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Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (3)
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Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (3)
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Segment:0 .
Good morning, everyone.
And welcome to this discussion, calls for a force exams. And some of you have attended our courses before as participants or observers, but for those who are new, we will cover all exam stations today, Viva and clinical stations one hour per station. It will be an intensive day with aim to end around to finish today at 5 o'clock and there will be a lunch break.
And just after one. There's a faculty we have top faculty today are very experienced in providing exam specific. Education for the FARC is and they've been taking part in these courses for very long time, they're very experienced. I encourage you guys to make the best out of their experience today.
So we'll have today. We have today as six participants and each participant will be examined on each station. And you'd be given feedback. And please listen carefully to the feedback you are given.
We won't share the slides, the slides, unfortunately, so if you want to take notes or take screenshots, please do. And I want to emphasize that today we are not aiming to teach you everything about orthopedics, but to focus your revision and you focus your technique on how to improve your scores and how to score higher. What are the buzzwords to use? What are the phrases to use?
The key notes, the key phrases, the key principles that you need to discuss in your answers? Yeah we will encourage interaction, we encourage you to ask us questions, but we will have to keep it FRC specific. So if there is any question that goes above and beyond the curriculum or then we will, we will have to skip that. Yeah, but otherwise everything that FRC is relevant, we will answer for you.
I would ask you guys, please respect the faculty today and respect each other and make sure you allow time for each one to take their own time and speak and get their feedback. As I said, please write down the questions, write down the feedback you're given.
So mainly, we are here today, as I say, to help you improve your score in the exam. OK, so improve your technique, how you answer the questions, what are the key topics? So today we will be discussing in our stations and our seven stations. We are discussing all the. We were discussing about 40 to high yield exam specific questions is guaranteed that one of you will get some of these questions.
Definitely in your exams. So, you know, the concepts will always be the same and will help you to answer this the best of your abilities. So for I'm going assume today that no one is going for that exams tomorrow. If anyone is going for the exam tomorrow, let us know, but I don't think any of you is. If any of you is going, for example, tomorrow, let us know.
Well, I don't think any of you is. And so please, guys, come back and join us in our future events and future courses. We run webinars as well. So our other successful course has been the basic sciences course, we have next one on the 19th of march, we run one last week. And it went very well.
We had very positive feedback from that one. It was very popular. So the basic sense, of course, we cover also is the same like today, but the whole day just dedicated to basic sciences covering all aspects of it. So look, guys, we are here to help you and support you to any issues at all. Any questions, anything not clear.
We don't leave today until it's all clear yet. We can have a chat in the breaks, we can have a chat and lunchtime or IL after the course or during the course, so please don't leave today until you are happy that all your questions have been answered and everything is clear. But we'll have to stick to the FARC case if our case level discussions. Yeah, no.
Where the wonderful stuff. Great, so without further ado, I'll hand over now to David. David is one of the founders of the Academy. He's very keen educator and he's we're very privileged to have him with us today. He's going to start kick off this course with the basic sciences section and we will go through. Guys, we've named you pay participant 1 to participant five while we are waiting for participant six to join.
So, OK, David, if you're happy to start, so the first participant is Thomas, who's the keenest of you all? He's the first one to join today, so. All right. Morning, Thomas, I think you're around last a couple of weeks back with the basic science, weren't you?
Uh, I did one of the webinars here. OK, so. First question, can you tell me what's happening this X ray? Yeah, this is actually really a longitudinal deficiency of the four on the radial deviation of the hand. So this is a failure of formation as classified by Swanson.
The limber developed in the fourth to six week of life and its regulation is regulated by a few different zones. So really, you own differentiation is regulated by the zone of polarizing activity, which is on the ulnar nerve side of the bed and expression of the sonic hedgehog protein regulates ulnar nerve to radial growth, so this is a deficiency and not properly.
OK, so what? So you've talked about those seven steps. So can you tell me a bit about the formation of joints? And so joints are formed by apoptosis of segments within the limb. I don't know much more about it or not.
OK, so sometimes you can get things where the fingers might not separate, what happened when you have finger separation? What causes that? So seductively it's caused by so it normally there's controlled apoptosis between the digits. So this is a failure of that apoptosis. OK and the only thing about limp happening. Lynn part.
Uh, I'm not sure what the meaning of sorry. So when we talk about embryology, there's a spatial diagram that we can produce. Can you describe it to me? You mean the limbic development or yes, so limber development. The limbic development is between 4 to six weeks. There's an atypical epidermal ridge, which regulates longitudinal growth fibroblastic growth factor.
Then there's this zone of polarizing activity on the ulnar nerve side, which does ulnar nerve to read your growth. The sonic hedgehog and then dorsal ventral growth is controlled by the w.a. pathway. OK well, I think it will be about exhausted, you there haven't been told us. It's a difficult one to start with, isn't it?
So should we go through this sort of go through that, ok? Yes so if in the exam you have this, you should try and hopefully produce something along these lines. So the key thing is they're talking about you're quite right butts development and you got that very quickly. So what still gone wrong in utero? So we had a radio club hand there.
We're talking about some of the bugs. So we've got that progress zone, apical epidermal ridge, the ventral, dorsal. And obviously you have to be able to work out in terms of what's a what's posterior, what's proximal and distal ulnar claw can never say devastate myself, the zone of polarization mesenchymal. So making a thumb, making a pinky, so you're quite right, he said.
He got your radial and your ulnar side and the Sonic the Hedgehog. So key things live in terms of the genetic code, right? So yeah, you're quite right. It starts around 4 to six weeks. It's controlled by FGF, which is sort of my head. Fibroblast growth factor peel-back is obviously not a court suppress expressed in sonic hedgehog and that regulates the formation of the liver and grows outwards in terms of the ectodermal apical ridge.
It's roughly 26 days after fertilization, hence the 4 to six weeks. Now, I mean, in terms of impact, we talk about proximal distal on the apical that the devil ridge and a posterior in terms of the zone of polarizing activity and dorsal ventral non-equity, not a limb ectoderm. So that's what we're sort of talking about, and you're quite right with finger separation just to raise their evidence and have a hand paddle around 41 days.
And there's programmed cell death and that's regulated by the Hox gene. OK, so those are sort of embryology is really difficult, to be honest. No one's going to be, you know, it's going to be a world expert on it. So it's going to be someone who is sort of a consultant who remembers doing it when they were studying for their exam, and so they will have the marches in front of them.
So these are sort of the key things that they want you to be saying. But as I say, to be honest, if you can get this drawing out and talk about it as you're drawing, you're going to be doing really well and you're going to pass that station properly. Ok? and then it's talking about in terms of getting a higher mark, we want you to describe why they want you to describe why you've had the radial club hand.
OK and so that's a failure on this side, on the right side is going off. And on the sort of radio side, as you quite rightly said, OK. And it's that sort of thing in terms of the key thing of any sort of basic science topic is in terms of clinical application. So if you can apply to the clinical situation, they're going to be happy.
They're going to be they're going to be positive towards you. OK any some questions to us? You asked about how joints are formed? Have a buddy Roma myself. So there we go. So the formation of joints requires the repression of control genesis, so you still have that.
Growing for them. But it's that repression in the middle allows the joint to form. See what I mean? OK, we're on to the next one. OK, here's number two. Yeah, I am. Hi Hello. Hi OK.
So we've got an 18 month year old child who's crying and not moving their right arm. Can you tell me what this shows? This is the clinical graph of immature person showing an elbow right elbow. According to that, there seems to be a postural. Medial sort of dislocation, but then again, this is an immature 18 month old, so it is a highly likelihood of physical injury to this patient.
And I'll be concerned about non-accidental injury in this, assuming that had been ruled out. I would approach this patient and do take the history. I would like to know what exactly happened and the history is not moving on for how long. The patient is not moving the arm if there are any associated injury with that, or if the deformity is there for a long time and I'll document the clinical examination, I would like to see a different deformity.
I will document the vascular status as well as see if the child is moving the fingers and hand and. And then I would say, OK, I'll give you a bit of history, so the child fell off a chair, a high chair and the parents seem to be, you know, telling you the right story and they're very worried.
And it happened about six hours before you see them. There's no other significant medical history and you're not worried about non-accidental injury in this particular case, but I appreciate that these injuries can be associated with not accidental injury. So he's neurovascular intact, and he's got a deformed elbow. So tell me what you're going to do next. So I would during the daytime, I would take a appropriately prepped this patient and take this patient to theaters in an appropriately marked and consented patient.
I would put him on anesthesia with extra control. I would see if I'm able to correct the deformity. I would like to use an omnipod injection on table to delineate union at the upper phases of this elbow. And most of the time, they tend to reduce by manipulation only, and we don't need to open up the joint, but I'll be guided by my intra articular program to see OK.
All right. So you reduce it and you check it with the arts program and it's reduced what you do afterwards. So if it's reduced. And I will, I will screen it and I will see if it is clicked back, I'll feel for that, but I would tend to put to care with small cars on the large aspect 1.2. It's an 18-month-old child.
And then confirm my position and then put him into an above L peel-back slap. OK Are you aware of any techniques when putting Cuellar across the growth plate? So, yeah, so from one side, Uh, the egawa should cross outside the, Uh, the skin. Uh, and they should be divergent. And what about the actual? So the nurse gives you a threaded choir from the radio set?
Which I would like to use the turkey with, yes, I would be happy with that. OK and which of the Jets traded at the end, isn't it? So yeah, but I'm going through the lateral aspect. I would. I will. I will not go through the cortex. I will just stay inside the cortex.
OK all right, good. How do you think you did? Um, I think I initially I wasn't sure where it's going to go, to be honest, and I'm not sure it's still not sure whether I gave the right answer or not. I think you did well, I think you did well. I would tend to use smooth, quiet go and cross growth plate.
And the other thing is, you want to do a single part, you don't want to be doing multiple passes, that's any other thing. All right. Let's have a look at the answers. So you are correct. When you initially said dislocation, I thought I was going to go down that route, are we? But then you came back and thought of this so well done.
It's getting harder and harder for me to trick people with this question. These days, everybody knows it. And the point is, as you said, it's a distal seal. Funeral separation. Young children. And it is one of those injuries that can be associated with non-accidental injury. But that's not where my question was going for this one.
So you were right to bring it up early and exclude it. That's why I gave you the information that, you know, we're not going to go down that route. Yep so fractures young children under three fall on the outstretched hand. You can't have it in rotational forces. All right. Evaluation suspect abuse, which you did.
Examination, which you did hepatocytes. You know, I don't think many of us would start moving people's elbows that looked like that to try and elicit trepidatious. I think it would be too painful. Neurovascular examination, usually normal X-rays. And you can use ultrasound, you can use MRI, but I don't think we need to, as you said, I would do what you did, which is take them to theater and use some opaque to identify the joint and make sure it's reduced.
The price could be asked for gammie, said Kay wise. If it's unstable. And you really, really need to do an open reduction and complications. Anything that injures the pediatric growth plates at the elbow can cause various activities. Various egawa test Vargas missing the diagnosis is the other thing, and you can have some growth disturbance, so I think that's it for that one.
Yeah, it is. Is there any questions about this one? Just a quick question is being closer to the building and the image of a wire is that either the three or two in lateral from lateral, medial or cross similar exactly like sobre La or has the one. And potentially you could do either, I mean, obviously, we're going to go medial, remember to say you do a mini open, identify the ulnar nerve and move it out of the way.
Most of these will be stable after just a closed reduction, but you can put in a couple of wires from the lateral side just to hold it. It's not. You haven't got the same kind of rotational instability that you have with the epicondyle of fracture, and the child tends to be a little bit younger. So provided you can get a reduction and check it with the other gram, then the chances are it's going to heal.
I mean, the kids are young, you know, so they're going to heal really quickly. So if you are going to use KYC in this, I would use one or two smooth wires, single pass, and it's literally only just to hold it in place. But once you've reduced it. And usually we utilize our program to confirm reduction, or it depends on how in theater you can use it to confirm your reduction or if you were unsure about whether this was an elbow dislocation or a physical separation.
You could do an art program in theater so you can use it kind of diagnostic to check that you've got your diagnosis right? And also to confirm that you've got a reduction. It simply, you know, if you have a lateral condyle fracture that you know, it's a big cartilage component to it and you're not sure you've got it reduced or not. You can do an through ground there and you can see the outline to make sure you've got your reduction.
OK all right. So would there be any question like how do you do our program for the elbow, something like that? And yes, yes, they could ask you that. I've not been asked that in England for Islam. I was asked in the Australian exams about how you mix up the omnipod, what percentage you use, what you mix it with, where you inject it.
I can't remember it off the top of my head now, but look it up because if they ask it in the Australian exam and the thing is, if you're going to do it in theatre, there's no reason why they can't ask you in the exam in this still the epimysium slap lesion, the anatomy would be distorted. So like normally, if you have to feel the unconscious triangle and then inject through there, it would be distorted, isn't it? So how do you kind of say injected?
Well, you've got fluorosis, you've got an A sleep patient and you've got fluoroscopy. OK, so you can see and obviously you don't get a syringe of 20 meals of omna page and bang it all in. You're going to screen elbow, see if you've got it reduced and then follow where your needle is going to go. Maybe inject a little bit and check where it's going. I think there is another safe way also to target the posterior or the olakunle fossa from the back, and it should be 50 saline, 50 iodine material or contrast.
Yeah, 50. Yeah, and then I think it's simply, you know, when you do an art program for Nadh and you can't even inject a little bit and then screen it to see if you're actually in the joint. And that would be reasonable to do, I think. Yeah can I come in? Thank you, KneeKG. Perfect explanation, guys for the exams.
