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Knee Examination for Orthopaedic Exams (Part 2 )
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Knee Examination for Orthopaedic Exams (Part 2 )
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Language: EN.
Segment:0 .
Egawa, are there ok? Good evening, everyone. Welcome to this. Wednesday's FRCS teaching from our mentor group. Tonight, we have the pleasure of having really two big bosses here, one senior, our senior mentor, Mr Malek Samavela, he's known in the group.
He's a consultant from consultant, lower limb surgeon. And he's been supporting this group since the start. He's given a lot of teaching here, and he's elsewhere also. And also, we have a show on tonight's session is slightly different. It's going to be a clinical session, so we will have an examiner who is Mr Movado and we will have a patient who is jobbing his registrar.
I will have a candidate exam candidates who one would be one of you. So I know exams coming soon. And we will get the preference to people going for the exam. It will be a very good practice for you guys. So please, whoever is interested in taking part, raise your hand to be next to your name. There will be a hand symbol. Please click on it so I can know you're interested in participating.
And we will give you immediate feedback. And they're not going to be any timing down. They come in here to your room. You are doing intermediate case now and come in and know. OK thank you for us. Thank you, Sean, for being there for everyone. As you know, this is the first we've done. Last time we managed about, I think, six or eight weeks ago we did the history and then we started on clinical examination and we said, let's try a clinical examination for this group.
It's going to be difficult, but I think it worked well last time. We won't do it with time, like Farah said, because we want to do really. And there are hundreds of books. There are hundreds of videos of clinical examination. But what me and for us and Sean will always try to say, this is geared for you and it's your talking so individually talk and I'll try to make it as simple as we can for the knee examination.
So if we go slow and we'll do it for about one hour, one hour, 10 minutes, and if we don't complete the clinical examination, it doesn't matter. We can do it the next day, but we have to be as thorough as we can. And that's the basis of this. Let's be thorough. There's no weakness about this today. Some of it has come to my.
Yes, of course I do a little bit of that and it's exactly what I do there. But let's try to do it in this webinar. So I'll just start now just to recap for everyone, Samir, do you want to just tell the group it's your intermediate case and this gentleman is sitting here, so now he's sitting on his chair, ok? Can you see him sitting there? Yeah, Yeah.
OK and this is real life for all the candidates. OK, so this is the only medication you've taken a good history for five minutes. And I'm telling you as examiners. Yes, Mr mizutani, please carry on with your clinical examination. He's sitting exactly like this. So carry on and see what are you going to say? Yeah, Hi.
I'm assuming it's funny, is it all right if I examine your meat and remove your trousers, socks and shoes and fasten your shoes? And do you have any walking aid? Well, yeah, I resisted. OK, good. So somebody, can I stop you there for a minute? All the candidates, this is just the cap. Like I said, somebody came to my class last week, so it's a good that he started off.
So for everyone. I'm telling you, please accept this is the best opening line for any lower limb case. OK, so for any lower limb case, you're going to sit there and say hello. Don't say your first name or surname, Mr. Please, can I examine you? Don't wait for an answer, but say, is it all right if I examine your left knee?
Please move your trousers, your socks and shoes and pass me your shoes and immediately in the next breath, do you have a walking stick? So this way you will never forget walking it. Yeah, everyone. Yeah know some of you. You carry on that you shoes we did last time, so I don't want to repeat the shoes because it's there in the last clip.
OK OK, so at this stage, I'm here the shoes. You would pick up the shoes and you will describe the shoes and the patient is ready and waiting for you completely exposed with his underwear on. All right. Yes here now. So this carry on. All right. Yes so what are you standing up now?
Yeah OK, what do you want him to do? Yeah so why isn't he standing there? I look at his knee from the front. From the flight and from the back. So while examining it from the front, I look, if there's any threat, if there's any wasting of the quadriceps or are there any cause of sinuses and is there any obvious deformity or shortening, which is apparently OK now for everyone?
We always think that we are, and this is your practice for all of you, that we go through books and like Samir said, he's stopped but something. If you don't mind what I want now, which is the difficulty for all candidates and for you, is whether we should talk or not talk. All right, you agree. That is one of the controversies. And how much should we talk?
Go beyond the inspection now? So from the front? Yeah, imagine this patient has a swelling in. Got a virus, right? You have to imagine some things. It doesn't matter if it's a real patient or not for all other candidates. I want you to speak in a particular manner. So just tell me this.
So imagine this. You've got a swelling in his knee. You go to various of his knee and you've got a midline scar or a knee replacement. Ok? OK. What are you going to do? An inspection from the front? He's got a swelling, which is around his left knee.
He's got a scar, which is healed by primary intention on the anterior aspect of the knee. And there is no sinus and he's got a virus deformity, which is obvious and there is no discrepancy. Moving on to the side, there is a comeback. When you move on to the side, have you given him instructions? I'm moving around him.
I'm asking him to stand there. OK, fine. So let's stop there for just one minute for all the candidates. There's not controversy, but each one of you stick to one thing. You know, you walk around for every patient, which is put me on a hip or you make the patient turn round. The Russians want any tips on this or what you should leave it to them.
Or should we tell them what to do? I personally make the patient. I give a command to the patient to say, face this wall, face that wall, face me. I do it like that. You think you advise them one way or the other? My my preference is the same. To make the patient turn around, you might be in a room, which is very small.
I think it's more difficult for you to get around. And you look awkward as you're trying to move the chair out of the way to get around to turn. That's your view. I think it would look more professional if the patient moves, however, you judge it sometimes by the patient. If you think you can take that patient who is not very cooperative and you have a difficulty moving and think you don't want to waste time with understanding you can move them, but generally is better, more professional to make the patient.
So let's accept what feroz is saying. But let's say 90% of the time, stick to 1. So you've said it very well. I don't mind you moving. It's not hard and fast, but let's imagine somewhere that you are not moving around. What order will you give him now you want? So it's a left knee. So what do you want to do?
