mentors don't mind, I can just talk about it here, but it's very commonly can be asked in the clinical is, you can see in incredible gait. You can start by saying the basic principles of the trainable gait and the test is as follows.
You can say in when a patient stands on its normal hip and start with that job, the best advice I'll give when you try to explain something, say what happens normally. So when a patient stands on a normal hip, the pelvis of the other side raises and that is normal. You agree, joe? Yeah, Yeah. So you going to make that statement?
So when the patient stands in the normal hip, the pelvis of the opposite side raises and this is normal, then say if a patient has a trend in a positive trainable gait or a test when the patient stands on is affected or is bad hip, the pelvis of the other side dips. And this is the principle of the trainable gait. So clear how simple it is. Happy with that job? Yeah, Yeah.
So that's your second. What is the third common is gait in orthopedics. Just one question, sir. Is there is the dipping of the pelvis, happens during the gait or happens during the test. Don't worry about it now, because the reason is that both the principle is what we are talking about right then as to what happens when your center of gravity goes.
You know, it's a matter for discussion. But what I'm trying to say is, no, you're saying anything else when the basic principle is what you're picking up, is this. In other words, it's very clear when a patient is walking in a strindberg gait pattern, the opposite pelvis dips down. Yeah, that's what is again. So the third is a high slippage gait.
For that, let's stick to bilateral training, which is called a waddling gait. You agree? Yeah so that's the third. Fourth would be short limbed shortly. So what happens in the short limb? Uh, I happen in the short term, that the patient actually attacks have an exaggerated knee flexion of the unaffected side were on this stance in the sense.
Yeah, it's one and more. But from the pelvis point of view, it can happen. The pelvis of that side dips down because that's the only way you can get his foot planted, right? Right? Yeah. So that's all for the short term. You sure you don't just call it a short rib because the pelvis of that affected side will be lower, because that's the only way you can get this foot planted, right?
Yeah, that's one. Yeah next, we'll go onto in orthopedics. There will be can talk about the high stepping gait, which is a foot drop. Now there are three gates and cerebral palsy, and it'll be three gates and cerebral palsy, which you know, scissoring get you to overacting at doctors, at the hip. So everyone, this is why I'm covering this is because you're going to get children with cerebral palsy.
They'll throw you. But if you have the system of talking, it's very clear. So yeah, that's one. Number two, Aquinas Aquinas due to Aquinas is where it happens. At the ankle, at the ankle. Yeah, tiptoeing gait and doing it and doing it due to construction of the gastric penis or the Achilles and crouch gait. If the Achilles lengthening happened before hamstring release or the flexion, which is flexion of the knee and flexion flexion of the hip and the patient, actually try to increase the energy expenditure by time.
And the third one will be. A windswept yet windswept, windswept, windswept, typekit, yeah, so that's the third one, and in neurological gates just to complete. I want you to keep in mind Parkinson's gait will be shuffling. Yes, happy with that. Yes then will be a taxable AI based a tax, which is a wide based get right?
Basically Yeah. And sort of like allopathy. What said you have to attack six or posterior column involvements, really wide based and circumspection, which will be in hemiplegia. So we've covered 9 or 10 gates and this will cover most of your work. Yeah, yeah, I'll agree with that. You?
Yes. Yes OK. The others, is anyone anything else you'd like to add, forget or you've covered it? From my point of it? But do you agree it might just ask dementors. You agree. My feeling is, and I know you all have done a lot of examination examined candidates that my feeling is when candidates are always taught in courses to yes, please describe the gate, talk with the foot.
My feeling is no one has the skills or you're so stressed you can't talk all these phrases and assess the patient and talk sense. So that's what I'm telling you not to do. You agree with that? I agree. It's very easy to make an error and then an exam that can seize upon that and start asking you questions if take you and take you away from what you're there to do, which is examine the hip.
Exactly, exactly. Thank you for that. That's what I'm telling everyone. So don't get that perfect. It's a waste of time. It's not a clinical examination front desk question. Talk about the rockers, I think is not necessary to put yourself to talk about the rockers and the rockers.
Just make it simple. Yeah, happy with that, as you know, but for you and for the other to be a little careful of this because my tip to you is that you'll be so tense after doing the walking because, you know, walking, you going to get the room ready and things that you may forget to return, but your mind may forget you, and you may make the patient go straight to the couch. So my tip to you and my tip to others is not a scientific trip.
It's just a practical tip. So you don't forget is front backside inspection. Hold my hands. Do general book. Thank you very much. Please walk the walk back. Please lie down on the couch. So this is my statement, so you'll never forget. But please don't change your pattern.
But I'm just Warning you that you may forget general book because patients walking all over the place. If anyone noticed just there, Mr Michael ausiello at the end of his gait, he told the patient to sit on the couch and every one of you, I can guarantee you thought, well, he's Mr and Trendelenburg. That's because he always stays consistent.
He always does the term first, then the gait. And it's important to develop your consistency, so it becomes instinct later on. So the instinct for me was that my statements are the same in my clinic, in real life. Every case, I do the same thing. So you just as long as your phrase is coming out of your mind, is all the same, right? So let's imagine you're doing it any time.
And now how do you want to do it? So this is the patient. Imagine you're doing the treadmill, but I know it's very difficult, but let's do it together. So imagine I'm. You tell me whatever you want me to do, I'll do for you. Good have a seat. So for everyone, the very good. I think you handle it perfectly.