Don't really worry about you're not going to ask you, how much are you going to inject in the elbow? Just, you know, they will tell, you know, how much are you going to inject to elbow the child? You just throw any number because, say, one male and I will see if it's adequate, if not required to give another male. Just as simple, keep it simple. You're not going.
You're not a pediatric surgeon who knows all about injecting joints with contrast stuff like that. And you just keep it simple, guys. They're not going to dig you into how much, how many males they're going to inject in, how much, how many males can be given a chance interval and/or what's the technique of using it? It's just not really an exam. You know, technique is just put in, you know, in the soft spot in the triangle and put the needle and could give some injection so they might more, you know, they want more interesting concepts to test you on.
So I wouldn't worry too much about that. And so there was one. And a question about the size of the wires and obviously for superconductors too millimeters. But according to bolster. Yeah I think a reasonable answer, but yeah, I don't think you need to go as big as 2 millimeters because it's not the same rotational instability.
So you can go with the 1.25. You know, it depends on the size of the child as well, but these are kind of like really young children. Yeah Yeah. Yeah I think. Yeah, I think that's. That's very reasonable, I think, yeah, so broken, the fractured kids are older.
Um, and the Allen wanted to clarification of how, you know, it's not show, it's not elbow dislocation, just go over that again if it's quickly or a sneaky. Well, the key is that you need to think of it because you can't see. The you can't see the cartilage, you're going to see this.
And so you have to think, OK in this age group with this X-ray appearance, is it truly a dislocation or is it this distal seal of separation? It's difficult. It's difficult, but you have to have a high index of suspicion. And if you are unsure, that's why you do the program and screen in theater because it does look like sorry.
It does look like an elbow dislocation. So that's why I put it in here so that you are aware of it. Nick, can you put the x-rays back up, please, that you had? Yeah Yeah. Yeah, that's fine, that's great, thank you. OK it does look like a dislocation, it does, but it can be a dislocation. But but.
And that's why. It's difficult if you've got to assume the worst, it's not going to be and, you know, and I'm not going to be the staycation. Let's let's be realistic about it. They're not going to ask you about elbow dislocation in a child in the exam. No, they're going to ask something like that.
That's what we are here for. To be realistic of what we expect in the exam, they're going to ask you about this physical separation, not about elbow dislocation, a child. There's nothing much to talk about it. Then they could get elbow dislocation. Adults may be terrible. There's more interesting stuff to talk about, but Yeah. Oh, yeah, I mean, it's difficult, yeah, and it dislocation the relationship between radius and allies, more distorted and stuff like this.
It might look different, but you know, sometimes it's difficult to be sure. I mean, you could argue, you could argue that the relationship between the radius and ulna. Is more or less normal, but you can't really tell, I mean, you know, if you look at that, you could say, OK, well, maybe because these are relatively in the right position because your distal humoral thesis has gone with the radius and ulna.
But I just think it's too hard to say that based on the X-rays alone, I know it's only theoretical isn't just theoretical. That's but you can never be sure you can never be 100% sure. Yeah, it will be fair in the exam to say, I want to rule out dislocation. Absolutely, absolutely. But but I can tell you that the discussion is not going that direction.
There's nothing much discussed there for a child. No and if you get this in X out in an exam, you will probably be going down the route of non-accidental injury. Yeah, I haven't gone down that route because I'm going down that route soon, but for this case, if you get this in an exam, it probably will go that way. That's a very good case, thank you very much, KneeKG.
Can I ask a question? Very good question. Yes, peace. Yeah go ahead. My understanding was that this age group like less than two years, you tend to have more so if at all, like a radial head dislocation rather than elbow dislocation. Is it common to have an elbow dislocation this age?
Guess my understanding of it would be either when I said, Oh no, because I'm not Rodriguez 18 months, it may be. What's the difference, bubba? What's the? It's a reasonable question, but what exactly trying to get from that question, so we can no one untouched? Well, my mind what's more common here?
Yeah, but my understanding was an elbow dislocation child is at least more than two to three years old. I've never seen an elbow or heard of an elbow dislocation, more like a radial head dislocation. Yeah, it must be correct. You must be correct. But I think in the exam, you have to mention that I would want to make that can be an elbow dislocation.
It's most likely to be a distal humerus. You won't go wrong with that. Yeah, I mean, I mean, if you told me this was a Radiohead dislocation, I wouldn't be happy. No, I know that that's the reason. I hope if you see the incongruence, it is both in radio capsular and L know you joined. Isn't it?
So if it was just a radial head dislocation, the other joint wouldn't be incongruent in a child welfare epiphytes is not visible. It's a broken little fracture. Looks like this. It's a good answer rather than. Yeah and the thing is, it's unlikely that you're going to get a radial head dislocation in the exam because there's nothing to talk about.
Yeah you know, this is something that they need you to know because it is one of those cases that could be a marker for child abuse. So they want to know that you are not going to miss this. So put radial head fracture in the back of your head and go with the distal human or physical separation and differential of elbow dislocation, and then you won't go wrong. OK OK.
Shall we move on? Brilliant, brilliant. Now to gollum, he's the third candidate. Hello hi, Ghulam, how are you? Yeah, I'm good. Thank you. Good luck. Good Oh, sorry.
No, no. It's OK. I understand this. But So, gulam. Yes, look at the picture. Yes what can you see? So this is a clinical photograph of the hind. They are good stretch and they're border. I think they are doing just for the one disease.
Althea, you think this is because once disease could be declared one disease, or could it be the lateral epicondylitis? Just so you think this is different or lateral epicondylitis the koran? OK, that's fine. So because this is what is the good doctor once Crohn's disease is a degeneration of the sheath of the first compartment of that after the All of the rest, which is the abduction pollicis longus and extensor pollicis.
Previous and this she should become thick and inflamed and then causes pain just about the residual side of the rest. And so how are you going to examine this patient? The examination is first submitted with a history, and then when examining there will be some tenderness about the original satellite and and also there will be some reporters sometimes and some religious will be there and also by putting the ulnar deviation of the wrist.
It will be painful. So a lot of this doesn't cause pain. So the ulnar nerve deviation doesn't cost, ok? No, to do anything else with ulnar nerve deviation. Yes I can put the thumb inside the palm. And then I will do the ulnar nerve.
Well, he got pain with that lot of pain with this manual. So generally speaking, if the patient is getting a radial sided, then what can be the causes? And the cost can be a multiple of the original, I mean, I need to take the history and examine and rule out there is any fracture of the styloid process of the radius or any scale forward microfracture or to present or osteoarthritis.
And also, there is a transition symptom is a syndrome is also on the radial side of these transactions in the transaction system. Is that the. That the extensive policies as crossing over the extensor capital registered in previous this is transection and Wattenberg syndrome, my sense is that superficial rate ulnar nerve is coming between these muscles, which they are crossing on the wrist like as extensive, extensive coverage and as long as injuries with extensive policies.
Previous and there are superficial regional scams inside, and it's painful. All right. So we'll go to decoherence disease, ok? You said it is entrapment. Gammopathy sclerosis tick come curtain on which is pressing the tendon, isn't it? Yes a little what tendons like there?
The attention as the first compartment tendons, which are the abductor pollicis as well, is the extensive policies. Previous one, which is where which is more Waller, but what tensions are on the radial side and are some and the extensive policies previous is more towards the middle, which is more Darcel than the radial.
But the abductor is more rigid. OK, so this is the first person compartment for how many compartments are the total? There are six. The second one is the extensive carburetor gels as in previous. And the third car compartment is the extensive pollicis longus. And the fourth one is the extensor digitorum and as extensive indices. And the fifth is the extensor carpi ulnar nerve is in.
The sixth one is the extensor digitorum. The fifth one is extensor digitorum medium and the second one is the external subscapularis. You're right. OK, that's fine. So you diagnose this as it is a decoherence disease, ok? Yes and you know, you're doing the right work for six months, but come at 1 and 1/2 years with repeated symptoms and you think that she is what she then you are taking for decompression patients consented and prepared.
How we're going to do decompression. And decompression is I will explain to the patient as Marty consented, as you said, and the patient will be supine and the arm porch and with the naked eye socket. And then my landmark is the skylight process of the radius and just about it and the more superficial tendon and swelling part.
I will make decision incision. I would do very clear a very careful dissection to avoid injury to the superficial branch of the nerve. And once I reach through the tendons, I will just release the capsule and make sure the tendons are not injured. Well, when you are doing this, you said that there is too much bleeding, profuse bleeding, pulsatile bleeding, what might be a problem?
It is after it's bleeding or the original radial artery is Wolof traject, and I should be careful to try not to injure and/or maybe some branches of the retail industry which is coming to towards the snuff box. So I will try to cut through that, which can be the complication of this procedure.
The complication of can be infection and can be bleeding, and it can be a recurrence of this one and can be complex regional pain syndrome. So you said you can record your release date. So why should it trigger, is there a reason why. The reason is that it's in spite of its release, the capsule can be regenerated again and the study this I knew well, shit can be regenerated again.
It can be formed. So they will make a sandwich. I think that Rick McCallum will be formed again, isn't it? Yes can it be any other reason? Yet? the other is a scar. Scar tissue can be there and also neuroma from the superficial radial nerve as the other. That's fine.
So I'll give you an answer, and then we'll talk about it, ok? OK also, the picture shows a Finkelstein's test to The city of egawa one sign what is all right? Yes so constant test you grasp the thumb and ulnar nerve David and you get excruciating pain. Yes one of modification or variant is called age of manual, in which you release the thumb and allow it to extend and pain goes away.
OK, so it's important that you grasp, so it is in this condition that is the entrapment of the first dorsal compartment tendons. Isn't it? Yes extensive policies and extensive, sorry, extensive policies and policies. Abductor policies lies Waller to the extent that policy spread is OK.
So what can be the causes of the radiologist being? OK it can be decoherence sinologists. OK other type of it can be intersection syndrome. Hoping it can be Wattenberg box syndrome, which is a changing of the public interest and extend subscapularis longest. It can be something, as you mentioned earlier, it can be trauma causing the delay or the scaphoid fracture.
There'll be arthritis in the wrist or in the CMC on some sort of arthritis can affect only rage. Yes, it can be neuroma, isn't it? The neuroma of radial, superficial plans of regional and sometimes axilo tendon losses. These are all the causes of rigid sided wrist pain. So technology, as we discussed, it's a physically entrapment, you know, putting this thickening of the retina column.
There are certain causes like it's not common woman with repeated trauma. And it is. It got quite coincidence with the post-partum just immediately after delivery. You can get it. Commonly, you answered the dorsal compartment compartments, right? Ok?
when you describe decompression. So basically you can take a simple take. I would consented market, and you can either take identical dorsal, dorsal, radial transpose or linear incision. OK and then you expose the extent of first dorsal compartment and release it. OK it can be done in the local anesthesia or general anesthesia.
One of the important thing is that sometimes the extensor pollicis rabies as a separate compartment, so there are two compartments in the one compartment and that is one part of clearance. Yes OK. Like in carpal tunnel syndrome, the proximal release is inadequate and it's common cause of recurrence. This is common cause of frequent in this case. So what can be the risks?
This can be injury to structures like radial artery, superficial dental of now, OK, which can in turn form neuroma. Look at the risk of infection. The risk of recurrence of symptoms. It's all right. Yes and as you said, regional pain syndrome. Through the feedback for you in terms of improvement is that I gather that, like me, English is not your first language.
So to think in your own language. And then translate into English can be a problem, and it's still difficult to learn. In turn, you can use the orthopedic language. OK this is the bitterest disease, which is a more entrapment retinopathy of first dorsal compartment.
OK, so use. Don't think and just mentioned the orthopedic language. OK, but otherwise your knowledge is good. And anything it should be systematic, you shouldn't use transaction and all these stock transactions into submission. Intersection, Yes. Intersection, yes, sir. So basically, that's one thing.
Certainly, you need to practice. I think your recently started preparing, isn't it, the practice to get the flow? It's not a big it is an easier thing to describe it in orthopedic terms rather than thinking and translating it. And that orthopedic dumps, which people go for buzzwords can only come with practice. Yeah all right.
Yeah, thank you very much. Yeah well, so let's find. OK, thank you. So we go to next question to Islam. You are in the clinic. And this lady. She's 48 years pregnant with the pain in her big toe, right? What can you see?
So this is a big grab of immature patients showing not doing joint space in bilaterally in both a metatarsal first metatarsal pharyngeal joint, what's your diagnosis? It is a rigid bilaterally severe on the right side compared to the left. So she's symptomatic on the right side. Left side is not giving her any problem.
What are you going to do? So I will assist the patient. First of all, I will ask what is a probation? What is? And profile, what where is the pain? What make us makes it better? What makes it worse in the treatment underwent with it? To what extent has improved the pain with a underwent steroid injection or not, or any previous surgery?
Then I will assess patient clinically. I will assess the range of motion. I will check passive range of motion to what extent patients can achieve those flexion and flexion of metatarsal pharyngeal joint. And then I will take it further passively. So I will ask patient active range of motion, then I will take it passively to check where what the range of motion without a pain in the mid-range or in the terminal if it is in terminal that guide the treatment options to list lesser invasive compared to midfoot range or midfoot pain.
Midfoot range of pain mid-range of motion, pain. Sorry, then I will assess the other joints, internal energy and joint, as well as various types of metatarsal metatarsal John I would look for. I will assist and conclude my examination by neurovascular status, as well as any history of diabetes, smoking or any vascular problem. So when you say you did not make patient walk, but when you made her walk, just trying to avoid the push off, she was just trying to walk on a hill.