Yeah so if you could turn to your right side? Yeah so yeah, so can I stop you there somewhere for all patients and for your information for the candidates, try not to ever say left and right right. Yeah, we say, please face this wall. Yeah, that wall or face me. Yeah, right? And even if you're in the future, telling him to do treadmill test, why are you going to stand on the left and don't say left or right?
It will all be good leg and bad leg? OK, all the candidates. The little small tips like this make you talk much more professionally, ok? Otherwise, you get confused. You say left, he says right. You know you're playing fooling around right. So someone just tell him, please face that. No, please face that wall.
Now he's there standing like that. Yeah, like this. Is the knee visible? Yes yes, sir. Yes, sir. Yes, sir. And from the side, I can appreciate that, that he's got a flexion to form flexion attitude of the left knee and moving on to the back of his knee.
Excuse me, sir, could you turn to that wall? So Yes. So from the back, I there is fullness in the complete fossa with the raising of the hamstring and Solis muscles. So if you could face back looking towards me, please and. I also see the pelvis level is a pelvis is the same level in this girl.
Yeah so some of you, you're not very well. And like I said, I'm just for the others. So what have you done so far? And this, if you want to write down or you want to take some tips because this is not going to be in any textbooks, it's an amalgamation of what is the integral that my way is that when you start from the front, let's start in my mind. I divide my examination of any joint into three parts.
The first is swelling and wasting come together. All right. Yeah Yes. Yes and second, big heading will be scars and sinuses and this headache, deformity, deformity from today onwards. For all of you, whether it's your hip or knee or your shoulder, you will start by saying so somebody, you stay there. You start by saying on his left knee the swelling of his left knee and this swelling and wasting go together and immediately the next word would be there is or there is not quadriceps resting here, right?
And then you'll go into your skull as if you are in the real FR case exam. Yeah, OK, OK. So this is a continuation of imagine you are some here and you've seen a scar in the front of the knee, right? OK and/or it's a scar anywhere in the body. So this is a good shot case. You'll have a scar for nonunion, you'll have a scar somewhere in the humerus, so he's standing in front of you again.
He got a midline scar. Just describe a scar. What do you see about a scar? Yeah, I can see a midline scar on the left knee on the PBS aspect, and the sky is well-healed and no features of acute infection or inflammation. And looking at it seems to be a surgical scar, which is healed by primary intention. And I can't see any features of sinuses or any infections.
I want to visit. I want to pick the I'll talk with the easy talk if I ask any tenderness of regarding the scar. Yeah, don't worry, that was very good at. So coming back to scar for everyone, the way we do scars is that, first of all, describe where in the body it is. So and there are some classic scars. If it's a classic scar, you need to say the name.
But what is your classic scar in the knee called it's a midline incision? Is that correct? Yes and then off in the anterior aspect of the knee, he and it is of 12 centimeters or 14. So we'll talk about the way it lies in the body. If it's a classical skull like a deltopectoral or a bra strap incision or a Yes or a Smith Peterson, you would be saying that directly.
It's a Smith Peterson skull. It's a scar, it's a bra strap. You hear what I'm saying? Yeah, yes, Yes. And now next, you say it is 12 centimeters. Now the next thing for everyone. Just say it's healed throughout its length by primary intention. OK, just use that word.
Suppose it's healed in the pop part by primary intention and a lower part by little puckering. You will say it is healed by primary intention throughout its length, but in the lower end of the scar, I notice it is healed by secondary intention with surrounding redness with sinus or is healed by secondary intention. But there's no sinus and no surrounding it. Don't use the word acute infection and things like that because you're not going to get a patient like that, right?
All you're going to say is, is it got a sinus? Is the surrounding redness? You agree. Yeah, Yeah. So let's use the two words that are sinus, and there's no surrounding redness of the surrounding redness, and it's healed by primary intention or Secretary intention and the name of the scar. Clear OK.
Yeah is that all right? Anything else you'd like to know? Absolutely correct. Keeping it succinct. The only criticism I had before Rajiv was repeated yourself. There was finally healed by the intention. Well, demarcated anterior scar with no signs. That's correct. Exactly that's exactly what we are trying to say, that the words coming out, you have to write down what we are saying and it doesn't matter if me Faraj wants it.
Can you say it in 30 seconds or maybe 10 seconds? Yeah and your words, your writing, your words. So, so write it down and repeat it. And now. Carry on. Imagine that we've done the scar in the stand in you. I can't see a significant left side me, whereas deformity and it's about by inspection. It'll be like 20 degrees, whereas deformity and looking at the lateral view also, there is no worry about.
That's fine. I get this for everyone. I get like, what? What one will agree with me? You said it right, but we can just be very short, very suction. There is various of the left knee compared to the right. Don't worry about using the word significant. Don't worry about using the word 20 degrees.
You can't really measure it. Don't say things which are not true. So my personal opinion would just and don't use the word deformity because it could be attitude, cetera. Right so just say there's a variation of the left knee compared to the right or there's values of the left knee compared to right. And I would not say anything more because you need to move on and you're saying things correctly.
Agree Sean Faris Yes. You have to be very focused again with this one. You might think you have time 5 minutes for examination, but there's very little time and you have to go through it quickly. So be as clear with your instructions, the patient as clear with describing your findings to the examiner.
So there's no, you know, fully understand what you mean, and you don't have to guess what you meant and whether a 15 by 15 is your 20 or 25. So don't get into that yet, right? Happy with that. Yes Yes. OK, now, ajit, what do you want him? Do you want him to turn round? So tell him, given the instructions to face the wall?
Yeah would you mind to turn on this wall, please? OK, now he's now Ajit. He's like this. He's dead. Yeah, Yeah. I can see a flexion deformity compared to the right knee and his ankle is also I can see a little bit transposition escaping. So it could be functionally fine as a position because of his suffering from flexion deformity.