Your phrase was good, but a few points. Yeah the first point is when you finish it, I want you to tell him, thank you very much. Put your hands down. Please have a seat on the couch. Immediately turn to the examiner and say the treadmill test was positive or negative. All right. But don't talk and please don't all to when he's holding your hands, he's worried he's falling over and you're talking about, yes, the shoulders are coming over.
My left hand is going over. Don't say all that. We all know what you're doing. The most important person is who the examiner or the patient tell Mason is the patient, right? So forget the examiner. Finish that put it down and say tenotomy just positive or negative. So let's do it like this.
The other point to give you. So the first thing is, don't get into arguments with your colleagues about whether you should go down and hold the pelvis and go, there are many ways of doing it. My advice to both patients is do this, which is the appellee's modification. We don't just say, but that's the best way of doing it, going down like this.
I'm not criticizing it, but I'm telling you it's sometimes difficult to do in all the people. It's difficult to verbalize to a patient. So this is the way I do it. So the first stage is always, like you said, stand in front of me. Please hold my hand and put your hands as I do now. One of the things I do as a note is don't say left or right. You agree.
OK slap lesion, Mr smith, which is your bad hip? That, Yeah. So ask him that first, that's your question, which is your body? Yeah, yes, your left one, then say, Mr smith, I want you to stand on the good side. Happy to say that is another. Yes so I want you to stand on the good side and do as I do. Yeah very clear instructions, happy with that.
Yes, that's right. Thank you very much. Now I know it's difficult, but I want you to stand on the bad side and do as I do. Oh yes, you're certainly bending over. Thank you very much. Please have a seat on the couch. The test was positive. Yeah, isn't it?
No, I would agree, it's very important to not worry about left and right because the patient is going to be nervous. You'll be nervous. So just as you said, worst about it, what's your good hip? Copy me. Yeah, exactly. Simple words. And this is what gives us. We know that a patient can be difficult.
We know he's going to fall over. Yeah and please don't get into arguments about should I do it for 1 minute or 30 seconds or 70 seconds? Do it for a reasonable length of time, which you feel appropriate, which you would do in a clinic and where you'll get your judgment. Imagine you're not getting it. You can always say, is it all right? Can we do a little longer?
It's important for me. You know, you're telling the examiner indirectly telling you're telling the patient, but indirectly telling the examiner that you're doing it as long as you get. Yeah there is AI don't know what the governments feel about this. I tend to ask the patient to lift their bad leg off the ground.
Mm-hmm Exactly the same way as you have. But I, I, I, I do the same thing as in. I show them what I want them to do. So that their bad leg is off the ground. But I don't actually. I keep my two legs planted when they lift their good leg off the ground because especially in the heavier elderly person, you may not be stable enough to hold on one leg, let them counter your weight if they've got to.
It's just the modification I've always done because I'm worried that the patient drops in front of me in the exam. Thank you. Oh, good point. And another point sticking to what she wants is said everyone. That's the reason why I feel bending forward, bending on going on your knees, holding the patient by the pelvis, then looking up at him.
Then you tell him, lift your leg and he kicks you in the face. You know these things happen and you're going backwards. He's falling over. That's the reason I don't do it in a traditional manner and we will recommend. Is it all right for the metal to say if you have time to practice, you recommend this or is too much to say that? Sorry, repeat that again.
You know, there are many ways of doing the training, but there's some people bend down on their knees, all the pelvis and then tell the patient, you know, I think I think is dangerous is time wasting, but also it's very awkward looking. Have you ever seen someone doing this, especially on a hip? Exactly it feels awkward. It looks awkward that you've now got scuffed your trousers and it just doesn't look right.
And you you look as if you're not in control. So therefore, can we recommend shrine that we do it this way and not the other way, just as a general recommendation? Yeah Yes. Question that came up. Most of us asked sound side first. Is that necessary? Or is it a waste of time in the real examination?
What do you mean? Sound side first for what? For the general book lifting? Lifting the bad leg up first is no. I would say we have to do it because it's very important for two reasons. One is a patient knows what you're doing and the patient's confident to stand on his good left, good leg or lift the bad one.
It doesn't matter phrase which you're using is lift a bad one or stand a good one. But I think it's vital to do because otherwise, the confusion I see happening in this test is enormous. You know, the patient doesn't know what he's doing or whatever it is. This is setting the stone for at least getting the confidence of you, your patient and ultimately paying the examiner that I'm getting confident of what I'm doing.
So I think it's vital we do the good side first because you demonstrate they can do it on the good side. Yes show what it looks like compared to the bad side. Excellent and they could also have offered an average of on that side as well. Yeah, I yeah, that happened to me before a previous hip replacement, which you need to demonstrate. Their abductors are working out what I do and when I do my core site, everyone, I mean, all five, six people can just do the same thing and I can demonstrate it can actually do it in a minute and a half.
If the words come out correctly, it's a minute and a half. Yeah, but if it's not, it'll take you five minutes. I'm telling you clarify minutes I have from the moment they stand up. Not, it turns out, of course. Yeah all right. I think the best way to keep practicing the test and you develop your own technique. Considering what we talked about and just in the exam, we have to look professional.