Yes, to the active hill with. Difficult when you told it was painful when you made a foot alignment was quite OK. You should localize tenderness in the joint range of motion was restricted and the was meat being. She had a painless IP joint, OK, Ross Perot status of. Nor the problem ankles of Taylor and tarsometatarsal joints supple and painless.
So you think this is at once arthritis? Yes what are you going to do? What treatment you're going to do? So I will offer the patient first, all conservative options, including activity modification. Rest, analgesia, physiotherapy or orthotics, including any metatarsal or forces. So what did the authorities use for this one?
I think it might be offloading blunter authors Martin Stowe. What's that Morton's do? Yeah and then, Uh, if a patient has exhausted all of the conservative treatment, probably I would offer patient also in the conservative steroid injection. If exhausted all of the measures, I will offer the patient first infusion.
However um, if it's low, this is that I want a mobile joint, I don't want your I will do so. That's why if it's so it's a bit controversial if it's mid-range pain. However, I can't do colectomy as a less invasive procedure and that her cousin had a joint replacement. Can you do one for? So the literature showed that it is a lot less outcomes compared to the artery disease.
It has sinusitis. So you are. Take the patient. It's consented, marked and prepared. Tell me your r tenodesis. I will do a dorsal incision over the first ray. I will. And a question to be taken to a sensor helps us longest and then take it laterally, and then I will go straight to the inside of the capsule.
The colectomy exercise all of the osteoarthritis in the medial aspect of the medial imminence. Then I will few. I will. And the exercise, all of that eroded articular surface, and then I will feel the. Do you want to do rimming or no? Yes, I would go there is a concentric reaming coupling in a concentric manner which is given to renew to a bit of open joints and it.
Flex the joints. Yes you find it very difficult to flex the joint, what are you going to do? Well, I will release that, so I will release the middle capsule as well as I can release the capsule, but you cannot flex it at all. This is difficult. Totally difficult. What else you want to release at Dr. Harris's tendon? Oh no, no.
The Stewart capsule, I'm not sure. I don't know. OK, so you really are inside the dorsal capsule and not flex to release? Isn't it? Release what collateral ligaments? Yeah, OK, you did women and what position won't you freeze. And what implants you're going to use? I will use a plate because there is a few fusion plates designed for this one, and I will put the position of the.
Grade 2 in 10 degrees of subtraction with 5 to 10 degree Vargas, then I will indicate the median capsule over. You don't need to. You're not going to take an dorsally approach. I know the gold medal, but it's the plane is not there. Sometime all right. So what can be complications of this procedure, so complication stock by nonunion?
One of the problems extensor tendon rupture and neuromuscular problems and damage. Which is that. So that branch of the student deep ulnar nerve, as well as. Like that, that terminal branch of slap ulnar nerve, probably, but. Dorsal branch of dorsal mediano.
Tarsal brand. Yeah so let's go to peel-back Islam. You're quite all right. You'll learn quite a lot, and I think you'll be a little bit of I think rather than practice, I would suggest you need to do some courses here that you know, that will help you. No, but you got a very good knowledge they see, just like listening.
OK so this is basically to are property of empty joint. So basically, arthritis can be joint, can be idiopathic or it can be trauma, multiple trauma, rheumatoid arthritis or varying pointed foods, high heeled shoes, et cetera so most important thing is to say asking how did problems start? What? how does it affect brain function in this case, wearing shoes?
OK and what has been done? What are the risk factors? And you should make patient walk, please. And in this case, he'll raises important. OK, then you see very little class and then assess that joint for end of range pin or midgar me pain and assess the VIP joint also, I'd be joined also. And when you say you go to Canada, great, but it's mild, moderate or at once, OK, and a procedure you don't properly about Jill colectomy versus this is quite all right.
No so basically, you told approach denoting type of succession, but when you are told you about the part and how. In the reflex, you didn't know you have to release four letters type of succession, most people would put a screw and played. They saw it in their front of truth and a locking plate blocking law provide plate. All right.
So you're quite all right, you're done. Well OK. Hi. All right. So this is your case. 89-year-old baby, she complains of pain in the right hip and groin for one day denies any history of trauma. She has significant medical problems, as you can see, so she has decompensated heart failure.
The stenosis if your population. Hypertension MRI is not mobile to the peripheral vascular disease Tia. This operation was done back in November. 1991 So describe what you see and proceed, how you're going to manage this exhibition of pelvis showing both hips on the right hip, that is a total hip replacement, which on the X-ray is dislocated.
That is evidence of. Change in orientation of the established component with potential. Lighting areas around the established cup with superior and inferior license of the established world on the hip, it is a long stem prosthesis, probably modular with probably 22mm head.
There is evidence of lysis in the proximal femur. It is an inadequate X-ray because the whole length of the femur and the tip of the stem is not seen. So I will. On on the lateral view, the orientation of cup is. Tilted the. Stem, as well as the distal femur, is intact and.
OK, so this picture that you see is the post of X-ray from 1991. Yeah so there is evidence of. That the sorry, the current X-ray from. This is the current X-ray. Yeah, this is the X-ray in 1991. Whoever did this procedure took the X-ray post-operatively. Yeah so. Anything you want to suggest, what do you think it is and.
So you mentioned something about lysis here. Yeah do you think that is lysis as well? Be license. Um, so it is an unlimited cup, so. I'm not sure whether it drill hole. I'm not sure. What about this stem? Is it cemented?
Stem is also cemented stem. OK because I can't see any semen mantle around the distal part of the stem. So I guess it is an unlimited stem. So looking at the lateral view here? Yeah, is the and you say that the US is in the correct position? So on the lateral view, there is a retroversion of the cup.
OK no worries, how are you going to proceed now? So she's coming out with this? Yes so I would need for I would. You take a proper history from the patient regarding how she progressed after her initial total hip replacement. Was she completely asymptomatic? Almost completely asymptomatic? Very happy with her procedure that was done in 1991.
I would also ask the primary indication why the hip replacement surgery was done and that was the neck of femur practice. OK, so if it has been completely asymptomatic and from the history, she has got significant past medical history and she has not been mobile. So I would ask her how, for how long she has not been mobile and what does she do for the last five years, she has been really struggling with her when she saw the cardiologist who said that we shouldn't be walking if she is not walking anymore.
So, so then I would ask her if she, if she is immobile, whether it is transferred to a wheelchair, if that was to escape from back to jail because of. Yeah so I will discuss the X-ray with her and talk to her about the dislocation and. Well, alignment of the cup, I would see if she is fully complimented, if she can understand the accomplishment that 10 out of 10.
Yes so I will discuss her with her regarding the further plan, which ideally, if the cup was oriented, I could have tried an EMU and reduced the hip, which I think in this particular scenario, it would not work because of the cup is dislocated, cup is rotated and it's also potentially loose. So I would tell her that the first thing I would want to do would be to rule out any prosthetic infection.
I will ask her specifically if she has been having any. How would she tell you that she hasn't got a prosthetic infection? So if she had been systemically unwell for the last few weeks or months, she has been because of her heart and chest problems. The hip was brilliant. She was very happy with the hip procedure. OK, so sometimes if there is evidence of any swelling or redness around the operative side as she is not mobilizing if there was any pain while hoisting out of the wheelchair, there was no pain at all.
It just became painful yesterday. Sorry so it became painful yesterday only before that she was happy with her. So, but again, I would tell her that the surgical procedure would depend on whether that the prosthesis is infected or not. So ideally, you would want to do some blood investigation to rule out mainly full blood count ERP ESR.
Labor investigations are all normal. OK, so the ones that you have mentioned have to be scrubbed. OK so I would tell her that the next step to proceed would be to consider a surgery, which would help her with her current status and current activity level. I would discuss the possibility of having a stable hip by doing a revision.
Hip surgery was an excision arthroplasty and giving her pain relief and. And take it from there. OK, so this is Saturday, you are the consultant on call, so you decided to take her dictator on Sunday for revision of tuberosity or tuberosity. I would. I would tell her that would be the basic principle of surgery, but I would discuss her local MDT, discuss with arthroplasty plastic surgeon to get their opinion on how we proceed from there.
And I would tell her that similar cases would be best managed by the plastic surgeon. So but I would tell her that the main principle would be to consider a revision surgery. If if, if, if she has had it, if she wanted a stable hip. For a transfer and for pain relief versus excision of tuberosity. Any other management options apart from surgery?
And would be to give traction to the limb for the pain. Investigate with the CT scan to look if there is any, any associated fracture and pain management. OK all right. So you can ask the anesthetist just to speed up things so that you can do this on Monday, and he needs to bas status that she is not fit for anesthesia.
Yes so I would tell her that I will tell her that we have discussed her with the anesthetic team and they would add as she is medically unstable, she would not be a fit candidate for surgery. So I will tell her that we would have to discuss her in a bigger MDT with the reconstruction as well as the hip surgeons to get for the management plan.
OK, I'm going to stop here. Just one quick question. Do you want to have a quick look again and think, what could this be? Is it a hip replacement? One, this one, this is the post of operation post of images from 1991. Sorry, I didn't get the question.
OK, no worries, that's fine. So how do you think you have dealt with this case? Um, I couldn't organize my thoughts. I was going back and forth and. Yeah, that is right. I think you need a lot of preparation on this particular aspect that you need because there will be cases which will be out of the box.
There might come a case which you never have seen in your life, for example. But what they are looking at the exam is the higher order thinking that are you a safe surgeon? And can you manage such a case that you haven't seen in your life in a safe manner? And that's the whole intention. So and you approach any case with all those steps that is very well thought and agreed upon.
So history, examination and then do the necessary investigations and then, if required, you get into the MDT involvement. I tried to give you some problems here. I agree. Looking at first glance, it does look like a PHR or total hip replacement is a common cause here. But this is the immediate post-op X-ray after the operation, and you don't normally see that in that version, isn't it?
On Glaxo's, it's a bipolar out of plastic. It's a very old system. We call it basement. It's an American one. But historically, as I said, it was done in 1991. The thing that really is that I need to mention and give you feedback on is not being able to identify. This is not a big problem, but the approach needs to be safe.
I think in your case, you went straight to a very major surgical options of revision of to blast the excision of the B and that you mentioned even before mentioning the MDT. You later on did mention about MBK. However, that was as you described the back and forth kind of conversation. And then when I mentioned the patient is not fit for a haircut, according to the anesthetist.
You still want to discuss with the higher end meeting for a major reconstruction operation. So I give you the promise that can it be managed non-operated, make these cases, the thought process here should be focused on patient oriented well-being or patient care. We're not trying to solve the problem what we see on the X-ray. Yes, that is part of the patient management.
However, it's not something that we see. It is broken and we just need to that out and forget about other aspects of the patient. So no, that's not the same approach. The safe approach is you look a holistic picture of the patient and then make a decision of management plan that is the most suitable for that particular patient. And that would give the best outcome. And that in this particular case is a non operative management because she's not according to the anaesthetist, she's not fit for anesthesia, the type anesthetize that she would die.
Yeah so you put this particular case for two reasons, one that England is very old, and the second is that to give you the inside of how we manage patients rather than managing just the X-rays. OK anything not clear to you or anything you want to ask or anybody. So would it mean that the patient would have pain management and yes, so she's getting hoisted?
She does have a pain because this got dislocated and had we had a time, we could have discussed further on the factors that would result in dislocation of a hemi of the blast or replacement, and that would have scored higher marks later on. But yes, because she is not fit for her because we didn't manage just the pain. Basically, there will be no punishment.
Wonderful case, wonderful case of it. Very good one. It's just here. That's the higher order thinking there would be looking at the exam. Yeah, this you won't find it in the books. Yeah, and the book tells you have failure help. You have need revision. Yeah but here we have a real life scenario.
Higher order thinking or consultants, they were looking at that. You have a holistic approach. Yeah and that you will consult mdc-t, consult anesthetist. Yeah and initially, and you listen to them. Yeah, well, there's no point consulting anesthetist and then still tell you he's not fit, but you still want to do operation. You see what I mean.
So safety, that will be a safety thing. Yeah, that will be safety. Unfortunately, if there is an anesthetist telling your patient not fit and you taking the patient to theater, no matter how well you do in that questions, then you will be deemed unsafe here. So look at those all hints. These are all tick boxes in these questions. Um, you know, mdc-t approach to these patients considering patient by patient scenarios, safety.
And you understand the complexity of matters. Yeah and. It's really just as simple as that, sometimes, yeah, you don't have to. I know sometimes when you're faced with such a difficult case, your mind gets blocked and that's what you are here for. So we can just help you to unlock your brain and let your inner and lock your method of, you know, analysis and thinking so that you can go through this in the exam.
Just go back to the principles. Yeah complex cases like this. Always, always MDT. Yeah, always comes first. Yeah, you don't need to jump into this at all. Yeah and that's how you differentiate, too, as a consultant that you sit back. And don't rush things. You don't need to rush a tool.
That's good, good one, good one. Well done. Importantly, that some candidates or some people think that not knowing each and every implant is a big problem because it's not at all. I mean, I didn't know when I saw this case that I expected it to be vacant, but I wasn't sure till I got the upload. So not knowing the implant is not a problem, and it is definitely not going to fail in the exam, but it's the higher order thinking and your safe approach that matters.
OK, not smoke. Now we we're putting our clinicals hat on. OK, guys. So now these clinicals now in the exam are mainly scenario based, simulated patient base. There are no real patients, at least until we know for this setting and next setting, at least. So we'll be all simulated and this is how we go over to you.