And it's roughly it's about 15 degrees flexion deformity of what? What are you talking about? Knee or the ankle flexion flexion deformity of the knee? OK, fine. So once again, I get very good. I think you picked up two good things with some it did. But the so from the side, everyone, just for everyone. Just to recap again from the side one of my three headings again.
What are the three headings? I have linguistic scars and sinuses and deformity. Right so now you're very right from the side. We are all orthopedic surgeons. We know that 90% of the time there will be no swelling or wasting on the side of the knee. So you didn't mention it, so don't mention it again. You agree that most of the time there'll not be any sort of lateral aspect.
So don't mention it again, but the form of dementia. So once again, what? I'm sorry I missed. What word did you use when you did you say that reflection? What? the affliction flexion deflection attitude, right, so let's use it, deformity, yeah, seriously. Right, so let us all agree. It's not bad.
I'm not saying it's wrong at all, but just to be safe. Let us all. If you're inspecting, let's use the word attitude. So there's a flexion attitude of his left knee. Are you happy with that traject? Yes OK. So use the word flexion at your left knee and then you go and look down. That his foot and ankle, if the foot and ankle is absolutely flat on the floor, what is the phrase you will use?
Integrate plan degree, so you will. Correct so you will say he's got a flexion attitude of his left knee with a blunt decred foot. Happy with that, everyone and judge it. Yes, Yes. Now, if he had like you saw, he was holding his ankle in. Don't worry about anything about the amount and don't give the explanation. Just say you go to flexion attitude of his left knee with egawa test at his ankle.
Happy with that. Yes repeat it again. Just repeat that statement. He got up. He got it. Here is a flexion at the knee and so forth. Egawa a attitude is it 14 equine? Is the ankle in decline so. Sorry sorry about that.
Its knee is in the flexion attitude and his ankle is in the position. Yeah so and that's all you say and. You agree. Keep it short as well. Absolutely if I was the examiner and you said deformity, the first question I'd say is, how do you know it's a deformity? Fantastic thank you.
Excellent Yeah. You see, so don't get into controversies where you have to get out of it. Happy with that object? Yes yeah, you can. You can always if you say something, but you could always withdraw from it. If you said deformity, you're not sure to say, I'm not sure this deformity.
Maybe I will confirm that with my examination later on. So if you said something and you want to withdraw, withdraw it, you could always do that. Yeah but more importantly, I would just say write down and don't even say anything else, you know? But if you make it my mistake, like I said, just withdraw it. But don't do it as intentional mistake. Just do it that you'll say attitude. And like, if you made a mistake for us is very right.
You can just withdraw whatever you want. No one's going to hold anything against you. And I would say Ajit do not give in a clinical examination. This is, I'm telling you as just direct advice. Please do not give explanations for anything. We do not want explanations unless we ask you as examiners. OK, so you are not to give an explanation that the equine was due to this or the other. If I ask you, please volunteered.
Otherwise, just give your inspector your findings. Happy with that logic. Yes yeah, you're not going to score any more marks because you're losing time and giving me a minute and a half of something which I wasn't on my grid to mark you. You understand this thing. Sinuses and deformity. So say again what you see.
So I cannot see any scars or sinuses. There is no swelling. I can see that he has got his knee in a fixed altitude infection altitude position. Can you say flexion altitude from the back when he was holding his knee in the first position? That's why I said it. No, can't. You can't say that.
You can't see it from the back, right? Yeah so what I'm trying to tell you is just let's go back to just because this is not in any textbook. So anything. What we tend to do like MRC style and we all do it. We try to just repeat the same thing. No scars. No this no that. Try it in your mind.
Compartmentalize again, that on the balance of probabilities at the back of the knee, the correct orthopedic world would be swelling awfulness in the optic fossa. That's what you expect, right? So if you say there is or they know, so let's imagine there is no swelling. So just say there is no fullness in the popular fossa. There's no fullness in the pocket fossa. Now that sounds a little more.
You know that this guy is sounding more knee oriented like a, you know, rather than just saying all this swelling sinus like, that's all I'm saying. And you agree that in my heading, you always whether it's the deltoid or with the humerus, you will always say there's no or there's associated muscle, right? So you can see more fullness in the popple fossa. But I notice this hamstring wasting and this calf wasting right or there.
Yeah, so see it. So there's no for less than the popular fossa, but I notice that they've got some resting in the calf or hamstrings. Do it always have to write it down, you remember? So you always go to the thigh with the hamstrings and we can't see no scars. So let's not say anything about scars. And as you know, there's not much of a deformity you're going to see from the back.
You agree because you already talked about it from the front, so you don't have to say it again. Right? so now you make the patient turn around again in front of you. Not at all, for me. Now you can see the knees now. Yeah now for everyone at this stage, you have to inspect the joint above and the joint below, right?
So they've just verbalize what? How are you going to? You talked about the knee done, the front, back, side very well. And now how are you going? You're going to finish in. Inspection by doing joint and joint below. So how are you going to talk about the pelvis? What are you going to say?
What is the phrase coming out of your mouth? I'm going to say that the pelvis is in the pelvis. Is is it an equal level? Just not. No imagine it's your exam. You're talking to me. And first and 2 on the pelvic is an equal level. I cannot show them the scars that are on the hip. There is the OK.
So what I would just say is that when you talk about inspectorate finding the joint above and joint below, I would really say don't get much into the inspectorate findings of scores unless they of course say it. But the only thing which will most likely be there is the deformity, right? And that's what he said was correct. Just say the pelvis appears symmetrical or your phrase was right, but stick to 1 phrase.
Yeah so what phrase are you going to say? The pelvis? What? what is your phrase? The pelvis is, is at an equal level, equal level. Yeah, now you stick to that, it sounds good. It's your phrase, but don't change it tomorrow to something else. That's what I'm saying. Yeah very, very nice.