You know what you're doing and you talk in a clear way to the examiner, gives clear instructions to the patient the best way just to practice it. Every opportunity in the clinic, even if you examine need, try to do it. This make you happy that you're confident. Absolutely this is to generate some controversy this time. No test, no comment. Sorry Mustafa commentated that he's been at a previous course that.
Force will not be mentioned, but he's been told that to do it with kneeling down with the patient's resting their arm. I'll give you an example of why it's not a good idea. One of my colleagues sees a very slight lady. She's a very good surgeon. She did it that way. And she had a very big patient. So it just it doesn't look right.
And it's and not as we've said, you're not in control. So I would say as well as well, if you have to put one foot down, you may have a really arthritic, elderly patient who could be any size and you don't want them toppling over you. And I think your standing, you can't touch them from the pelvis. That's the problem. My feeling is that, look, you know, I think what I'm trying to get at and all of us are trying to tell you is this passing of this exam is to demonstrate to your consultant colleagues that your consent level the way you're talking.
And if you do it in the manner which I've done it, or which one or any of my mentors will do it and you're doing it in a slick manner with complete control of the situation, I cannot accept that doing it in this way is wrong and that whoever said in the course is right. Yeah, so you need to do it quickly and pass. That's where you are. Yeah this is one of the minutiae detail as long as you're comfortable and you're controlled and you're in a slick way of doing it.
The exam is going to be happy if you're looking uncomfortable, like you've never done it before. They'll know. Yeah, and if you do it kneeling down and you're happy and slick with it, fantastic. You know what I'm saying? That's perfect to do. So I won't change anyone who does it in that manner, provided once again you're talking well and talking strictly.
So that's actually have you noticed, Chetan said classically is described from the back, so even the other courses said it's wrong has got it wrong as well. So I've not. If you could do it from the back, I'll be very impressed. Yeah, I don't think anyone would recommend it from the back because you can't see the patient. Yeah, yeah, Yeah.
Yeah so all this is about you being in control, but yeah, there's no point in describing it.
Segment:0 .
Uh, questions without further ado with his two registrars who are helping him, Zubin and Sunil will introduce Zavala to continue Part two of his hip examination. Thank you very much, one for that very good of you and all the other mentors who joined is David de Gea as well.
Yes, David's here, because with three of us did the history and welcome to the other mentors, so we just move on. Just to recap, last time we stopped at history, Sean made an important point is that today and for the next session for examination, he will try to go to just the basic system of examination of the hip. More importantly, really, it's the way you talk and how we do the examination correctly.
And then if it's going well, then for the future, we can do things like difficult cases or the cases you most likely will get in a short case like or tenodesis impingement, et cetera. But it's no use going onto that or seeing a case of that if you don't have a system in place. OK, so today's is for a system. Just imagine I'm going to give you a scenario once again. We are doing it fresh.
No one else is really doing this interactive type of examination anywhere. So so let's try to be interactive, and let's imagine it's real life. And once again, it's the same patient who you took a history from. So imagine the same candidate last time has taken a history. It's a left hip.
Let's say it is an arthritic hip, and this time I want you to start by coming towards a patient. You've already introduced yourself, but just introduce it one more time. And I want you to tell us how you're going to tell the patient what you want to do. OK, so I want you to say, you know, remove your clothes or whatever, whatever.
Let's see the phrases you use, and then let's take it forward. Imagine now I'm going to move away from the screen and I'll point you towards the patient, and I want you to imagine that it's your intermediate case. So I'll get. Can you see the patient there? Yes, I see him. OK, so now just, yeah, you're coming. I'm there as examiner.
I'm standing somewhere here and Sean is standing on the left of the patient somewhere there. So you've come in and, yeah, go ahead and start talking to the patients and tell me, what are you going to do? And yeah, it's is Mr smith, his name is Mr. smith, and you've already taken a history. So now you tell him, thank you, Mr. smith, I've taken you've given me a history now. Carry on, so please speak.
Yeah OK. First of all, please, could I get a chair to sit beside my patient? Thank you so much. Yeah and then. Hello, Mr Smith. Muhammad Ibrahim. Could I take a history previously under examination with you?
Yeah, sure. And now imagine that you've taken the history, which is very good. And now you said, thank you. Now we're moving on to the examination. Very good. Thank you. OK a routine examination. Yeah, yeah, exactly.
You've taken a history. The problem was the left hip and now you're going to tell him what you want to do so. Yes OK. Just for a reminder, Mohammed, this is an elderly gentleman who's having problems in his left with decreased walking distance and a couple of other comorbidities. You went there last week, I think, this last week, but please go ahead.
History is of it. Yes, and everyone, says a typical 70-year-old old man with arthritic left hip. Just for everyone in the group, this is a good opening line, and what I'm trying to tell you is, please, there's a statement which you can all use and you can use it for foot and ankle or hip and knee and spine.
So I don't want any fumbling or anything you introduce yourself like you have moment. Very nice. And the next thing you say, Mr Schmidt. I need you to remove your trousers. I need to remove your socks and shoes. Leave your underpants on and have a seat, right? And then when and say as you're removing your shoes, please pass me your shoes.
So Abraham and everyone else. This is a statement, which means you will not forget examining shoes, and you will not forget saying what you want them to do. And at the same time, you'll tell him you look around and say, Mr smith, do you have any walking stick? So in other words, in one statement, you've covered everything which you will not miss a removing your trousers, socks and shoes.