OK Yeah. So it's all us. So you go first one. So you're in clinic. You're doing your congratulations. You're newly appointed up Allen consultant. Your GP sent you this 47-year-old gentleman who is coming because he's got problems of his hands. But he's also saying to you, he's got pain in his back and he gets headaches a lot.
And you also get some pain in his chest around both sides of the chest wall. Tell me how you approach this gentleman. So, first of all, take a full history from him and ascertain a little bit more about his symptoms when they started, whether there was any inciting event in the history of trauma or anything like that, which or in those specific trauma as such. I mean, he does remember many years ago when he was a younger man he had he did hurt himself playing rugby, but he never went to hospital as such.
But it's been the last sort of six months he's noticed. He's been getting the feeling. He's getting clumsy with his hands. We don't know whether there's any specific position where he puts, you know, or any specific activities, which makes things worse or makes things worse. It does. As I say, he has noted this sort of clumsiness. He occasionally gets this all back pain, particularly in his upper between his shoulder blades.
He does feel a bit of back. He's been getting back pain recently, and he's always had some headaches for the last couple of years on and off. What they don't know about any history in the neck at all, any pain in the neck or no pain, specifically a neck, mainly just between his shoulder blades. OK I wouldn't know about any sort of color changes or cold intolerance in the hands at all.
Mm-hmm no such call. He does find he doesn't feel the cold as much as he used to. OK and I'd want to know if this is bilateral or one more on the other, it's all bilateral. It's brief hands. Ok? whether he has any problems in his lower limbs at all? No, it doesn't. No, you haven't noticed any problem in lower limbs.
It's bad. They seem pretty much spared. OK, I want to know if he has any medical problems, any sort of diagnoses of any sort of syndrome and conditions or any. No, he's not diabetic. I mean, he doesn't have any medical history. He works as a. He works as a builder, as I say in the past.
He did play rugby, but no, nothing specific sort of stands out. OK um, and whether he has any neurological symptoms in the many pins and needles, sensory changes, how you know, How's he going to be able to that to you? How would you ask him specifically and ask him whether he has pins and needles in his hand or whether they feel does get something needles in his hands? Also get some pins and needles going into his armpits.
OK maybe on one side or on the right side, let's say on his left side, ok? So, OK, I'd like to move on to examine him. So I want to start by examining his neck and his neck range of movement and seeing if this exacerbate any of the symptoms doesn't exacerbate such. I mean, when you look at it back, you notice that you notice that.
OK, so on the right side, his scapula seemed higher than the higher than the left. Mm-hmm so I want to confirm that this is whether this is a smaller scarpelli than the left or sort of higher or whether this is scapula. It could be a couple of wings. It's not clear from the full. What about his? What about his back?
I can also see scoliosis. Ok? would that be the reason why he has a slightly more prominent scapula? OK, Yeah. So it looks like a right sided sort of thoracic curve on this image. But now, so in terms of seeing this. So how might you look for a tone, let's say so to look for a tone, I would just ask him to relax his arms and sort of do a shaking, shaking hands and works to soothe the nation.
That proved the doing so if he's got a slightly increased tone in his up in his upper lip. Peel-back normal tone in his lower them. OK so I also want to examine the reflexes which as the Hoffman's reflex, and look for any individual Hoffman's reflex. But he noted, yes, quite brisk reflexes in his upper lip. So in his lower limb. OK, I want to examine to see if he's got any sensory level and I want to examine his Mayo terms.
Ok? he's got pretty good strength in his low lobes. But you do know there is a subtle weakness plus free 3 and 1/2 out of 5 and power in his arms compared with what you would expect compared to his lower ends. I also examine the vascular status of his arms, feeling the pulses and doing a good, good process. No, no problems with pulses.
OK, I'm also a dynamic test to look for any thoracic outlet type syndromes. No, no, no, no, no. No evidence of that. OK I'd also like to examine for long track signs Miller with limbs who are doing the wrong bergs test, examine his for any illness in the ankles, although it mainly for increased spasticity in his upper limbs, is long too exciting to be fine.
OK, fine, so just to summarize, this gentleman's got bilateral upper limb symptoms and back pain with a scoliosis and motor neuron picture. So I'd like to get, first of all, X-rays little differential. So my differential is probably seems to be a spinal cause. You may have some sort of spinal lesions like a syrinx or cervical and my allopathy?
Yeah it's one of those. Again, you got an X-ray that'll really show you very much. It's good enough to get an MRI scan of the whole spine, so as if by magic you get your MRI scan. OK, so this does show a cervical spine syrinx, evidenced by high signal within the cervical spine, extending from C four level to as distal as I can see what the theories.
It's a syrinx is a fluid filled lesion within the spinal cord. Look, and what might you expect to see in a serious in terms of features, clinical features in a patient, you mean? Yes Yeah. So it might cause an run to picture. Yeah well, like central court, isn't it? Yes the upper limit is dead.
Yeah OK. In terms of your management for this gentleman, what might you what sort of options do you think you're going to do? What might you do? Because obviously he's worried because he's only 47. Yeah, I don't discuss this with a spinal surgeon. Probably a new rules, new rules, surgical spinal surgeon. And yeah, there doesn't seem to be any extrinsic compression on the spinal cord looking at these MRI slices.
But I'd like to see the rest of the spine to see if there's any area of compression which can be dealt with surgically. From your understanding was the mainstay of management with these patients. Um, a conservative management. Yeah, it's mainly observation that other surgical interventions, what might you go down? What route might you go down?
Um, I'm not sure whether it's possible to decompress the syrinx, but. I that's something have no experience of. Presumably that would be a neurosurgeon if. So generally, yeah, so overall, tell us that was a good answer, you went for racist. I think sorry, I know you'd have a lot more time in the world thing. Apologies we're obviously doing this within a very constrained space of time.
But yeah, so with the history focus, do you have to keep figures of focused history or sort of a history to try and elicit your thing? So Yes. Do go for you. Want to know about your upper motor neuron lesions because he's talking about bilateral symptoms. So you're quite right. You have to have in the back of your mind, long track signs.
I was trying with sort of talking about upper and lower limb being spared. I was hoping to get you thinking about something more like a central star picture. But yeah, but from a differential, I was happy. You got that right. You're quite good. You want to get differentials. Admittedly, I would probably put a little bit lower down normally when you have a more standard question, for example, but that was overall that was good.
But yeah, so it can come up, I'm afraid, guys in the exam because there's something that is a winner within hours or we will get them in our clinics on occasions when we have people who have been referred to us with bilateral hand symptoms. We think it's coming from the neck and we get an MRI scan. And Lo and behold, that it is a May 8 or six. Yes so I did try and give you a clue as well at the beginning. I thought we were at up Olympic games, up the him.
Oh, right, OK. Yes, sir. So Spain's working on the upper limit and so central cord syndrome sprains anything. The growth will be happening because none of them may talk about this disease. Scoliosis this is a good one because, as I say, 18 percent, up to 80% of people with severe cases will have some form of sclerosis.
OK as I said, a few over the quarter will, but a lot of people say up to 80% OK, so but as I say, it's one of those ones where but I had a good set. You have a bit of higher order thinking, a good approach. So you've got that diagnosis. This is a tough one. So getting diagnosis is part of your approach. You're getting your marks for in the clinic in this situation. OK, thank you.
Good I have a question. Does it give the same similar symptoms of cervical cancer or doesn't give the way? So the key here is the lower limb is spread typically so and so central cord style syndrome. OK Yeah. Um, it depends whether it does depend on the position of the syrinx, but in this situation, it was, it was barely below that, OK, which is what I was hoping to get across, but they will keep me as well just double check with things, though it is a result from a lesion partially obstructed in CSF.
So that injury and is rugby maybe may have caused it. I don't know, but it was one of those ones where you can have one of the potential causes can be of that. OK how was spinal fusion improve it or as an option? Spinal fusion is a situation where, as I say, I would have to talk to the neurosurgeons about it. They tend to deal with this more than we do, but from my understanding, they would decompress the back.
So they're almost even though the lamina are fine, they almost take the back off the diffuser to give it stability. Because what's happening is as a fluid builds up, it presses on the nerves. You can try decompressing it, but you'll be more likely going to cause issues to the spinal cord. Aren't you sticking a needle into that to take the fluid off?
Thank you. Right OK, so next. Thank you. OK, so the next one is another hip. OK, so who's up next? Hi all right. So remember with the fast, yes, the key is in the question. All right, so here we've got a 21 year old, she's a dancer and she's got a hip pain, but she also complains of it popping and snapping.
So what's going through your mind? Then a young patient like that, it was more like a soft tissue liberal thought of a pathology. I'll be looking or thinking about. So I will take the history from this patient regarding the symptoms. When do they come up for how long she had this, any trauma associated with the initiation of these symptoms?
And if the symptoms are with daily activity or doing just with dancing or any impact exercises she tends to have, she had them for about three months and initially there were only when she was dancing. But now, when she tries to go for a run or she goes to the gym, she notices it and whether she point to towards the pain. So she points around the groin area.
OK and if you're taking painkillers for that? No, she's not. It's not affecting her activities. More to do with the popping sensation and often on. OK and if she having these symptoms of tapping or turning in bed as well or just one walking, no, she's only noticed it when she's doing something active. OK, so the just prior to three months, she was perfectly fine. No symptoms whatsoever.
No, she didn't notice anything before then. OK? and she'd been fit and well, healthy. Never had any trouble with her hips in the past and child. OK so I would examine her now and the examination. I would like to see her walk, see the gait. I presume it would be a normal gait because it's just the popping sensation she's complaining of. Then I would do the traditional book test to see if it's positive or not.
Then I would make her sit at the edge of the bed and I will ask her to lift the knee up to stress the alias of mother to see if there's any impingement of the ethos. OK, so that's very painful for her. All right, OK. That's painful, and I'll make a lie on the bed, and then I would gently have a look of any obvious discrepancy I would.
I've noticed that in the gait as well. But then I would, Uh, if I didn't ask which hip was it is bilateral, you just want for it. It's just one side, but it doesn't matter which side is in this case, then I would do the range of movements, see how much flexion she has got. OK, so when you do that, when you flex her up and a little bit of external rotation, you hear a snapping noise like this reflection and reduction of flexion and abduction.
So sort of a. And the abduction doesn't really bother her. It's more the external rotation. OK, fine. So and then I would just dip with her leg on the bed, I will roll her leg to see internal external rotation and full extension of her hip and her knee, if that causes any problem or not.
Not particularly, not when you passively do it like that now. OK all right. So what are you thinking? So this seems to be more like either an alias of impingement or liberal pathology. The liberal pathology would be my first differential there. And OK, and then I would after this hour and complete my examination with Mr neurovascular examination of the lower limb and examine screen the spine as well, then I would allow for investigation, radiologic investigation, the form of brain radiograph to see if there is any dysplasia or anything like that I can see in this young lady.
Any evidence of any dysplastic hips, which may be the cause of her later pathology. OK, so have you heard of a snapping hip? No OK. All right, well, we'll come on to that in a second, so it's either an external snapping hip or an internal snapping hip, or it can be intra articular pathology. So besides labor or pathology, is there another condition that could maybe give you that sensation inside the joint?
Not it's usually not in the hip. It's usually in the knee or the ankle, but you can get it any joint, any sign over your joint in the body. Snowmobile condo mitosis, ok? That's not what she has, but that's one of our differentials. All right, let's have a look.
So the two main types are the external snapping hip and the internal snapping hip. So the external is when the ITB slides over the gt, and it said that you can see that happening. So when you examine them, if you put your hand over the gti, it stops it sliding. The internal one is, as you correctly identified, is the idea. So it's tender, which slides around from my head over the Olympic, which.
It can't you can't have an actual status of the lesser traject or the boat bursa, which is causing that. And the other reason that you can have an internal slap in hip is if you've had a joint replacement, you've got some impingement there. So history and examination by activity, so any locking might indicate intra articular pathology like synovial Kondo mitosis.
And this is the thing. So an external snapping hip, you can see it and the internal snapping hip, you can hear it. That's why I said, when you flex, although you hear a snap. And this is so with the external. You can do obus test looking for tightness of the tensile forces yalata, the internal. Let me just move that out the way because you we can't see it.
There we go. So if you move from a flexed and externally rotated position to an internally rotated position, that's when they get the snapping sensation. So what else do we got to imaging? So the X-rays are usually normal. Unless you've got sine oval control mitosis, you can do an ultrasound scan.
It's dynamic. It's nothing band. And the advantage is if you've got good stenographers or radiologists, you might be able to do an injection into the trough and take the alias of a tendon or intra articular. And I think I think we sometimes do that. Then we've got someone that's close to post-op hip replacement and they're having eylea, so type impingement.
You can do an ultrasound guided injection to see if that relieves the symptoms. So an MRI scan might show intra articular pathology like a labeled tear or synovial Conroy mitosis, and it might show an inflamed bursa. The other one that I've put in for completeness is also is orthography less common. Basically, it's fluoroscopy and contrast, and then you can do a therapeutic injection.
Management usually it's painless and they don't need any treatment, it's just annoying. You can activate activity modification. And if it's acute under six months of painful internal external physiotherapy, if it's persistent and painful and interfering with the ADLs an operative, you can do a z plus of the ITB. You can release of tendon. If it's find some intra articular pathology, you can do a hip arthroscopy with removal of the loose bodies or labeled Brightman and repair.
So any questions about that one? No, thank you. All right. Good, very good.