And then if you notice scars in the hip, you say, but otherwise, let's not say that. And what about the foot? How are you going to talk about the food? So the feet are at an equal level as well? And I can't appreciate any deformities around the ankle. So in the knee problem, what associated common foot problem would you associate with a bad knee, for example? Let's say it's a 19-year-old girl with a bad knee.
What would she probably have in a foot and ankle? So she could have a collapsed argument, she might have that very likely flat feet. Yes, you agree with that. Yes well, so and so therefore you can say I notice that the feet are satisfactory and there's no particular collapse. Arch you know, that's what you're looking for, right, Debbie.
So we've done that. Have you done your inspection now? What you want him to do is you want done, you've done your inspection very well. And we either nod or we don't not. But you've said all this. What do you want to do now? Can you take a few steps for me and turn around and walk towards the wall and come back towards the office again?
OK, so what is the exactly like this? I know it is a little difficult. He's standing so far from the camera. I give him instruction. Give me clear instruction. What do you want? Can you turn it on and walk towards the wall and then come back and walk towards me?
What it. Yeah so I can appreciate that he's working with little, as demonstrated by a short stance phase. OK, carry on. What do you want to do? He's walking toward you.
You told him to walk towards you, walking towards you and you stop. Stop no, please. Yeah and then what do you want him to do? OK, so I've already verbalized that he's walking with the gait. And can you lie down for me in the couch, please? Very good. Thank you.
Just a point for you. You did it very well. So please understand this is exactly what I want everyone to do. Control the situation and swan for us. All examiners will tell you. You want to see you control the situation? All right, we do not want. It's not your being arrogant.
You want to control it like you did. You decide that this guy walk in the room or not if there's a chair in the place? Please go and move the chair. If there's an examiner there, please tell the examiner, please move away. You're very clear instructions to him. Yes, please walk. What I tend to do is I tend to make you start going as far away from the patient as you can.
Don't make him turn and walk away. That's confuses him. Please walk towards me. That's the best advice to give. Walks towards me. And when he comes as close to you, say, please turn around and walk towards that wall, right? Like you said, and go from the side and watch him and then don't talk to the examiner during that time.
Because if you start using words like repulsion and this and that, what will happen is that this guy is walking around the room, not knowing what to do. So you finish this walking. Tell him, thank you very much. Lie on the couch. Look at the examiner and say he got up and told you get a puppy. Yeah, so do that.
Repeat again. Just say walk to us just to tell him he's not there, but just say, what are you going to say? Walk to us or walk towards me. So can you please walk towards me and then walk towards the wall? Then turn around, give him clear instructions. I want to see that turn round, so look towards me. Turn around and walk towards the wall.
Yeah, and you're going from the side. And then what are you going to tell him? Thank you very much. Thank you very much. Lined on the couch and then immediately look at Sean and tell him this patient. This patient has an end target, right? But you can't take your time in this. You have to be very quick.
Yeah so but the next advice to you for the clinical and is I'm telling you as I've done, you know, I've given my course for 10 years. I've been with Kevin Sherman. I've been all the examiners in the short case or in the intermediate case, your marking is just identification of a gait pattern. Your theory about whether it's a foot propulsion, whether it is a short stepping gait, that description is going to be tested on your Viva station.
OK, so I don't want any of you all to go into this long spiel about this is they're short that unless you're asked if you are, say it that way, just identify it like you did, ok? And for us, that is my view. I don't know. Other people may not agree, but I think that is perfect. I think I just want to say, sorry, Sean, go ahead, Sean. Go ahead. I'm no after you first.
So please, no. Just a simple thing I want to say. You can't show that obviously to you this video conference. But I would recommend that if you are describing deformity of any part that you, your eye side should be at the level of that part. So if you describing a knee, you bend down actually to the level of the knee you're describing your hips, you bend down to the level of the hips where you look at it just so of examine that it's like a driving test.
You're showing them bending down or you squatting down to that level as you're describing the deformity. Absolutely, Yeah. In terms of as just one other thing about when you're describing the gait, steps and things like that, you can get yourself into a lot of trouble in a clinical scenario. Just use succinct words just like we talked about in the scar.
Just this is the normal, normal heel to toe pattern or normal antalgic gait. Leave it. Don't explain it. Don't do anything. Because that's if the examiners want you to describe it. That's where the marking is. They're asking you guys move on to the rest of the exam. Thank you, swan.
Thanks Thanks for clarifying that it is something which you agree. All the candidates are always worried. You're always saying, let's say this more because I'll be impressing them. Believe me, you're not because you're going to say something wrong, because you're so stressed. I want you for five minutes. I just want you to describe just the gait pattern.
Like Sean says, one is an traject. Just tell me what you mean by until you get that is a short. It means that the stance phase is shorter, so let's keep it that simple. One that it stands for is shorter. What is the second most communist or we? So just give me one at Brandenburg Gate. OK, so now please tell me and my co examiner, what do you understand about Brandenburg Gate gait as you are examining the objective mechanism?
up the mechanism includes the pivot, which is a giant, the lever, which is the building structures, the head and neck and the muscles that we through this medium. Mm-hmm So you cross the patient first to stand on the bad side? Mm-hmm So I mean, it's just kind of look on the bad side. Yeah so where the patient stands on the stand, on the good side stands on the good side, the opposite sides pelvis tends to get down, but that's prevented by the intellectual objective mechanism.
And as a result, the contralateral pelvis lifts up. Whereas the patient, when the patient stands on the bad side, the contralateral pelvis dips down due to gravity. I mean, what you said was right, I would say try for a clinical scenario. When we ask you when you say it was a treadmill, birgit, I'll ask you why you don't have to go into the explanation. If you don't mind Ranjit about the pivot something, just say when a patient stands and a little tip to every candidate in yourself.