Ask me your shoes so you're not going to forget examining the shoes, and you're going to look around and say, Mr smith, do you have a stick? Say all these things together in one statement, and everyone is the best opening line. OK, so the minute the foot becomes in your hands, you will. Can you see the camera now? Yes, Yes.
OK, so I want you to first look at it like this. Yeah and first of all, the first statement will be there's no external heel raise. All right, very clear. The word is external. He'll raise OK. Yep then you're going to put your hand inside. Like this and say and look and say there's no internal Hillary's.
Happy with that moment. Yes, happy. OK, then you're going to put your hand inside and look for what is a communist or ptosis you get in feet will be the medial arch support. You agree. People put a medial support inside so you can put your hand inside and check. There's no medial arch support, right?
Then you're going to turn over the foot like this and say there is no undue wear pattern of one foot over the other, right? Correct and then you're going to say there is no look at it, the frontier. There is no stretch suggestive of a bunion or a bunny in it. Yeah So I repeat again for you the minute that while the patient is changing, you're going to take the shoes and you're going to start external.
Hillary's internal Hillary's medial support, the outer belt, undue wear pattern and stretch of a bunion or Bonnet. And this gives a good opening statement because while the patient is undressing, you are doing this. All right, mama bear with that. This is what you're going to say for everything. Lovely, Sean and David and the others. Is there anything you'd like to add or should we move on? No, but it's something that is very important for the I just reinforcing what you said.
Very important. Proper examination. So proper shoe examination for anything lower limb is critical. It's one of the first things you should do for any part of an oral examination and you look for your anything like walking aids and/or support. All right.
And that's what I was telling you. You know, you're so tense in the exam. You know, you're comfortable with us here, but you can imagine the exam, how tense you'll be. So you're going to forget walking it and you're going to forget shoes. But if you practice this for every lower limb, you'll never forget it. Right So this is the statement you'll make.
And when it comes to the shoes, just a little, I don't know, harp on it. But if there are no negative findings, you don't have to say there's no external heel, but at least you're looking for it. So I don't want you to just pick up the screws. Shoes, ladies do this and put it down. I'm going to look with a purpose, which is like this. Then like that with your hands inside, turn it over.
And then looking like that, you may not have to say it, but at least still looking for it. And that's done now. Thank you. That was very good. You're talking style was very good. Don't change that at all. You are very clear. Yeah, thank you.
Just one. Anyone else just beforehand. Everyone else. Please don't bother with the introduction because you've already met this patient. But for future reference, don't ask the patient can I take a history examination? That's what they're there for in the exam. It's a better introduction is hi, my name is.
Thank you for coming today. I'm going to ask you a few questions, or I'm going to ask you to do a few things. That's it. Don't bother trying. I'm going to do a history examination. They know why you're there. So it just wastes time and makes it feel awkward for you. OK the only way where I agree, let's say thank you very much.
It's just that sometimes implied consent is implied in a manner that's the only reason why. So but you're saying thank you and coming there is good, but I only that statement is only whether implied consent. But the message with both of us are giving is don't make it law. Yeah, Yeah. Yeah, absolutely. And one of our mentors is typing a message, he said, reminding people that sometimes there isn't any shoes because they're wearing hospital slippers still make the effort to say, I'm looking for shoes.
Yeah thank you so much. Yeah lovely. Exactly Thanks for the next person. I'm putting the patient back there. Imagine now he's undressed. You've done your shoes, you've done his walking it, and he's undressed in front of you. What do you want him to do now? He's dead.
You want to stand up? Yeah, please stand up, Mr Smith inside. But in real life, in the stress of it, you probably haven't. Is that correct? Yeah, Yeah. Yeah so so therefore, just to remind you again, the front is front now. Tell them what you want to do. Yeah can you turn around for me, please, to the side?
So I want you to stand like this and say, can you turn around so you can face that wall? You know, I want you to point with your hand and say, that will turn around and face that wall? Yeah so Mr smith, can you turn around and face that wall, please? Yeah, lovely. Very clear. Fantastic now imagine the actor left and he's standing a bit like this and a bit like that.
And just put up your foot a little higher. Yeah, yeah, that's it. Now, now, now, do you agree? That what you had talked about from the front, you should have said from the side, the foot. Can you mention it from the front? No, right? You can. From the side.
OK and now, what do you want them to do? So yeah, so I so there is a good spinal line. Yeah, Yeah. You've talked about that spinal cord where the spinal cord as if you may have mentioned some point. But for everyone in the audience, let's stick to some points for all examinations of the body. All right. So in inspection, let's all agree.
We are going to examine from the front, we'll examine the side and examine from the back. Is that right for every joint? Yeah now from the front and from the back of side, the system will be, which I keep is let's put three headings. The first big heading is swelling and wasting. All right, let's keep that as one second would be scars and sinuses. Third would be deformity.
all right. Where are you, abdullah? Where are you? Yeah, I'm here. Yeah, sorry. Yeah, sorry. So it is deformity and just stick to that. So don't jump from one to the other. So let's say from the front.