Segment:0 .
Good morning, everyone.
And welcome to this discussion, calls for a force exams. And some of you have attended our courses before as participants or observers, but for those who are new, we will cover all exam stations today, Viva and clinical stations one hour per station. It will be an intensive day with aim to end around to finish today at 5 o'clock and there will be a lunch break.
And just after one. There's a faculty we have top faculty today are very experienced in providing exam specific. Education for the FARC is and they've been taking part in these courses for very long time, they're very experienced. I encourage you guys to make the best out of their experience today.
So we'll have today. We have today as six participants and each participant will be examined on each station. And you'd be given feedback. And please listen carefully to the feedback you are given.
We won't share the slides, the slides, unfortunately, so if you want to take notes or take screenshots, please do. And I want to emphasize that today we are not aiming to teach you everything about orthopedics, but to focus your revision and you focus your technique on how to improve your scores and how to score higher. What are the buzzwords to use? What are the phrases to use?
The key notes, the key phrases, the key principles that you need to discuss in your answers? Yeah we will encourage interaction, we encourage you to ask us questions, but we will have to keep it FRC specific. So if there is any question that goes above and beyond the curriculum or then we will, we will have to skip that. Yeah, but otherwise everything that FRC is relevant, we will answer for you.
I would ask you guys, please respect the faculty today and respect each other and make sure you allow time for each one to take their own time and speak and get their feedback. As I said, please write down the questions, write down the feedback you're given.
So mainly, we are here today, as I say, to help you improve your score in the exam. OK, so improve your technique, how you answer the questions, what are the key topics? So today we will be discussing in our stations and our seven stations. We are discussing all the. We were discussing about 40 to high yield exam specific questions is guaranteed that one of you will get some of these questions.
Definitely in your exams. So, you know, the concepts will always be the same and will help you to answer this the best of your abilities. So for I'm going assume today that no one is going for that exams tomorrow. If anyone is going for the exam tomorrow, let us know, but I don't think any of you is. If any of you is going, for example, tomorrow, let us know.
Well, I don't think any of you is. And so please, guys, come back and join us in our future events and future courses. We run webinars as well. So our other successful course has been the basic sciences course, we have next one on the 19th of march, we run one last week. And it went very well.
We had very positive feedback from that one. It was very popular. So the basic sense, of course, we cover also is the same like today, but the whole day just dedicated to basic sciences covering all aspects of it. So look, guys, we are here to help you and support you to any issues at all. Any questions, anything not clear.
We don't leave today until it's all clear yet. We can have a chat in the breaks, we can have a chat and lunchtime or IL after the course or during the course, so please don't leave today until you are happy that all your questions have been answered and everything is clear. But we'll have to stick to the FARC case if our case level discussions. Yeah, no.
Where the wonderful stuff. Great, so without further ado, I'll hand over now to David. David is one of the founders of the Academy. He's very keen educator and he's we're very privileged to have him with us today. He's going to start kick off this course with the basic sciences section and we will go through. Guys, we've named you pay participant 1 to participant five while we are waiting for participant six to join.
So, OK, David, if you're happy to start, so the first participant is Thomas, who's the keenest of you all? He's the first one to join today, so. All right. Morning, Thomas, I think you're around last a couple of weeks back with the basic science, weren't you?
Uh, I did one of the webinars here. OK, so. First question, can you tell me what's happening this X ray? Yeah, this is actually really a longitudinal deficiency of the four on the radial deviation of the hand. So this is a failure of formation as classified by Swanson.
The limber developed in the fourth to six week of life and its regulation is regulated by a few different zones. So really, you own differentiation is regulated by the zone of polarizing activity, which is on the ulnar nerve side of the bed and expression of the sonic hedgehog protein regulates ulnar nerve to radial growth, so this is a deficiency and not properly.
OK, so what? So you've talked about those seven steps. So can you tell me a bit about the formation of joints? And so joints are formed by apoptosis of segments within the limb. I don't know much more about it or not.
OK, so sometimes you can get things where the fingers might not separate, what happened when you have finger separation? What causes that? So seductively it's caused by so it normally there's controlled apoptosis between the digits. So this is a failure of that apoptosis. OK and the only thing about limp happening. Lynn part.
Uh, I'm not sure what the meaning of sorry. So when we talk about embryology, there's a spatial diagram that we can produce. Can you describe it to me? You mean the limbic development or yes, so limber development. The limbic development is between 4 to six weeks. There's an atypical epidermal ridge, which regulates longitudinal growth fibroblastic growth factor.
Then there's this zone of polarizing activity on the ulnar nerve side, which does ulnar nerve to read your growth. The sonic hedgehog and then dorsal ventral growth is controlled by the w.a. pathway. OK well, I think it will be about exhausted, you there haven't been told us. It's a difficult one to start with, isn't it?
So should we go through this sort of go through that, ok? Yes so if in the exam you have this, you should try and hopefully produce something along these lines. So the key thing is they're talking about you're quite right butts development and you got that very quickly. So what still gone wrong in utero? So we had a radio club hand there.
We're talking about some of the bugs. So we've got that progress zone, apical epidermal ridge, the ventral, dorsal. And obviously you have to be able to work out in terms of what's a what's posterior, what's proximal and distal ulnar claw can never say devastate myself, the zone of polarization mesenchymal. So making a thumb, making a pinky, so you're quite right, he said.
He got your radial and your ulnar side and the Sonic the Hedgehog. So key things live in terms of the genetic code, right? So yeah, you're quite right. It starts around 4 to six weeks. It's controlled by FGF, which is sort of my head. Fibroblast growth factor peel-back is obviously not a court suppress expressed in sonic hedgehog and that regulates the formation of the liver and grows outwards in terms of the ectodermal apical ridge.
It's roughly 26 days after fertilization, hence the 4 to six weeks. Now, I mean, in terms of impact, we talk about proximal distal on the apical that the devil ridge and a posterior in terms of the zone of polarizing activity and dorsal ventral non-equity, not a limb ectoderm. So that's what we're sort of talking about, and you're quite right with finger separation just to raise their evidence and have a hand paddle around 41 days.
And there's programmed cell death and that's regulated by the Hox gene. OK, so those are sort of embryology is really difficult, to be honest. No one's going to be, you know, it's going to be a world expert on it. So it's going to be someone who is sort of a consultant who remembers doing it when they were studying for their exam, and so they will have the marches in front of them.
So these are sort of the key things that they want you to be saying. But as I say, to be honest, if you can get this drawing out and talk about it as you're drawing, you're going to be doing really well and you're going to pass that station properly. Ok? and then it's talking about in terms of getting a higher mark, we want you to describe why they want you to describe why you've had the radial club hand.
OK and so that's a failure on this side, on the right side is going off. And on the sort of radio side, as you quite rightly said, OK. And it's that sort of thing in terms of the key thing of any sort of basic science topic is in terms of clinical application. So if you can apply to the clinical situation, they're going to be happy.
They're going to be they're going to be positive towards you. OK any some questions to us? You asked about how joints are formed? Have a buddy Roma myself. So there we go. So the formation of joints requires the repression of control genesis, so you still have that.
Growing for them. But it's that repression in the middle allows the joint to form. See what I mean? OK, we're on to the next one. OK, here's number two. Yeah, I am. Hi Hello. Hi OK.
So we've got an 18 month year old child who's crying and not moving their right arm. Can you tell me what this shows? This is the clinical graph of immature person showing an elbow right elbow. According to that, there seems to be a postural. Medial sort of dislocation, but then again, this is an immature 18 month old, so it is a highly likelihood of physical injury to this patient.
And I'll be concerned about non-accidental injury in this, assuming that had been ruled out. I would approach this patient and do take the history. I would like to know what exactly happened and the history is not moving on for how long. The patient is not moving the arm if there are any associated injury with that, or if the deformity is there for a long time and I'll document the clinical examination, I would like to see a different deformity.
I will document the vascular status as well as see if the child is moving the fingers and hand and. And then I would say, OK, I'll give you a bit of history, so the child fell off a chair, a high chair and the parents seem to be, you know, telling you the right story and they're very worried.
And it happened about six hours before you see them. There's no other significant medical history and you're not worried about non-accidental injury in this particular case, but I appreciate that these injuries can be associated with not accidental injury. So he's neurovascular intact, and he's got a deformed elbow. So tell me what you're going to do next. So I would during the daytime, I would take a appropriately prepped this patient and take this patient to theaters in an appropriately marked and consented patient.
I would put him on anesthesia with extra control. I would see if I'm able to correct the deformity. I would like to use an omnipod injection on table to delineate union at the upper phases of this elbow. And most of the time, they tend to reduce by manipulation only, and we don't need to open up the joint, but I'll be guided by my intra articular program to see OK.
All right. So you reduce it and you check it with the arts program and it's reduced what you do afterwards. So if it's reduced. And I will, I will screen it and I will see if it is clicked back, I'll feel for that, but I would tend to put to care with small cars on the large aspect 1.2. It's an 18-month-old child.
And then confirm my position and then put him into an above L peel-back slap. OK Are you aware of any techniques when putting Cuellar across the growth plate? So, yeah, so from one side, Uh, the egawa should cross outside the, Uh, the skin. Uh, and they should be divergent. And what about the actual? So the nurse gives you a threaded choir from the radio set?
Which I would like to use the turkey with, yes, I would be happy with that. OK and which of the Jets traded at the end, isn't it? So yeah, but I'm going through the lateral aspect. I would. I will. I will not go through the cortex. I will just stay inside the cortex.
OK all right, good. How do you think you did? Um, I think I initially I wasn't sure where it's going to go, to be honest, and I'm not sure it's still not sure whether I gave the right answer or not. I think you did well, I think you did well. I would tend to use smooth, quiet go and cross growth plate.
And the other thing is, you want to do a single part, you don't want to be doing multiple passes, that's any other thing. All right. Let's have a look at the answers. So you are correct. When you initially said dislocation, I thought I was going to go down that route, are we? But then you came back and thought of this so well done.
It's getting harder and harder for me to trick people with this question. These days, everybody knows it. And the point is, as you said, it's a distal seal. Funeral separation. Young children. And it is one of those injuries that can be associated with non-accidental injury. But that's not where my question was going for this one.
So you were right to bring it up early and exclude it. That's why I gave you the information that, you know, we're not going to go down that route. Yep so fractures young children under three fall on the outstretched hand. You can't have it in rotational forces. All right. Evaluation suspect abuse, which you did.
Examination, which you did hepatocytes. You know, I don't think many of us would start moving people's elbows that looked like that to try and elicit trepidatious. I think it would be too painful. Neurovascular examination, usually normal X-rays. And you can use ultrasound, you can use MRI, but I don't think we need to, as you said, I would do what you did, which is take them to theater and use some opaque to identify the joint and make sure it's reduced.
The price could be asked for gammie, said Kay wise. If it's unstable. And you really, really need to do an open reduction and complications. Anything that injures the pediatric growth plates at the elbow can cause various activities. Various egawa test Vargas missing the diagnosis is the other thing, and you can have some growth disturbance, so I think that's it for that one.
Yeah, it is. Is there any questions about this one? Just a quick question is being closer to the building and the image of a wire is that either the three or two in lateral from lateral, medial or cross similar exactly like sobre La or has the one. And potentially you could do either, I mean, obviously, we're going to go medial, remember to say you do a mini open, identify the ulnar nerve and move it out of the way.
Most of these will be stable after just a closed reduction, but you can put in a couple of wires from the lateral side just to hold it. It's not. You haven't got the same kind of rotational instability that you have with the epicondyle of fracture, and the child tends to be a little bit younger. So provided you can get a reduction and check it with the other gram, then the chances are it's going to heal.
I mean, the kids are young, you know, so they're going to heal really quickly. So if you are going to use KYC in this, I would use one or two smooth wires, single pass, and it's literally only just to hold it in place. But once you've reduced it. And usually we utilize our program to confirm reduction, or it depends on how in theater you can use it to confirm your reduction or if you were unsure about whether this was an elbow dislocation or a physical separation.
You could do an art program in theater so you can use it kind of diagnostic to check that you've got your diagnosis right? And also to confirm that you've got a reduction. It simply, you know, if you have a lateral condyle fracture that you know, it's a big cartilage component to it and you're not sure you've got it reduced or not. You can do an through ground there and you can see the outline to make sure you've got your reduction.
OK all right. So would there be any question like how do you do our program for the elbow, something like that? And yes, yes, they could ask you that. I've not been asked that in England for Islam. I was asked in the Australian exams about how you mix up the omnipod, what percentage you use, what you mix it with, where you inject it.
I can't remember it off the top of my head now, but look it up because if they ask it in the Australian exam and the thing is, if you're going to do it in theatre, there's no reason why they can't ask you in the exam in this still the epimysium slap lesion, the anatomy would be distorted. So like normally, if you have to feel the unconscious triangle and then inject through there, it would be distorted, isn't it? So how do you kind of say injected?
Well, you've got fluorosis, you've got an A sleep patient and you've got fluoroscopy. OK, so you can see and obviously you don't get a syringe of 20 meals of omna page and bang it all in. You're going to screen elbow, see if you've got it reduced and then follow where your needle is going to go. Maybe inject a little bit and check where it's going. I think there is another safe way also to target the posterior or the olakunle fossa from the back, and it should be 50 saline, 50 iodine material or contrast.
Yeah, 50. Yeah, and then I think it's simply, you know, when you do an art program for Nadh and you can't even inject a little bit and then screen it to see if you're actually in the joint. And that would be reasonable to do, I think. Yeah can I come in? Thank you, KneeKG. Perfect explanation, guys for the exams.