Always, if you're going to explain something difficult, could be walking. Length of the nail could be a tension man principle. Just say what happens normally in life. OK, so just tell the examiner. When the patient stands on the normal hip, the pelvis of the other side lifts up, and that is normal. You agree. Yes in about five seconds, I've said what you said when a patient stands on a normal hip.
The pelvis of the other side raises that is normal. Then say when the patient stands on the bad hip, the pelvis of the other side sags. This is the basis of the treadmill test. And if I ask you what happens, then you explain. Right? Yes. Now what is the third commonest or to mitigate it? Yeah let's be simple, and let's stick to bilateral trade, which is called whatling.
Get everyone happy. Yeah, that's a common gait we see in the older population, right? So a person walking towards us waddling, you say this is a waddling gait. Potentially this could be a bilateral trade. You're talking sense. Yeah fourth will be a short legged right. That's what he said.
Yes, please tell me. What do you understand about short legged short luggage means when the patient walks, he would tilt towards the lateral side? Mm-hmm What do you mean by oscillator? Yeah, the short lived side. But like you said, keep your right. You're very right. But if you keep to the same nomenclature, when the patient stands on the affected hip, the only way you can get that hip down to get his foot planted it is that pelvis dips down.
That's what you're trying to say. That's true. Yeah, that's what. So stick to the same nomenclature when the patient stands on the affected hip or the bad hip, the pelvis will group down on that side, and that is called a short leg, which is exactly the opposite of a general. Yeah, that's a short leg.
51 high stepping gait. Yeah so high stepping gait is in common is in good drop. Yeah so you have to have a high clearance. And now if you're asking, you have just finished. If you are doing well, what are the three other cerebral palsy gets? You got a strange gait. Yeah, good one. Scissoring slap lesion.
Then you get crouching, crossing it. Yeah, and third. Windswept, OK, so everyone, so I'm just giving you a little gait patterns, because if you get a difficult patient, you just say these gait patterns here. So we finish the fight so that five orthopedic gates and Tajik Milberg bilateral training bug, short leg and high stepping or foot drop.
Then I divide my mind into three cerebral palsy will be where you have tightness of the adaptors. I can be a crouching and that crouching could be flexion at the hip flexion of the knee with or without Equinix at the ankle clip. And then you can have a wind-swept wins by means latching on one side and values on the other. Yes, or windpipe. And just to finish two or three neurological gait patterns.
Common neurological gait that. Parkinson's, what does a get in parkinson's? I got a certificate. A shot, shot shot, stepping it or shuffling it. Yeah second is a. So let's get production, get in, hemiplegia, Yeah. OK and then what do you get which you're going to get in a spine case?
What are the common spine cases going to be? But it's going to be a collapse with. But what do you get, what do we get a posterior column sign problem? What will the gait of a posterior column problem be? A proper Section will be lost. So will. Broad basket. OK, yeah, so what I'm trying to say is we all know it, but if we can identify it for a patient, we are very confident now.
So you have 10 kids, so you are really looking forward to a lower limb. It could be spine, hip, knee. You're going to see it in any course you go to now in any exam you do now say this is the case. I don't think any more gates there are strong any more gates you want to talk about, which are coming up next. Pretty much covers everything.
The reality is, if you're short, if you can't get the words, just describe what they're doing. Yeah, absolutely. Yes, I have a question. So the gave you just name what it is, and then move on. That's that's all that's required that I'm most of the time. If it's a very clear gait like an Intel or a peel-back or a foot drop, why did you say what it is?
Then if I ask you or one of us, ask us examiners, explain it. Otherwise move on. Control it because it's your intermediate case. You've said it and you've moved on. That's what I'm trying to tell all of you. This is the only time when you actually have control, and if you don't take that control, you're open. Unicef, the control say, yeah, this is it. You're going to.
Until you get these, please lie down and then charge towards him and do the line on examination. So therefore there's no chance of him to ask you anymore. But if you stutter. And this guy is walking around in his underpants, they're going to ask you something more. You see what I'm trying to say? You control it for that time. I just want to say, yes, absolutely.
It's your station. You need to control it. The examiners might not always guide you through. And if you say something about gait and they dragon about gait gate, yeah, you're not going to pass that because you still have to do all inspection. You have to move. have to feel the joint. You have to discuss the management.
You have to do all of that. There are tick boxes for each one of these. And if it is a short case, it's possibly just about gait. It could be, but that case will never be just about gait. If you stuck on gait, you're not going to get anywhere. Even if the examiner wants to keep talking about gait. You try to move on. Yeah, absolutely efficient. Yeah hi, how are you?
Hi, Mr. Yeah treat this like this if you are in real exam. Yeah, OK, so take it seriously. Yeah, Yeah. Now you want to just recap you had finished your gait better, and now you've told the patient to lie down as you ask, do I know you've done it with me before? But do you want to do something next or are you lying down next? What will you do next to everyone?
So once the patient won. Yes, he's variously partially improved after lying down. No, you want to do lying down or do you want to do sitting? You know, do you want to make the patients sit and do sitting tests or do you want to do lying down? And no, I would like it is his comfort. Probably he is comfortable by sitting like that, so I would sit him like that, you know, lie him, lie down flat.
No, what I meant is that you want. I know you want him to do sit on the side of the couch or you want to lie down. I would for him to lie down. Yeah light up. So just what I'm trying to tell all the other candidates is that at this stage, there's always a controversy that when you finish your gate, people make the patient, sit on the chair or they make the patient, sit on the side of the couch and they do Sitting Test next.
Is that right? Well, it. Most people do that. My advice to everyone is that sitting tests are only important for mainly patellar framework. They are very difficult tests to do. And in my AIIS and in my way of doing things, I put on the special tests and a 70-year-old man. You're not going to get much information from sitting so late.