Imagine you were standing up this. The first thing you say is you don't expect the hip to see swelling. Is that right? most of the time. So you won't say there is a swelling in the hip, right? But you expect to see some wasting. So you'll see I notice there's left quadriceps wasting, so you're standing up there. Yeah and I say and I don't see it from the front because the examiner knows you're looking at from the front, but there is quadriceps Mason.
Next is a scar. So there's a skull. If it's a classic scar, you describe it as a classic scar. So if this doesn't scar, you say it's been put inside. If it is an ostrich approach, you say it's a posterior approach. If it's for the Delta pectoral in the shoulder, you say, all right, it was a classic. Say that and not for scars, everyone.
I want you to describe it in a particular manner. So we'll say there's a skull, which is a smooth Peterson scar in the anterior aspect of his hip area, which is healed, which is of how many centimeters length approximately. So we say about 10 centimeter length. So we talk about where it is. It's a classical scar or not. How long is it it? And it has healed throughout its length by primary intention.
Happy to use that, Abdullah. Yeah, Yeah. Now imagine and you'll get a scenario in the exam, which our previous mentor who gave the excellent talk on prosthetics, had in his case is you'll get a patient with scars everywhere. So you describe this. Suppose the scar healed in the lower part, not by primary intention.
I want everyone to say this guy is healed by primary intention throughout its length, but the lower end of the scar as healed by secondary intention. But I do not see a sinus or I see a sinus with surrounding redness. Yeah, so you've covered that part, and I notice that there is no hypertrophy in the skull or the scar is not hypertrophic. Yeah so you want to repeat that, Abdullah.
The third is deformity. Now, you know, from the front and my mentors and Chuan, I lost them. But you said that there's limb length discrepancy. All you can make out from the front and the hip is whether the size of one side is lower than the other. You agree with that. Yes Yeah. So why don't you just say that?
And now this is a typical hip examination for the future. The side where the pathology is. So I'm telling you now for Mr smith, the pathology, the left side, which is here, right? Yes you mention whether that side exercise is lower or higher, not the other side, you know. Right because one has to be lower. One has to be higher. So the dip for everything is the pathology side is what you comment on the size.
Imagine this is lower, right? So what are you going to say? I notice. I notice that the ISIS on the left side is lower than the other side. Yeah so if you want to be better. And this will explain why the left is lower than the right? That's one phrase. Another phrase which you can use, and I'll ask the mentors what they prefer.
You can say there's a pelvic tilt, with the left side being lower than the right. You don't make it simple, but whichever phrase you want to use, please write down the phrase practice that phrase, because that's what you're going to say on that day. Happy with that. Up to that. Yes Yeah.
Now you want to move to the left, so we'll be moving in. Can you face the wall, please? Now, I don't mind that always a controversy from all of you. Whether you should ask the patient to turn or whether you should walk around the patient, please do whatever you're comfortable, but stick to 1. Don't do one day and the other day, and please don't change your pattern for old person or young person because you're so stressed and an older person will look young and a young person will look older.
Just stick to one, right? So if you want to make the patient turn, turn all the time and practice facing the wall from the side. Sticking to the same things, Abdullah. You agree that it's going to be no swelling at all because you don't see swelling wasting from the side, right? Yes so don't mention it scar sinuses important. So if there was a scar tissue or plastic electrical use, you'll see that, but there's no scar.
And third, for deformity, you're going to say, exactly, let's start from the top. You're going to say there is an exaggerated lumbar lotuses. There isn't say that there's no exaggerated lumbar doses, and you can say the hip is an attitude of flexion. You agree. Yeah and the knee is an attitude of flexion flexion and the foot is accused of plantar flexion. You can say the ankle is an acquaintance all.
Let's put it straight against. See Sunil making it straight down. So now and imagine you still have the flexion of the hip and knee. Just verbalize this. You're going to say there's a flexion attitude of the head. So there's a flexion attitude of the hip flexion at the knee and the foot is planned to read, yeah, yeah, Yeah. So these are the options and then may turn around and face the wall, please.
So when Mr Smith is facing the wall at once again, you're not going to swelling you. There's going to be no swelling, but you're going to talk about hamstring and gluteal wasting. Is that right? Yes so mentioned it. Say I said, there's no or there is whatever you want, but practice it. There's no gluteal wasting.
There's no hamstring. So there's no obvious gluteal or hamstring wasting. Yeah and don't talk about scars and sinuses because no one really operates from the back, right? So don't mention it. And don't walk towards skin changes and things. You're not going to see that there. And as well as deformity is concerned, you've already mentioned all the deformities right from the front.
So you don't have to mention it again. But don't forget the back and say, I notice when I'm standing, there's no obvious scoliosis. Yes, right? So that's and then so in other words, what I'm trying to tell you is in front, back side, you've continued on the hip, but talked about one joint above and one joint below, right? Yeah, Yeah.
And that's all you do. So, you know, shoulder, it'll be cervical, spine. It's with elbow, it'll be shoulder and wrist. Yeah, so don't go all the way up. So if we're talking about the knee, you don't have to talk about the hip, you don't have to talk about the spine. It's just one joint about one joint below. Happy with that, Abdullah.
Yes Yeah. Very good. Excellent way of talking, Sean and any of the others. Anything you want to add for this part. Don't forget to look at the other hip quickly. Yeah, yeah, Yeah. Very correct. Exactly yeah, I personally, I went for my inspection. I look stuff from the shoulders.