Don't really worry about you're not going to ask you, how much are you going to inject in the elbow? Just, you know, they will tell, you know, how much are you going to inject to elbow the child? You just throw any number because, say, one male and I will see if it's adequate, if not required to give another male. Just as simple, keep it simple. You're not going.
You're not a pediatric surgeon who knows all about injecting joints with contrast stuff like that. And you just keep it simple, guys. They're not going to dig you into how much, how many males they're going to inject in, how much, how many males can be given a chance interval and/or what's the technique of using it? It's just not really an exam. You know, technique is just put in, you know, in the soft spot in the triangle and put the needle and could give some injection so they might more, you know, they want more interesting concepts to test you on.
So I wouldn't worry too much about that. And so there was one. And a question about the size of the wires and obviously for superconductors too millimeters. But according to bolster. Yeah I think a reasonable answer, but yeah, I don't think you need to go as big as 2 millimeters because it's not the same rotational instability.
So you can go with the 1.25. You know, it depends on the size of the child as well, but these are kind of like really young children. Yeah Yeah. Yeah I think. Yeah, I think that's. That's very reasonable, I think, yeah, so broken, the fractured kids are older.
Um, and the Allen wanted to clarification of how, you know, it's not show, it's not elbow dislocation, just go over that again if it's quickly or a sneaky. Well, the key is that you need to think of it because you can't see. The you can't see the cartilage, you're going to see this.
And so you have to think, OK in this age group with this X-ray appearance, is it truly a dislocation or is it this distal seal of separation? It's difficult. It's difficult, but you have to have a high index of suspicion. And if you are unsure, that's why you do the program and screen in theater because it does look like sorry.
It does look like an elbow dislocation. So that's why I put it in here so that you are aware of it. Nick, can you put the x-rays back up, please, that you had? Yeah Yeah. Yeah, that's fine, that's great, thank you. OK it does look like a dislocation, it does, but it can be a dislocation. But but.
And that's why. It's difficult if you've got to assume the worst, it's not going to be and, you know, and I'm not going to be the staycation. Let's let's be realistic about it. They're not going to ask you about elbow dislocation in a child in the exam. No, they're going to ask something like that.
That's what we are here for. To be realistic of what we expect in the exam, they're going to ask you about this physical separation, not about elbow dislocation, a child. There's nothing much to talk about it. Then they could get elbow dislocation. Adults may be terrible. There's more interesting stuff to talk about, but Yeah. Oh, yeah, I mean, it's difficult, yeah, and it dislocation the relationship between radius and allies, more distorted and stuff like this.
It might look different, but you know, sometimes it's difficult to be sure. I mean, you could argue, you could argue that the relationship between the radius and ulna. Is more or less normal, but you can't really tell, I mean, you know, if you look at that, you could say, OK, well, maybe because these are relatively in the right position because your distal humoral thesis has gone with the radius and ulna.
But I just think it's too hard to say that based on the X-rays alone, I know it's only theoretical isn't just theoretical. That's but you can never be sure you can never be 100% sure. Yeah, it will be fair in the exam to say, I want to rule out dislocation. Absolutely, absolutely. But but I can tell you that the discussion is not going that direction.
There's nothing much discussed there for a child. No and if you get this in X out in an exam, you will probably be going down the route of non-accidental injury. Yeah, I haven't gone down that route because I'm going down that route soon, but for this case, if you get this in an exam, it probably will go that way. That's a very good case, thank you very much, KneeKG.
Can I ask a question? Very good question. Yes, peace. Yeah go ahead. My understanding was that this age group like less than two years, you tend to have more so if at all, like a radial head dislocation rather than elbow dislocation. Is it common to have an elbow dislocation this age?
Guess my understanding of it would be either when I said, Oh no, because I'm not Rodriguez 18 months, it may be. What's the difference, bubba? What's the? It's a reasonable question, but what exactly trying to get from that question, so we can no one untouched? Well, my mind what's more common here?
Yeah, but my understanding was an elbow dislocation child is at least more than two to three years old. I've never seen an elbow or heard of an elbow dislocation, more like a radial head dislocation. Yeah, it must be correct. You must be correct. But I think in the exam, you have to mention that I would want to make that can be an elbow dislocation.
It's most likely to be a distal humerus. You won't go wrong with that. Yeah, I mean, I mean, if you told me this was a Radiohead dislocation, I wouldn't be happy. No, I know that that's the reason. I hope if you see the incongruence, it is both in radio capsular and L know you joined. Isn't it?
So if it was just a radial head dislocation, the other joint wouldn't be incongruent in a child welfare epiphytes is not visible. It's a broken little fracture. Looks like this. It's a good answer rather than. Yeah and the thing is, it's unlikely that you're going to get a radial head dislocation in the exam because there's nothing to talk about.
Yeah you know, this is something that they need you to know because it is one of those cases that could be a marker for child abuse. So they want to know that you are not going to miss this. So put radial head fracture in the back of your head and go with the distal human or physical separation and differential of elbow dislocation, and then you won't go wrong. OK OK.
Shall we move on? Brilliant, brilliant. Now to gollum, he's the third candidate. Hello hi, Ghulam, how are you? Yeah, I'm good. Thank you. Good luck. Good Oh, sorry.
No, no. It's OK. I understand this. But So, gulam. Yes, look at the picture. Yes what can you see? So this is a clinical photograph of the hind. They are good stretch and they're border. I think they are doing just for the one disease.
Althea, you think this is because once disease could be declared one disease, or could it be the lateral epicondylitis? Just so you think this is different or lateral epicondylitis the koran? OK, that's fine. So because this is what is the good doctor once Crohn's disease is a degeneration of the sheath of the first compartment of that after the All of the rest, which is the abduction pollicis longus and extensor pollicis.
Previous and this she should become thick and inflamed and then causes pain just about the residual side of the rest. And so how are you going to examine this patient? The examination is first submitted with a history, and then when examining there will be some tenderness about the original satellite and and also there will be some reporters sometimes and some religious will be there and also by putting the ulnar deviation of the wrist.
It will be painful. So a lot of this doesn't cause pain. So the ulnar nerve deviation doesn't cost, ok? No, to do anything else with ulnar nerve deviation. Yes I can put the thumb inside the palm. And then I will do the ulnar nerve.
Well, he got pain with that lot of pain with this manual. So generally speaking, if the patient is getting a radial sided, then what can be the causes? And the cost can be a multiple of the original, I mean, I need to take the history and examine and rule out there is any fracture of the styloid process of the radius or any scale forward microfracture or to present or osteoarthritis.
And also, there is a transition symptom is a syndrome is also on the radial side of these transactions in the transaction system. Is that the. That the extensive policies as crossing over the extensor capital registered in previous this is transection and Wattenberg syndrome, my sense is that superficial rate ulnar nerve is coming between these muscles, which they are crossing on the wrist like as extensive, extensive coverage and as long as injuries with extensive policies.
Previous and there are superficial regional scams inside, and it's painful. All right. So we'll go to decoherence disease, ok? You said it is entrapment. Gammopathy sclerosis tick come curtain on which is pressing the tendon, isn't it? Yes a little what tendons like there?
The attention as the first compartment tendons, which are the abductor pollicis as well, is the extensive policies. Previous one, which is where which is more Waller, but what tensions are on the radial side and are some and the extensive policies previous is more towards the middle, which is more Darcel than the radial.
But the abductor is more rigid. OK, so this is the first person compartment for how many compartments are the total? There are six. The second one is the extensive carburetor gels as in previous. And the third car compartment is the extensive pollicis longus. And the fourth one is the extensor digitorum and as extensive indices. And the fifth is the extensor carpi ulnar nerve is in.
The sixth one is the extensor digitorum. The fifth one is extensor digitorum medium and the second one is the external subscapularis. You're right. OK, that's fine. So you diagnose this as it is a decoherence disease, ok? Yes and you know, you're doing the right work for six months, but come at 1 and 1/2 years with repeated symptoms and you think that she is what she then you are taking for decompression patients consented and prepared.
How we're going to do decompression. And decompression is I will explain to the patient as Marty consented, as you said, and the patient will be supine and the arm porch and with the naked eye socket. And then my landmark is the skylight process of the radius and just about it and the more superficial tendon and swelling part.
I will make decision incision. I would do very clear a very careful dissection to avoid injury to the superficial branch of the nerve. And once I reach through the tendons, I will just release the capsule and make sure the tendons are not injured. Well, when you are doing this, you said that there is too much bleeding, profuse bleeding, pulsatile bleeding, what might be a problem?
It is after it's bleeding or the original radial artery is Wolof traject, and I should be careful to try not to injure and/or maybe some branches of the retail industry which is coming to towards the snuff box. So I will try to cut through that, which can be the complication of this procedure.
The complication of can be infection and can be bleeding, and it can be a recurrence of this one and can be complex regional pain syndrome. So you said you can record your release date. So why should it trigger, is there a reason why. The reason is that it's in spite of its release, the capsule can be regenerated again and the study this I knew well, shit can be regenerated again.
It can be formed. So they will make a sandwich. I think that Rick McCallum will be formed again, isn't it? Yes can it be any other reason? Yet? the other is a scar. Scar tissue can be there and also neuroma from the superficial radial nerve as the other. That's fine.
So I'll give you an answer, and then we'll talk about it, ok? OK also, the picture shows a Finkelstein's test to The city of egawa one sign what is all right? Yes so constant test you grasp the thumb and ulnar nerve David and you get excruciating pain. Yes one of modification or variant is called age of manual, in which you release the thumb and allow it to extend and pain goes away.
OK, so it's important that you grasp, so it is in this condition that is the entrapment of the first dorsal compartment tendons. Isn't it? Yes extensive policies and extensive, sorry, extensive policies and policies. Abductor policies lies Waller to the extent that policy spread is OK.
So what can be the causes of the radiologist being? OK it can be decoherence sinologists. OK other type of it can be intersection syndrome. Hoping it can be Wattenberg box syndrome, which is a changing of the public interest and extend subscapularis longest. It can be something, as you mentioned earlier, it can be trauma causing the delay or the scaphoid fracture.
There'll be arthritis in the wrist or in the CMC on some sort of arthritis can affect only rage. Yes, it can be neuroma, isn't it? The neuroma of radial, superficial plans of regional and sometimes axilo tendon losses. These are all the causes of rigid sided wrist pain. So technology, as we discussed, it's a physically entrapment, you know, putting this thickening of the retina column.
There are certain causes like it's not common woman with repeated trauma. And it is. It got quite coincidence with the post-partum just immediately after delivery. You can get it. Commonly, you answered the dorsal compartment compartments, right? Ok?
when you describe decompression. So basically you can take a simple take. I would consented market, and you can either take identical dorsal, dorsal, radial transpose or linear incision. OK and then you expose the extent of first dorsal compartment and release it. OK it can be done in the local anesthesia or general anesthesia.
One of the important thing is that sometimes the extensor pollicis rabies as a separate compartment, so there are two compartments in the one compartment and that is one part of clearance. Yes OK. Like in carpal tunnel syndrome, the proximal release is inadequate and it's common cause of recurrence. This is common cause of frequent in this case. So what can be the risks?
This can be injury to structures like radial artery, superficial dental of now, OK, which can in turn form neuroma. Look at the risk of infection. The risk of recurrence of symptoms. It's all right. Yes and as you said, regional pain syndrome. Through the feedback for you in terms of improvement is that I gather that, like me, English is not your first language.
So to think in your own language. And then translate into English can be a problem, and it's still difficult to learn. In turn, you can use the orthopedic language. OK this is the bitterest disease, which is a more entrapment retinopathy of first dorsal compartment.
OK, so use. Don't think and just mentioned the orthopedic language. OK, but otherwise your knowledge is good. And anything it should be systematic, you shouldn't use transaction and all these stock transactions into submission. Intersection, Yes. Intersection, yes, sir. So basically, that's one thing.
Certainly, you need to practice. I think your recently started preparing, isn't it, the practice to get the flow? It's not a big it is an easier thing to describe it in orthopedic terms rather than thinking and translating it. And that orthopedic dumps, which people go for buzzwords can only come with practice. Yeah all right.
Yeah, thank you very much. Yeah well, so let's find. OK, thank you. So we go to next question to Islam. You are in the clinic. And this lady. She's 48 years pregnant with the pain in her big toe, right? What can you see?
So this is a big grab of immature patients showing not doing joint space in bilaterally in both a metatarsal first metatarsal pharyngeal joint, what's your diagnosis? It is a rigid bilaterally severe on the right side compared to the left. So she's symptomatic on the right side. Left side is not giving her any problem.
What are you going to do? So I will assist the patient. First of all, I will ask what is a probation? What is? And profile, what where is the pain? What make us makes it better? What makes it worse in the treatment underwent with it? To what extent has improved the pain with a underwent steroid injection or not, or any previous surgery?
Then I will assess patient clinically. I will assess the range of motion. I will check passive range of motion to what extent patients can achieve those flexion and flexion of metatarsal pharyngeal joint. And then I will take it further passively. So I will ask patient active range of motion, then I will take it passively to check where what the range of motion without a pain in the mid-range or in the terminal if it is in terminal that guide the treatment options to list lesser invasive compared to midfoot range or midfoot pain.
Midfoot range of pain mid-range of motion, pain. Sorry, then I will assess the other joints, internal energy and joint, as well as various types of metatarsal metatarsal John I would look for. I will assist and conclude my examination by neurovascular status, as well as any history of diabetes, smoking or any vascular problem. So when you say you did not make patient walk, but when you made her walk, just trying to avoid the push off, she was just trying to walk on a hill.