I advise that. Do sitting later on. All right. So let's all agree that we lie down and do the lying down test next. And what Walid was trying to say, if it's a knee, the patient does not have to be flat as a pancake. You can be sitting uncomfortable with some pillows, but he's on the bed.
Now, while it is now lying like that, you can see the knee. I know it's difficult for you to do palpation now, but what are you going to say? How are you going to start now? So my first phrase his yeah, his virus needs is improved or immunity. So thank you a little for everyone. All the other candidates write this down as you noticed the minute you finished your gait and you make the patient lying down.
Your mind goes into a blank. You agree. Your mind goes in a blank. That's life because you're doing something different. So you have to have some phrases which make you kick start your mind. So for me, the best phrase which you just go on is that there's only one inspectorate finding which will change by lying down to standing.
And what is that? Is your value. So varies. So when the patient lies down, just look at them and say, Yes. The various of his left knee has improved or the variance of the left knee has remained the same. That kick starts your mind. And next, we'll go into what? So what do you want to do next?
Will you tell me what can I do it for? You know, I'm going to touch you need by the back of my hand? Yeah so what are you looking for next temperature? Yeah OK. Now this is difficult. What I would like now is the time where if you were in real life, you as a candidate, well, it would have been actually doing things. You cannot do it to this patient. So in your heading would be temperature.
Is that right? Really, that's what you're saying. Yes OK. So for everyone, what I would do is I would say thank you very much. And I'll tell the patient, and this is what I'll do. I'll put both my hands like that. Thank you. And if the knee was warmer, I would tell the examiner the left knee is warmer than the right level it.
Yes so at the same time, now we have this controversy in inspection, we decided how much to talk and not talk. Now, when we come to the painting, which we are going to start now, let us be very clear that don't listen to people who have told you. Go on talking. Go and talk. You cannot do both things correctly at the same time, and please decide all the candidates.
Are you talking to the patient or are you going to talk and verbalize a statement, right? But at no times are you going to mumble about anything, so if you're going to talk to the patient? So I'll tell you how to do it. So what did you do in your first and you make a statement left me is warmer than the right next? What do you want to do? Now I'm going to bend your knee.
I'm going to move your knee. Let's bend it together, right? Fantastic so I'm doing that for you over there. OK that's right. Now, what do you want to do? Now I'm going to feel around your knee where my finger is. Is that sore? Yeah now I'm moving to the inside. The inside, if you join, is that so?
Yes, that's fine. And what about the medial ligament, the femur attachment, the midline? Good That's right. I know it's difficult. Yeah, it's great. What about the outside of your joints? This point is, is that hurt? Yes, fine. What about the back of your knee?
Is that toll now, OK, I'm going to move you on. Let's do it together. I'm going to move your kneecap outside feeling underneath. Is that so? No now I'm going to move it in. Is that soil? Yes likely look fantastic. Thank you very much.
Just for everyone. What I've done and what Walid is very clearly demonstrated that we all agree that his focus was who? Who do you think his focus was? He was completely the patient. And I want all of you to realize that there's only one important person is like Walid was completely bothered about only the patient. If you're an empowered patient, especially for 10 minutes, there has to be a complete rapport and the talk has to be with the patient.
Ok? you have now. So let me just recap how I will do it, which Walid did so for everyone. If you are going to move a limb, it could be the knee. It could be the hip, it could be the shoulder where you want the hip or the need to be. And you tell the patient we will move the knee together. Happy with that.
So I tell the examiner or the patient, I'm just going to bend your knee. Let's bend it together. OK, so this means he's not fighting you. I don't want anyone to do any palpation of the knee in the extension. It has to be done in a degree of flexion. All right. Well, you agree with that.
Yes, sure. Now I divide my palpation into three parts. There's a front of the knee, which is your anterior aspect. There's a medial, there's a lateral and there's a back. So let's repeat again. There's an extended slap mechanism. There's a medial, there's a lateral and the back. So I'm going to start by telling the patient, please let me know where my thumb is.
I want to be very clear. And what am I pressing here? Well, it is. The tibial is the front of me, which is the tibial tuberosity. Yeah, right? Yes well, and I'm feeling now just for everyone. What I'm feeling is the less is the pole of the patella suggestive of patella tendinitis. OK then I go up and I feel the top of the patella, what is that for?
Well, it is a quadriceps infection. Yes so what is that? What, what are the diagnosis? It'll be quadriceps tendonitis. I'm looking for clinical scenarios, you see. And then if I feel a gap, I'm going to say there's a gap palpable, which could be all quadriceps rupture, which is a common short case, right?
So it's like starting in the front of the knee. You see, just what this is for everyone is that's all. No, no. Is this all is? That's all. Yeah and oh, there's a gap there. You see what I'm trying to say. got that part down then because the camera is facing here and next go. But let's do laterally.
Let's see. This is that's all. And you see that well for us. Are you seeing that? Yes yes, very clear. Is that. So and this soul? And then this bone is important for me. Is that what am I indirectly telling the examiner?
Well, it is a fibular head lateral collateral ligament. Correct? and is that so? No, no. So what have I done? So the lateral side is the entry of lateral middle lateral posterior lateral attachment of the ligament and femoral attachment and then the same on the inside left to the inside.
So what am I doing here by 800? Yes Yep. Medial and posterior. And then the attachments of the. Collateralized debt. So see how particularly about the tenderness, then. Not not bad debt. Thank you. And then I straighten the knee and just can see what I'm doing.
I'm going to move your kneecap. Just tell me where my finger is. Is that so? I'm taking the latter facet. I'm moving only in words with my think that's all there. Yes, that's the media facet. Yeah, so we've done tenderness and it's been so thorough in 20 seconds and you've done as you do it. Stick way.
But Mr Murdoch's trying to show us the certain buttons that could be reproducible easily for everyone. And yeah, and Thanks for that for us. Sure so now we are on to the next part, which is we've done temperature, we've done tenderness right now. What in your heading is going to be next for you? So the next thing will be I will go for the look, feel and move then.