I make sure the shoulders level, I think antero-supero-lateral spines for the pelvis level. And also, as you mentioned, but I just held me like, if the shoulder is not level, I'll be thinking there's something going on with the spine as well. Good point. I agree with everything you have said, but I just want to reinforce the word attitude because so many times when I'm practicing this guy's clinical examination, they watch the patient standing in a particular position and then they say the patient has a fixed flexion.
Thank you, Sean. Thank you for that. That works. That's wrong. Must be the word attitude. Thank you for that, your honor. Good, you pick it up, please. No one at inspiratory level would say the word fixed and the word deformity.
It's just an attitude. Let's stick to that. Thank you, Sean, for that. Good now we'll go on someone else you want. You've done a you've done your gait. You've described it. And now you're going to do the treadmill test. Is that right? Yes, sir.
Fantastic so, Joe, before that, everyone I want you to. I want you to say, I want you to. First of all, be very clear with your instructions. So if you are in a place where the room is very cluttered, please, it's your responsibility. We want to make sure you take charge and we give you marks for being a consultant, so therefore clear the room. All right.
So the patient is not going to jump over chairs, so clear the room. And then the best is to tell the patient clearly walk away from you and then give him instructions. Please turn around and walk towards me. That's the best way. And when you're doing that, the only thing Joe is the minute the patient started walking, you started giving an opinion.
Is that correct, joe? Yes so why do it straight away? The patient walk there he was walking into the wall and you were speaking to me saying here until you get now, that's probably not taking control. The patient may walk out of the examination and hence if you want to see front, back and side see him walk in that manner and just look after him. So tell him, yes, walk towards the walk.
Thank you very much, miss Smith. Turn round. Please walk towards me and then go to the side. So I'll do it like this. The camera. So imagine and you see me here. Yeah Yeah so Mrs. smith, do you mind if you turn around and just walk and walk towards that wall? Thank you very much.
Now, John, come and walk towards me. Yeah, thank you very much and see what I'm doing. I just went to the site. That's right. Thank you very much. Please have a seat. Yeah now and then immediately look at the examiner and say this patient. And does it get right or this patient got up shortly?
Or this patient got up Burkett right? Yes so before we go into the dental test very quickly, there's always a controversy with the policy as to in the clinical examination. My advice to all of you is please don't talk about he's walking with a good foot progression. I'll tell his step off, his good. His stuff is good, please. This clinical examination is only to demonstrate whether you can pick up a clinical gait pattern if they ask you later on what it is.
Please do so. But I'm telling you very clearly after examining hundreds of people in my course, as well as when they are preparing for the exam, is doing everything together. You're talking a lot of nonsense and not saying what you're saying. So let's all agree that we just identify the gait pattern and they'll test you on these other things on Survivor.
So let's start with each one with you, Joe. What is a common? What does that tell you get? If I ask you, tell me about it, you? What does that tell you? It is a shortened stance, a stance phase of the affected. Right so the patient has a short time. That's correct. And can you tell me another?
The next common gait will do it. Gait? Yes. Thank you very much. Can you please tell me what do you understand by a trained gait is that the patient is trying to compensate for week for week abductors by swinging the center of rotation, a center of gravity over the affected limb?
And so what exactly happens in the clinical scenario? You said it is doing the burglars, which is yeah, so Joe, and for everyone the way I would say, this is a common question it could be asking in Survivor and if the mentors don't mind, I can just talk about it here, but it's very commonly can be asked in the clinical is, you can see in incredible gait. You can start by saying the basic principles of the trainable gait and the test is as follows.
You can say in when a patient stands on its normal hip and start with that job, the best advice I'll give when you try to explain something, say what happens normally. So when a patient stands on a normal hip, the pelvis of the other side raises and that is normal. You agree, joe? Yeah, Yeah. So you going to make that statement?
So when the patient stands in the normal hip, the pelvis of the opposite side raises and this is normal, then say if a patient has a trend in a positive trainable gait or a test when the patient stands on is affected or is bad hip, the pelvis of the other side dips. And this is the principle of the trainable gait. So clear how simple it is. Happy with that job? Yeah, Yeah.
So that's your second. What is the third common is gait in orthopedics. Just one question, sir. Is there is the dipping of the pelvis, happens during the gait or happens during the test. Don't worry about it now, because the reason is that both the principle is what we are talking about right then as to what happens when your center of gravity goes.
You know, it's a matter for discussion. But what I'm trying to say is, no, you're saying anything else when the basic principle is what you're picking up, is this. In other words, it's very clear when a patient is walking in a strindberg gait pattern, the opposite pelvis dips down. Yeah, that's what is again. So the third is a high slippage gait.
For that, let's stick to bilateral training, which is called a waddling gait. You agree? Yeah so that's the third. Fourth would be short limbed shortly. So what happens in the short limb? Uh, I happen in the short term, that the patient actually attacks have an exaggerated knee flexion of the unaffected side were on this stance in the sense.
Yeah, it's one and more. But from the pelvis point of view, it can happen. The pelvis of that side dips down because that's the only way you can get his foot planted, right? Right? Yeah. So that's all for the short term. You sure you don't just call it a short rib because the pelvis of that affected side will be lower, because that's the only way you can get this foot planted, right?