Yes, to the active hill with. Difficult when you told it was painful when you made a foot alignment was quite OK. You should localize tenderness in the joint range of motion was restricted and the was meat being. She had a painless IP joint, OK, Ross Perot status of. Nor the problem ankles of Taylor and tarsometatarsal joints supple and painless.
So you think this is at once arthritis? Yes what are you going to do? What treatment you're going to do? So I will offer the patient first, all conservative options, including activity modification. Rest, analgesia, physiotherapy or orthotics, including any metatarsal or forces. So what did the authorities use for this one?
I think it might be offloading blunter authors Martin Stowe. What's that Morton's do? Yeah and then, Uh, if a patient has exhausted all of the conservative treatment, probably I would offer patient also in the conservative steroid injection. If exhausted all of the measures, I will offer the patient first infusion.
However um, if it's low, this is that I want a mobile joint, I don't want your I will do so. That's why if it's so it's a bit controversial if it's mid-range pain. However, I can't do colectomy as a less invasive procedure and that her cousin had a joint replacement. Can you do one for? So the literature showed that it is a lot less outcomes compared to the artery disease.
It has sinusitis. So you are. Take the patient. It's consented, marked and prepared. Tell me your r tenodesis. I will do a dorsal incision over the first ray. I will. And a question to be taken to a sensor helps us longest and then take it laterally, and then I will go straight to the inside of the capsule.
The colectomy exercise all of the osteoarthritis in the medial aspect of the medial imminence. Then I will few. I will. And the exercise, all of that eroded articular surface, and then I will feel the. Do you want to do rimming or no? Yes, I would go there is a concentric reaming coupling in a concentric manner which is given to renew to a bit of open joints and it.
Flex the joints. Yes you find it very difficult to flex the joint, what are you going to do? Well, I will release that, so I will release the middle capsule as well as I can release the capsule, but you cannot flex it at all. This is difficult. Totally difficult. What else you want to release at Dr. Harris's tendon? Oh no, no.
The Stewart capsule, I'm not sure. I don't know. OK, so you really are inside the dorsal capsule and not flex to release? Isn't it? Release what collateral ligaments? Yeah, OK, you did women and what position won't you freeze. And what implants you're going to use? I will use a plate because there is a few fusion plates designed for this one, and I will put the position of the.
Grade 2 in 10 degrees of subtraction with 5 to 10 degree Vargas, then I will indicate the median capsule over. You don't need to. You're not going to take an dorsally approach. I know the gold medal, but it's the plane is not there. Sometime all right. So what can be complications of this procedure, so complication stock by nonunion?
One of the problems extensor tendon rupture and neuromuscular problems and damage. Which is that. So that branch of the student deep ulnar nerve, as well as. Like that, that terminal branch of slap ulnar nerve, probably, but. Dorsal branch of dorsal mediano.
Tarsal brand. Yeah so let's go to peel-back Islam. You're quite all right. You'll learn quite a lot, and I think you'll be a little bit of I think rather than practice, I would suggest you need to do some courses here that you know, that will help you. No, but you got a very good knowledge they see, just like listening.
OK so this is basically to are property of empty joint. So basically, arthritis can be joint, can be idiopathic or it can be trauma, multiple trauma, rheumatoid arthritis or varying pointed foods, high heeled shoes, et cetera so most important thing is to say asking how did problems start? What? how does it affect brain function in this case, wearing shoes?
OK and what has been done? What are the risk factors? And you should make patient walk, please. And in this case, he'll raises important. OK, then you see very little class and then assess that joint for end of range pin or midgar me pain and assess the VIP joint also, I'd be joined also. And when you say you go to Canada, great, but it's mild, moderate or at once, OK, and a procedure you don't properly about Jill colectomy versus this is quite all right.
No so basically, you told approach denoting type of succession, but when you are told you about the part and how. In the reflex, you didn't know you have to release four letters type of succession, most people would put a screw and played. They saw it in their front of truth and a locking plate blocking law provide plate. All right.
So you're quite all right, you're done. Well OK. Hi. All right. So this is your case. 89-year-old baby, she complains of pain in the right hip and groin for one day denies any history of trauma. She has significant medical problems, as you can see, so she has decompensated heart failure.
The stenosis if your population. Hypertension MRI is not mobile to the peripheral vascular disease Tia. This operation was done back in November. 1991 So describe what you see and proceed, how you're going to manage this exhibition of pelvis showing both hips on the right hip, that is a total hip replacement, which on the X-ray is dislocated.
That is evidence of. Change in orientation of the established component with potential. Lighting areas around the established cup with superior and inferior license of the established world on the hip, it is a long stem prosthesis, probably modular with probably 22mm head.
There is evidence of lysis in the proximal femur. It is an inadequate X-ray because the whole length of the femur and the tip of the stem is not seen. So I will. On on the lateral view, the orientation of cup is. Tilted the. Stem, as well as the distal femur, is intact and.
OK, so this picture that you see is the post of X-ray from 1991. Yeah so there is evidence of. That the sorry, the current X-ray from. This is the current X-ray. Yeah, this is the X-ray in 1991. Whoever did this procedure took the X-ray post-operatively. Yeah so. Anything you want to suggest, what do you think it is and.
So you mentioned something about lysis here. Yeah do you think that is lysis as well? Be license. Um, so it is an unlimited cup, so. I'm not sure whether it drill hole. I'm not sure. What about this stem? Is it cemented?
Stem is also cemented stem. OK because I can't see any semen mantle around the distal part of the stem. So I guess it is an unlimited stem. So looking at the lateral view here? Yeah, is the and you say that the US is in the correct position? So on the lateral view, there is a retroversion of the cup.
OK no worries, how are you going to proceed now? So she's coming out with this? Yes so I would need for I would. You take a proper history from the patient regarding how she progressed after her initial total hip replacement. Was she completely asymptomatic? Almost completely asymptomatic? Very happy with her procedure that was done in 1991.
I would also ask the primary indication why the hip replacement surgery was done and that was the neck of femur practice. OK, so if it has been completely asymptomatic and from the history, she has got significant past medical history and she has not been mobile. So I would ask her how, for how long she has not been mobile and what does she do for the last five years, she has been really struggling with her when she saw the cardiologist who said that we shouldn't be walking if she is not walking anymore.
So, so then I would ask her if she, if she is immobile, whether it is transferred to a wheelchair, if that was to escape from back to jail because of. Yeah so I will discuss the X-ray with her and talk to her about the dislocation and. Well, alignment of the cup, I would see if she is fully complimented, if she can understand the accomplishment that 10 out of 10.
Yes so I will discuss her with her regarding the further plan, which ideally, if the cup was oriented, I could have tried an EMU and reduced the hip, which I think in this particular scenario, it would not work because of the cup is dislocated, cup is rotated and it's also potentially loose. So I would tell her that the first thing I would want to do would be to rule out any prosthetic infection.
I will ask her specifically if she has been having any. How would she tell you that she hasn't got a prosthetic infection? So if she had been systemically unwell for the last few weeks or months, she has been because of her heart and chest problems. The hip was brilliant. She was very happy with the hip procedure. OK, so sometimes if there is evidence of any swelling or redness around the operative side as she is not mobilizing if there was any pain while hoisting out of the wheelchair, there was no pain at all.
It just became painful yesterday. Sorry so it became painful yesterday only before that she was happy with her. So, but again, I would tell her that the surgical procedure would depend on whether that the prosthesis is infected or not. So ideally, you would want to do some blood investigation to rule out mainly full blood count ERP ESR.
Labor investigations are all normal. OK, so the ones that you have mentioned have to be scrubbed. OK so I would tell her that the next step to proceed would be to consider a surgery, which would help her with her current status and current activity level. I would discuss the possibility of having a stable hip by doing a revision.
Hip surgery was an excision arthroplasty and giving her pain relief and. And take it from there. OK, so this is Saturday, you are the consultant on call, so you decided to take her dictator on Sunday for revision of tuberosity or tuberosity. I would. I would tell her that would be the basic principle of surgery, but I would discuss her local MDT, discuss with arthroplasty plastic surgeon to get their opinion on how we proceed from there.
And I would tell her that similar cases would be best managed by the plastic surgeon. So but I would tell her that the main principle would be to consider a revision surgery. If if, if, if she has had it, if she wanted a stable hip. For a transfer and for pain relief versus excision of tuberosity. Any other management options apart from surgery?
And would be to give traction to the limb for the pain. Investigate with the CT scan to look if there is any, any associated fracture and pain management. OK all right. So you can ask the anesthetist just to speed up things so that you can do this on Monday, and he needs to bas status that she is not fit for anesthesia.
Yes so I would tell her that I will tell her that we have discussed her with the anesthetic team and they would add as she is medically unstable, she would not be a fit candidate for surgery. So I will tell her that we would have to discuss her in a bigger MDT with the reconstruction as well as the hip surgeons to get for the management plan.
OK, I'm going to stop here. Just one quick question. Do you want to have a quick look again and think, what could this be? Is it a hip replacement? One, this one, this is the post of operation post of images from 1991. Sorry, I didn't get the question.
OK, no worries, that's fine. So how do you think you have dealt with this case? Um, I couldn't organize my thoughts. I was going back and forth and. Yeah, that is right. I think you need a lot of preparation on this particular aspect that you need because there will be cases which will be out of the box.
There might come a case which you never have seen in your life, for example. But what they are looking at the exam is the higher order thinking that are you a safe surgeon? And can you manage such a case that you haven't seen in your life in a safe manner? And that's the whole intention. So and you approach any case with all those steps that is very well thought and agreed upon.
So history, examination and then do the necessary investigations and then, if required, you get into the MDT involvement. I tried to give you some problems here. I agree. Looking at first glance, it does look like a PHR or total hip replacement is a common cause here. But this is the immediate post-op X-ray after the operation, and you don't normally see that in that version, isn't it?
On Glaxo's, it's a bipolar out of plastic. It's a very old system. We call it basement. It's an American one. But historically, as I said, it was done in 1991. The thing that really is that I need to mention and give you feedback on is not being able to identify. This is not a big problem, but the approach needs to be safe.
I think in your case, you went straight to a very major surgical options of revision of to blast the excision of the B and that you mentioned even before mentioning the MDT. You later on did mention about MBK. However, that was as you described the back and forth kind of conversation. And then when I mentioned the patient is not fit for a haircut, according to the anesthetist.
You still want to discuss with the higher end meeting for a major reconstruction operation. So I give you the promise that can it be managed non-operated, make these cases, the thought process here should be focused on patient oriented well-being or patient care. We're not trying to solve the problem what we see on the X-ray. Yes, that is part of the patient management.
However, it's not something that we see. It is broken and we just need to that out and forget about other aspects of the patient. So no, that's not the same approach. The safe approach is you look a holistic picture of the patient and then make a decision of management plan that is the most suitable for that particular patient. And that would give the best outcome. And that in this particular case is a non operative management because she's not according to the anaesthetist, she's not fit for anesthesia, the type anesthetize that she would die.
Yeah so you put this particular case for two reasons, one that England is very old, and the second is that to give you the inside of how we manage patients rather than managing just the X-rays. OK anything not clear to you or anything you want to ask or anybody. So would it mean that the patient would have pain management and yes, so she's getting hoisted?
She does have a pain because this got dislocated and had we had a time, we could have discussed further on the factors that would result in dislocation of a hemi of the blast or replacement, and that would have scored higher marks later on. But yes, because she is not fit for her because we didn't manage just the pain. Basically, there will be no punishment.
Wonderful case, wonderful case of it. Very good one. It's just here. That's the higher order thinking there would be looking at the exam. Yeah, this you won't find it in the books. Yeah, and the book tells you have failure help. You have need revision. Yeah but here we have a real life scenario.
Higher order thinking or consultants, they were looking at that. You have a holistic approach. Yeah and that you will consult mdc-t, consult anesthetist. Yeah and initially, and you listen to them. Yeah, well, there's no point consulting anesthetist and then still tell you he's not fit, but you still want to do operation. You see what I mean.
So safety, that will be a safety thing. Yeah, that will be safety. Unfortunately, if there is an anesthetist telling your patient not fit and you taking the patient to theater, no matter how well you do in that questions, then you will be deemed unsafe here. So look at those all hints. These are all tick boxes in these questions. Um, you know, mdc-t approach to these patients considering patient by patient scenarios, safety.
And you understand the complexity of matters. Yeah and. It's really just as simple as that, sometimes, yeah, you don't have to. I know sometimes when you're faced with such a difficult case, your mind gets blocked and that's what you are here for. So we can just help you to unlock your brain and let your inner and lock your method of, you know, analysis and thinking so that you can go through this in the exam.
Just go back to the principles. Yeah complex cases like this. Always, always MDT. Yeah, always comes first. Yeah, you don't need to jump into this at all. Yeah and that's how you differentiate, too, as a consultant that you sit back. And don't rush things. You don't need to rush a tool.
That's good, good one, good one. Well done. Importantly, that some candidates or some people think that not knowing each and every implant is a big problem because it's not at all. I mean, I didn't know when I saw this case that I expected it to be vacant, but I wasn't sure till I got the upload. So not knowing the implant is not a problem, and it is definitely not going to fail in the exam, but it's the higher order thinking and your safe approach that matters.
OK, not smoke. Now we we're putting our clinicals hat on. OK, guys. So now these clinicals now in the exam are mainly scenario based, simulated patient base. There are no real patients, at least until we know for this setting and next setting, at least. So we'll be all simulated and this is how we go over to you.