Yeah so you've done your look, you've done your feel. And are you going to movements right now for move? Yes OK, now remember, Sean raised a very important point. What is one thing? He said something very correct that he would do swelling tests before tenderness. And he would do he did it for a particular reason. Also that if you're going to do movements next, a large swelling may impair.
Maybe the cause of your movements are correct. So now is the time. Unfortunately, Sean, where I would do the swelling test, you see. So I've just changed it one not for any reason, just to be slick. So it's easier to do the tenderness first. That's all. That's true.
Yeah so I'm just I would advise you before you move, let's do swelling tests. All right. OK, so imagine let's bend up the knee. Now or now you take control. You tell me what you want to do for the swelling test. What do you want me to do? And I'll do it for you. What is the swelling interest?
Can you leave your knee flat? OK, she's down now. What do you want to do? Thank you very much. Now I am going to see the looking from the top to hold the suture pouch. Exactly so and then I'm going to move swipe from medial aspect. Yes and then and then a swipe from the lateral aspect and then see the bulge on the medial aspect.
Fantastic fantastic. What do you want to call this test? This sweet test, yeah, right. So very good, you said it like that, and I'm telling everyone that all these tests, you can call it swipe test, you can call it feeling test, you can call it whatever test you want. They are all the same. The principle is, and I'm telling you what I see happening very often is that when you ask people to do these tests, Amjad said it very right what he would do.
But I'm telling you, I see everyone doing this. They come there. They're very stressed. They start doing this. They start just massaging the knee in different directions, not really doing it with any purpose. So let's all do this test together. Let's watch. The first thing for this test is what am I doing?
I'm making sure that I get all the fluid into the knee, so my hand is on the quadriceps, right? By push down on the Super suprapatellar pouch. I'm just all right. Yes, correct. I don't want your hand. Your hand cannot be stabilizing the patella, right? Because otherwise the patella does not move clear right now when you did your test, right?
What is a swipe test important for? Is it for a small effusion or moderate infusion or a large infusion? It's for small and moderate effusion. So most of the time is for small one, and you agree it's a difficult test to do. So my advice to you object is let's do the patella tap test first.
OK OK. So when you do a patella tap test, guide me through the same thing. So my hand is here. Yeah? so your approach? Yeah and then what then I just push on the patella and tap on the patellar like I'm doing now. I couldn't see it.
I go on the other side. Yes, that would be better. Thank you very much, Mr. Yeah Yes. We can see now clearly sorry about not wanting the patella, but here my hand. Yeah and that right? OK and that's your patella. My advice to everyone is just do whatever. Tap first.
So you're going to do it. Imagine if it's positive. I want you to verbalize it so you can get. But before you do that, are you going to dial things like Sean said, are you going to tell, what are you going to tell the patient? So I will get a resonance. So in this test, I'm going to hold your leg from the top there.
Let me know if I cause you any pain. OK, I just want to be able to afford your tie and I'm going to top on your kneecap. You'll have to say so much. That's what I'm trying to tell you now. You don't have to go so much to just say, I'm going to do a test, I'm going to hold your tie and let's do that. OK, now what is it?
Do I want your hands to be removed from this? I don't want to just go and do this, and I don't want you to look at the examiner because who's the most important person? The patient? Right? yeah, I'm looking at you now, but seen the screen, but otherwise I do this. This watch you can examine and tap was positive.
So I want that manner to be done. So your first patient, you finished the test. Your hands are away. Look at the examiner immediately as possible. All right. OK imagine if the patella tap was negative, you were force through your next test, which is your swipe test that I'll do again. I don't keep my patient, Mr Mehta.
I'm just going to do one more test. I'm going to squeeze your card right? Then in my mind, I just move. See what I'm doing. I move the leg outwards, so my AIIS are looking at the medial side of the knee, right? And what do I do, I empty the Mediasite like this very clearly. And then you can wait for it to feel which is called the filet desk or the typekit along by swiping on the outside is a very simple thing to do, right, like you said.
Is that correct? Yes, that's exactly it. OK so this is for everyone to repeat. The simple way of doing it is squeeze the quadriceps, get the fluid into the propeller pouch. Your mind's eye is moving a little, so you're going to see they're empty the inside and help along by swiping on the outside. And that's your feeling.
Yes and the third test is victory finding. So what I would have said, suppose it was a short case. Like you remember, Farah said that supposedly sometimes focusing on short case only on swelling, for example. What is your first finding of a swelling of a small failing? What would be the inspector refining of that? So swelling or waiting? Yeah, you can. What the word would be that when you bend the knee like this and you're looking from the front, you will say there is obliteration of the furrows on either side of the patella tendon, you see.
Isn't that a small, subtle sign of a swelling? Yeah so repeat it. Yes, there the obliteration of the various on each side of the tendon. All you can say, there's fullness on either side of the patellar tendon. Use whatever phrases you all are happy with. But stick to 1 phrase, yeah, OK. And then you will say, thank you, Mr Mehta.
I want to keep your knees straight and then you do your Patel attack. Then you do your swipe test. Yeah, OK. Yeah lovely. Good so you see, we spend so much time, but what me and for us and Sean have tried to do is try to say, forget about textbooks, forget about videos. It's whether it comes out of your mouth, the correct words and whether you can control right.
Which you have is the principle, isn't it? Obviously, you could read books about clinical examination, but this is how you should perform in the fastest exam. It's very specific. Can I ask you, Mr maximus? They've been asked about examining the normal limb in the exam. Yeah, for comparison, I know the books say this is the standard way of examining you examine the normal limb.
But again, this is exam specific scenario here and exam. I think if you start examining the normal limb, you have no time left to examine the. Yeah, I agree. And I like this is a common question. Everybody asked me in my course, and I can tell you guarantee that why are you worried about things which are not a worry for the examiner? Truly, they're worried for some reason.