Yeah, that's one. Yeah next, we'll go onto in orthopedics. There will be can talk about the high stepping gait, which is a foot drop. Now there are three gates and cerebral palsy, and it'll be three gates and cerebral palsy, which you know, scissoring get you to overacting at doctors, at the hip. So everyone, this is why I'm covering this is because you're going to get children with cerebral palsy.
They'll throw you. But if you have the system of talking, it's very clear. So yeah, that's one. Number two, Aquinas Aquinas due to Aquinas is where it happens. At the ankle, at the ankle. Yeah, tiptoeing gait and doing it and doing it due to construction of the gastric penis or the Achilles and crouch gait. If the Achilles lengthening happened before hamstring release or the flexion, which is flexion of the knee and flexion flexion of the hip and the patient, actually try to increase the energy expenditure by time.
And the third one will be. A windswept yet windswept, windswept, windswept, typekit, yeah, so that's the third one, and in neurological gates just to complete. I want you to keep in mind Parkinson's gait will be shuffling. Yes, happy with that. Yes then will be a taxable AI based a tax, which is a wide based get right?
Basically Yeah. And sort of like allopathy. What said you have to attack six or posterior column involvements, really wide based and circumspection, which will be in hemiplegia. So we've covered 9 or 10 gates and this will cover most of your work. Yeah, yeah, I'll agree with that. You?
Yes. Yes OK. The others, is anyone anything else you'd like to add, forget or you've covered it? From my point of it? But do you agree it might just ask dementors. You agree. My feeling is, and I know you all have done a lot of examination examined candidates that my feeling is when candidates are always taught in courses to yes, please describe the gate, talk with the foot.
My feeling is no one has the skills or you're so stressed you can't talk all these phrases and assess the patient and talk sense. So that's what I'm telling you not to do. You agree with that? I agree. It's very easy to make an error and then an exam that can seize upon that and start asking you questions if take you and take you away from what you're there to do, which is examine the hip.
Exactly, exactly. Thank you for that. That's what I'm telling everyone. So don't get that perfect. It's a waste of time. It's not a clinical examination front desk question. Talk about the rockers, I think is not necessary to put yourself to talk about the rockers and the rockers.
Just make it simple. Yeah, happy with that, as you know, but for you and for the other to be a little careful of this because my tip to you is that you'll be so tense after doing the walking because, you know, walking, you going to get the room ready and things that you may forget to return, but your mind may forget you, and you may make the patient go straight to the couch. So my tip to you and my tip to others is not a scientific trip.
It's just a practical tip. So you don't forget is front backside inspection. Hold my hands. Do general book. Thank you very much. Please walk the walk back. Please lie down on the couch. So this is my statement, so you'll never forget. But please don't change your pattern.
But I'm just Warning you that you may forget general book because patients walking all over the place. If anyone noticed just there, Mr Michael ausiello at the end of his gait, he told the patient to sit on the couch and every one of you, I can guarantee you thought, well, he's Mr and Trendelenburg. That's because he always stays consistent.
He always does the term first, then the gait. And it's important to develop your consistency, so it becomes instinct later on. So the instinct for me was that my statements are the same in my clinic, in real life. Every case, I do the same thing. So you just as long as your phrase is coming out of your mind, is all the same, right? So let's imagine you're doing it any time.
And now how do you want to do it? So this is the patient. Imagine you're doing the treadmill, but I know it's very difficult, but let's do it together. So imagine I'm. You tell me whatever you want me to do, I'll do for you. Good have a seat. So for everyone, the very good. I think you handle it perfectly.
Your phrase was good, but a few points. Yeah the first point is when you finish it, I want you to tell him, thank you very much. Put your hands down. Please have a seat on the couch. Immediately turn to the examiner and say the treadmill test was positive or negative. All right. But don't talk and please don't all to when he's holding your hands, he's worried he's falling over and you're talking about, yes, the shoulders are coming over.
My left hand is going over. Don't say all that. We all know what you're doing. The most important person is who the examiner or the patient tell Mason is the patient, right? So forget the examiner. Finish that put it down and say tenotomy just positive or negative. So let's do it like this.
The other point to give you. So the first thing is, don't get into arguments with your colleagues about whether you should go down and hold the pelvis and go, there are many ways of doing it. My advice to both patients is do this, which is the appellee's modification. We don't just say, but that's the best way of doing it, going down like this.
I'm not criticizing it, but I'm telling you it's sometimes difficult to do in all the people. It's difficult to verbalize to a patient. So this is the way I do it. So the first stage is always, like you said, stand in front of me. Please hold my hand and put your hands as I do now. One of the things I do as a note is don't say left or right. You agree.
OK slap lesion, Mr smith, which is your bad hip? That, Yeah. So ask him that first, that's your question, which is your body? Yeah, yes, your left one, then say, Mr smith, I want you to stand on the good side. Happy to say that is another. Yes so I want you to stand on the good side and do as I do. Yeah very clear instructions, happy with that.
Yes, that's right. Thank you very much. Now I know it's difficult, but I want you to stand on the bad side and do as I do. Oh yes, you're certainly bending over. Thank you very much. Please have a seat on the couch. The test was positive. Yeah, isn't it?
No, I would agree, it's very important to not worry about left and right because the patient is going to be nervous. You'll be nervous. So just as you said, worst about it, what's your good hip? Copy me. Yeah, exactly. Simple words. And this is what gives us. We know that a patient can be difficult.