OK Yeah. So it's all us. So you go first one. So you're in clinic. You're doing your congratulations. You're newly appointed up Allen consultant. Your GP sent you this 47-year-old gentleman who is coming because he's got problems of his hands. But he's also saying to you, he's got pain in his back and he gets headaches a lot.
And you also get some pain in his chest around both sides of the chest wall. Tell me how you approach this gentleman. So, first of all, take a full history from him and ascertain a little bit more about his symptoms when they started, whether there was any inciting event in the history of trauma or anything like that, which or in those specific trauma as such. I mean, he does remember many years ago when he was a younger man he had he did hurt himself playing rugby, but he never went to hospital as such.
But it's been the last sort of six months he's noticed. He's been getting the feeling. He's getting clumsy with his hands. We don't know whether there's any specific position where he puts, you know, or any specific activities, which makes things worse or makes things worse. It does. As I say, he has noted this sort of clumsiness. He occasionally gets this all back pain, particularly in his upper between his shoulder blades.
He does feel a bit of back. He's been getting back pain recently, and he's always had some headaches for the last couple of years on and off. What they don't know about any history in the neck at all, any pain in the neck or no pain, specifically a neck, mainly just between his shoulder blades. OK I wouldn't know about any sort of color changes or cold intolerance in the hands at all.
Mm-hmm no such call. He does find he doesn't feel the cold as much as he used to. OK and I'd want to know if this is bilateral or one more on the other, it's all bilateral. It's brief hands. Ok? whether he has any problems in his lower limbs at all? No, it doesn't. No, you haven't noticed any problem in lower limbs.
It's bad. They seem pretty much spared. OK, I want to know if he has any medical problems, any sort of diagnoses of any sort of syndrome and conditions or any. No, he's not diabetic. I mean, he doesn't have any medical history. He works as a. He works as a builder, as I say in the past.
He did play rugby, but no, nothing specific sort of stands out. OK um, and whether he has any neurological symptoms in the many pins and needles, sensory changes, how you know, How's he going to be able to that to you? How would you ask him specifically and ask him whether he has pins and needles in his hand or whether they feel does get something needles in his hands? Also get some pins and needles going into his armpits.
OK maybe on one side or on the right side, let's say on his left side, ok? So, OK, I'd like to move on to examine him. So I want to start by examining his neck and his neck range of movement and seeing if this exacerbate any of the symptoms doesn't exacerbate such. I mean, when you look at it back, you notice that you notice that.
OK, so on the right side, his scapula seemed higher than the higher than the left. Mm-hmm so I want to confirm that this is whether this is a smaller scarpelli than the left or sort of higher or whether this is scapula. It could be a couple of wings. It's not clear from the full. What about his? What about his back?
I can also see scoliosis. Ok? would that be the reason why he has a slightly more prominent scapula? OK, Yeah. So it looks like a right sided sort of thoracic curve on this image. But now, so in terms of seeing this. So how might you look for a tone, let's say so to look for a tone, I would just ask him to relax his arms and sort of do a shaking, shaking hands and works to soothe the nation.
That proved the doing so if he's got a slightly increased tone in his up in his upper lip. Peel-back normal tone in his lower them. OK so I also want to examine the reflexes which as the Hoffman's reflex, and look for any individual Hoffman's reflex. But he noted, yes, quite brisk reflexes in his upper lip. So in his lower limb. OK, I want to examine to see if he's got any sensory level and I want to examine his Mayo terms.
Ok? he's got pretty good strength in his low lobes. But you do know there is a subtle weakness plus free 3 and 1/2 out of 5 and power in his arms compared with what you would expect compared to his lower ends. I also examine the vascular status of his arms, feeling the pulses and doing a good, good process. No, no problems with pulses.
OK, I'm also a dynamic test to look for any thoracic outlet type syndromes. No, no, no, no, no. No evidence of that. OK I'd also like to examine for long track signs Miller with limbs who are doing the wrong bergs test, examine his for any illness in the ankles, although it mainly for increased spasticity in his upper limbs, is long too exciting to be fine.
OK, fine, so just to summarize, this gentleman's got bilateral upper limb symptoms and back pain with a scoliosis and motor neuron picture. So I'd like to get, first of all, X-rays little differential. So my differential is probably seems to be a spinal cause. You may have some sort of spinal lesions like a syrinx or cervical and my allopathy?
Yeah it's one of those. Again, you got an X-ray that'll really show you very much. It's good enough to get an MRI scan of the whole spine, so as if by magic you get your MRI scan. OK, so this does show a cervical spine syrinx, evidenced by high signal within the cervical spine, extending from C four level to as distal as I can see what the theories.
It's a syrinx is a fluid filled lesion within the spinal cord. Look, and what might you expect to see in a serious in terms of features, clinical features in a patient, you mean? Yes Yeah. So it might cause an run to picture. Yeah well, like central court, isn't it? Yes the upper limit is dead.
Yeah OK. In terms of your management for this gentleman, what might you what sort of options do you think you're going to do? What might you do? Because obviously he's worried because he's only 47. Yeah, I don't discuss this with a spinal surgeon. Probably a new rules, new rules, surgical spinal surgeon. And yeah, there doesn't seem to be any extrinsic compression on the spinal cord looking at these MRI slices.
But I'd like to see the rest of the spine to see if there's any area of compression which can be dealt with surgically. From your understanding was the mainstay of management with these patients. Um, a conservative management. Yeah, it's mainly observation that other surgical interventions, what might you go down? What route might you go down?
Um, I'm not sure whether it's possible to decompress the syrinx, but. I that's something have no experience of. Presumably that would be a neurosurgeon if. So generally, yeah, so overall, tell us that was a good answer, you went for racist. I think sorry, I know you'd have a lot more time in the world thing. Apologies we're obviously doing this within a very constrained space of time.
But yeah, so with the history focus, do you have to keep figures of focused history or sort of a history to try and elicit your thing? So Yes. Do go for you. Want to know about your upper motor neuron lesions because he's talking about bilateral symptoms. So you're quite right. You have to have in the back of your mind, long track signs.
I was trying with sort of talking about upper and lower limb being spared. I was hoping to get you thinking about something more like a central star picture. But yeah, but from a differential, I was happy. You got that right. You're quite good. You want to get differentials. Admittedly, I would probably put a little bit lower down normally when you have a more standard question, for example, but that was overall that was good.
But yeah, so it can come up, I'm afraid, guys in the exam because there's something that is a winner within hours or we will get them in our clinics on occasions when we have people who have been referred to us with bilateral hand symptoms. We think it's coming from the neck and we get an MRI scan. And Lo and behold, that it is a May 8 or six. Yes so I did try and give you a clue as well at the beginning. I thought we were at up Olympic games, up the him.
Oh, right, OK. Yes, sir. So Spain's working on the upper limit and so central cord syndrome sprains anything. The growth will be happening because none of them may talk about this disease. Scoliosis this is a good one because, as I say, 18 percent, up to 80% of people with severe cases will have some form of sclerosis.
OK as I said, a few over the quarter will, but a lot of people say up to 80% OK, so but as I say, it's one of those ones where but I had a good set. You have a bit of higher order thinking, a good approach. So you've got that diagnosis. This is a tough one. So getting diagnosis is part of your approach. You're getting your marks for in the clinic in this situation. OK, thank you.
Good I have a question. Does it give the same similar symptoms of cervical cancer or doesn't give the way? So the key here is the lower limb is spread typically so and so central cord style syndrome. OK Yeah. Um, it depends whether it does depend on the position of the syrinx, but in this situation, it was, it was barely below that, OK, which is what I was hoping to get across, but they will keep me as well just double check with things, though it is a result from a lesion partially obstructed in CSF.
So that injury and is rugby maybe may have caused it. I don't know, but it was one of those ones where you can have one of the potential causes can be of that. OK how was spinal fusion improve it or as an option? Spinal fusion is a situation where, as I say, I would have to talk to the neurosurgeons about it. They tend to deal with this more than we do, but from my understanding, they would decompress the back.
So they're almost even though the lamina are fine, they almost take the back off the diffuser to give it stability. Because what's happening is as a fluid builds up, it presses on the nerves. You can try decompressing it, but you'll be more likely going to cause issues to the spinal cord. Aren't you sticking a needle into that to take the fluid off?
Thank you. Right OK, so next. Thank you. OK, so the next one is another hip. OK, so who's up next? Hi all right. So remember with the fast, yes, the key is in the question. All right, so here we've got a 21 year old, she's a dancer and she's got a hip pain, but she also complains of it popping and snapping.
So what's going through your mind? Then a young patient like that, it was more like a soft tissue liberal thought of a pathology. I'll be looking or thinking about. So I will take the history from this patient regarding the symptoms. When do they come up for how long she had this, any trauma associated with the initiation of these symptoms?
And if the symptoms are with daily activity or doing just with dancing or any impact exercises she tends to have, she had them for about three months and initially there were only when she was dancing. But now, when she tries to go for a run or she goes to the gym, she notices it and whether she point to towards the pain. So she points around the groin area.
OK and if you're taking painkillers for that? No, she's not. It's not affecting her activities. More to do with the popping sensation and often on. OK and if she having these symptoms of tapping or turning in bed as well or just one walking, no, she's only noticed it when she's doing something active. OK, so the just prior to three months, she was perfectly fine. No symptoms whatsoever.
No, she didn't notice anything before then. OK? and she'd been fit and well, healthy. Never had any trouble with her hips in the past and child. OK so I would examine her now and the examination. I would like to see her walk, see the gait. I presume it would be a normal gait because it's just the popping sensation she's complaining of. Then I would do the traditional book test to see if it's positive or not.
Then I would make her sit at the edge of the bed and I will ask her to lift the knee up to stress the alias of mother to see if there's any impingement of the ethos. OK, so that's very painful for her. All right, OK. That's painful, and I'll make a lie on the bed, and then I would gently have a look of any obvious discrepancy I would.
I've noticed that in the gait as well. But then I would, Uh, if I didn't ask which hip was it is bilateral, you just want for it. It's just one side, but it doesn't matter which side is in this case, then I would do the range of movements, see how much flexion she has got. OK, so when you do that, when you flex her up and a little bit of external rotation, you hear a snapping noise like this reflection and reduction of flexion and abduction.
So sort of a. And the abduction doesn't really bother her. It's more the external rotation. OK, fine. So and then I would just dip with her leg on the bed, I will roll her leg to see internal external rotation and full extension of her hip and her knee, if that causes any problem or not.
Not particularly, not when you passively do it like that now. OK all right. So what are you thinking? So this seems to be more like either an alias of impingement or liberal pathology. The liberal pathology would be my first differential there. And OK, and then I would after this hour and complete my examination with Mr neurovascular examination of the lower limb and examine screen the spine as well, then I would allow for investigation, radiologic investigation, the form of brain radiograph to see if there is any dysplasia or anything like that I can see in this young lady.
Any evidence of any dysplastic hips, which may be the cause of her later pathology. OK, so have you heard of a snapping hip? No OK. All right, well, we'll come on to that in a second, so it's either an external snapping hip or an internal snapping hip, or it can be intra articular pathology. So besides labor or pathology, is there another condition that could maybe give you that sensation inside the joint?
Not it's usually not in the hip. It's usually in the knee or the ankle, but you can get it any joint, any sign over your joint in the body. Snowmobile condo mitosis, ok? That's not what she has, but that's one of our differentials. All right, let's have a look.
So the two main types are the external snapping hip and the internal snapping hip. So the external is when the ITB slides over the gt, and it said that you can see that happening. So when you examine them, if you put your hand over the gti, it stops it sliding. The internal one is, as you correctly identified, is the idea. So it's tender, which slides around from my head over the Olympic, which.
It can't you can't have an actual status of the lesser traject or the boat bursa, which is causing that. And the other reason that you can have an internal slap in hip is if you've had a joint replacement, you've got some impingement there. So history and examination by activity, so any locking might indicate intra articular pathology like synovial Kondo mitosis.
And this is the thing. So an external snapping hip, you can see it and the internal snapping hip, you can hear it. That's why I said, when you flex, although you hear a snap. And this is so with the external. You can do obus test looking for tightness of the tensile forces yalata, the internal. Let me just move that out the way because you we can't see it.
There we go. So if you move from a flexed and externally rotated position to an internally rotated position, that's when they get the snapping sensation. So what else do we got to imaging? So the X-rays are usually normal. Unless you've got sine oval control mitosis, you can do an ultrasound scan.
It's dynamic. It's nothing band. And the advantage is if you've got good stenographers or radiologists, you might be able to do an injection into the trough and take the alias of a tendon or intra articular. And I think I think we sometimes do that. Then we've got someone that's close to post-op hip replacement and they're having eylea, so type impingement.
You can do an ultrasound guided injection to see if that relieves the symptoms. So an MRI scan might show intra articular pathology like a labeled tear or synovial Conroy mitosis, and it might show an inflamed bursa. The other one that I've put in for completeness is also is orthography less common. Basically, it's fluoroscopy and contrast, and then you can do a therapeutic injection.
Management usually it's painless and they don't need any treatment, it's just annoying. You can activate activity modification. And if it's acute under six months of painful internal external physiotherapy, if it's persistent and painful and interfering with the ADLs an operative, you can do a z plus of the ITB. You can release of tendon. If it's find some intra articular pathology, you can do a hip arthroscopy with removal of the loose bodies or labeled Brightman and repair.
So any questions about that one? No, thank you. All right. Good, very good.
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