We know he's going to fall over. Yeah and please don't get into arguments about should I do it for 1 minute or 30 seconds or 70 seconds? Do it for a reasonable length of time, which you feel appropriate, which you would do in a clinic and where you'll get your judgment. Imagine you're not getting it. You can always say, is it all right? Can we do a little longer?
It's important for me. You know, you're telling the examiner indirectly telling you're telling the patient, but indirectly telling the examiner that you're doing it as long as you get. Yeah there is AI don't know what the governments feel about this. I tend to ask the patient to lift their bad leg off the ground.
Mm-hmm Exactly the same way as you have. But I, I, I, I do the same thing as in. I show them what I want them to do. So that their bad leg is off the ground. But I don't actually. I keep my two legs planted when they lift their good leg off the ground because especially in the heavier elderly person, you may not be stable enough to hold on one leg, let them counter your weight if they've got to.
It's just the modification I've always done because I'm worried that the patient drops in front of me in the exam. Thank you. Oh, good point. And another point sticking to what she wants is said everyone. That's the reason why I feel bending forward, bending on going on your knees, holding the patient by the pelvis, then looking up at him.
Then you tell him, lift your leg and he kicks you in the face. You know these things happen and you're going backwards. He's falling over. That's the reason I don't do it in a traditional manner and we will recommend. Is it all right for the metal to say if you have time to practice, you recommend this or is too much to say that? Sorry, repeat that again.
You know, there are many ways of doing the training, but there's some people bend down on their knees, all the pelvis and then tell the patient, you know, I think I think is dangerous is time wasting, but also it's very awkward looking. Have you ever seen someone doing this, especially on a hip? Exactly it feels awkward. It looks awkward that you've now got scuffed your trousers and it just doesn't look right.
And you you look as if you're not in control. So therefore, can we recommend shrine that we do it this way and not the other way, just as a general recommendation? Yeah Yes. Question that came up. Most of us asked sound side first. Is that necessary? Or is it a waste of time in the real examination?
What do you mean? Sound side first for what? For the general book lifting? Lifting the bad leg up first is no. I would say we have to do it because it's very important for two reasons. One is a patient knows what you're doing and the patient's confident to stand on his good left, good leg or lift the bad one.
It doesn't matter phrase which you're using is lift a bad one or stand a good one. But I think it's vital to do because otherwise, the confusion I see happening in this test is enormous. You know, the patient doesn't know what he's doing or whatever it is. This is setting the stone for at least getting the confidence of you, your patient and ultimately paying the examiner that I'm getting confident of what I'm doing.
So I think it's vital we do the good side first because you demonstrate they can do it on the good side. Yes show what it looks like compared to the bad side. Excellent and they could also have offered an average of on that side as well. Yeah, I yeah, that happened to me before a previous hip replacement, which you need to demonstrate. Their abductors are working out what I do and when I do my core site, everyone, I mean, all five, six people can just do the same thing and I can demonstrate it can actually do it in a minute and a half.
If the words come out correctly, it's a minute and a half. Yeah, but if it's not, it'll take you five minutes. I'm telling you clarify minutes I have from the moment they stand up. Not, it turns out, of course. Yeah all right. I think the best way to keep practicing the test and you develop your own technique. Considering what we talked about and just in the exam, we have to look professional.
You know what you're doing and you talk in a clear way to the examiner, gives clear instructions to the patient the best way just to practice it. Every opportunity in the clinic, even if you examine need, try to do it. This make you happy that you're confident. Absolutely this is to generate some controversy this time. No test, no comment. Sorry Mustafa commentated that he's been at a previous course that.
Force will not be mentioned, but he's been told that to do it with kneeling down with the patient's resting their arm. I'll give you an example of why it's not a good idea. One of my colleagues sees a very slight lady. She's a very good surgeon. She did it that way. And she had a very big patient. So it just it doesn't look right.
And it's and not as we've said, you're not in control. So I would say as well as well, if you have to put one foot down, you may have a really arthritic, elderly patient who could be any size and you don't want them toppling over you. And I think your standing, you can't touch them from the pelvis. That's the problem. My feeling is that, look, you know, I think what I'm trying to get at and all of us are trying to tell you is this passing of this exam is to demonstrate to your consultant colleagues that your consent level the way you're talking.
And if you do it in the manner which I've done it, or which one or any of my mentors will do it and you're doing it in a slick manner with complete control of the situation, I cannot accept that doing it in this way is wrong and that whoever said in the course is right. Yeah, so you need to do it quickly and pass. That's where you are. Yeah this is one of the minutiae detail as long as you're comfortable and you're controlled and you're in a slick way of doing it.
The exam is going to be happy if you're looking uncomfortable, like you've never done it before. They'll know. Yeah, and if you do it kneeling down and you're happy and slick with it, fantastic. You know what I'm saying? That's perfect to do. So I won't change anyone who does it in that manner, provided once again you're talking well and talking strictly.
So that's actually have you noticed, Chetan said classically is described from the back, so even the other courses said it's wrong has got it wrong as well. So I've not. If you could do it from the back, I'll be very impressed. Yeah, I don't think anyone would recommend it from the back because you can't see the patient. Yeah, yeah, Yeah.
Yeah so all this is about you being in control, but yeah, there's no point in describing it.
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