Every candidate is mortally worried about that. But like we've said, if you start doing what we've done, so let's say you start on the abnormal on your bad leg like we've done for 10 minutes and we moved on. There's no place so far of doing anything to the normal limb. You agree everyone. There's no place when we have to do things like ACL, which we'll come to next time, then I'll tell you how I do it, and that's the only time that you may have to compare.
And that's when all of us can chip in as to where should we compare or not? Yeah, but for normal things, no. And even for ACL, I would do the abnormal limb. And if it is positive, I know it's positive. You know, I don't have to do the abnormal. So the answer is the correct answer is just forget about the normal limb concentrate with perfect technique on your bad limb.
And that's enough. Nothing more. I think that's what self-assurance I've done. The chatter is in Sichuan. Absolutely I think it's a case by case, isn't it? But I'm thinking exam. So there's to my thinking, there's only one useful reason to examine the other side in a five minute examination.
It's to compare if you've got an abnormality, which is bilateral or not. So for example, PCL rupture, rupture, ACL injury, ligament injury you're comparing what is the normal side for that patient to the other side is. So please tell the candidates that this is. Don't worry about it. It's not an issue whatsoever. I mean, if you would compare anyway during your inspection because you need something.
Exactly, exactly. Clinical examination. Again, I'm thinking if there is a patient, I think mainly ligament problem. If they are ladies, young ladies, they're thinking of ligament laxity or hyper mobility, then yes, examine that the other limb. But otherwise, I don't think, for example, the question on how much we talk to the patient and how much we talk to the examiners while doing this, it's very clear on this.
So let's all Mustafa. It's a very common question. As we've said in inspection, we have to say something and I. We knew that three phrases to say, right, and that could be anywhere in the body, so you were talking about a delta. You see the swelling in the deltoid region or supersprint is wasting, et cetera, and deformity, et cetera. You see all that.
You cannot keep quiet. You agree. You have to talk. The problem happens when you are doing. Tenderness in tenderness as one and everyone else says we will be concentrating on the patient only because that's the most important person. So you have to have a complete rapport with the patient, is it does it hurt here?
Does it hurt there? Does it here and do not try to tell the examiner while you're having a rapport with the patient that you have a medical axilo tenderness level, you're going to get it completely wrong. Just finish your tenderness with a complete focus on the patient, then look at the examiner and tell him, he admitted your NIPE tenderness with collateral tenderness and then move back to the patient.
Again, the focus I'm telling you that is probably the most for average person, but all of us are average. None of us are people who have these skills where we can talk and do everything perfectly. So for average person, the only way you can execute a correct tenderness is to rapport with the patient and then look at the exam and tell him your tenodesis when you go to special tests.
Once again, the most important is do the test with a rapport with the patient. Just tell him, I'm going to hold your leg, do your collateral, and then I tell them I drop the leg and then tell the examiner. There was reaction to the collateral ligament trying to explain the test at the same time as doing the test, 90% of people will get it wrong and get it perfectly. It's fine. If you it wrong, you're going to get wrong.
That's my. Not only will you get it wrong, but you'll miss of the non-verbal cue the patient is giving you. Absolutely so if you're trying to tell the examiner the collateral ligament is and you're still painting it as you're looking at the examiner, you've missed the patient's face. And the first Warning sign, the patient is in pain. Thank you, John, and I'm telling you, all of you, all your go to a number of people will tell you that they're not wrong.
The gold standard is to do everything, but we don't have the skills to do it. And like you said, you're going to miss the important points. So please accept do the test with a patient and then look at the examiner and tell them your result. OK, you agree. Should we give it a data format for from now on which one? And for us, that's the way. Yeah, that's very good.
That's good, very good way. And we could use the same methods in examining other joints also. Absolutely going through the knee and a lot of details step by step. So I think we covered the history in details. We covered the inspection gate, shoe examination and patient swelling and sweating, swelling, checking for the swelling and effusion.
So that's all covered now with the knee. We obviously still more to do with the knee examination movements. Next time will be movements and special tests, and we are done exactly one session and then we can have other sessions to reinforce this. For example, one, if you can show us, I can do hip again, you know, things like that. So we cover clinical art.
We had 67 people registered for today. Thanks everyone, particularly to those who came forward to talk. And I hope you. I'm sure you will all benefit from this in a way or another.
Segment:0 .
Egawa, are there ok? Good evening, everyone. Welcome to this. Wednesday's FRCS teaching from our mentor group. Tonight, we have the pleasure of having really two big bosses here, one senior, our senior mentor, Mr Malek Samavela, he's known in the group.
He's a consultant from consultant, lower limb surgeon. And he's been supporting this group since the start. He's given a lot of teaching here, and he's elsewhere also. And also, we have a show on tonight's session is slightly different. It's going to be a clinical session, so we will have an examiner who is Mr Movado and we will have a patient who is jobbing his registrar.
I will have a candidate exam candidates who one would be one of you. So I know exams coming soon. And we will get the preference to people going for the exam. It will be a very good practice for you guys. So please, whoever is interested in taking part, raise your hand to be next to your name. There will be a hand symbol. Please click on it so I can know you're interested in participating.
And we will give you immediate feedback. And they're not going to be any timing down. They come in here to your room. You are doing intermediate case now and come in and know. OK thank you for us. Thank you, Sean, for being there for everyone. As you know, this is the first we've done. Last time we managed about, I think, six or eight weeks ago we did the history and then we started on clinical examination and we said, let's try a clinical examination for this group.
It's going to be difficult, but I think it worked well last time. We won't do it with time, like Farah said, because we want to do really. And there are hundreds of books. There are hundreds of videos of clinical examination. But what me and for us and Sean will always try to say, this is geared for you and it's your talking so individually talk and I'll try to make it as simple as we can for the knee examination.
So if we go slow and we'll do it for about one hour, one hour, 10 minutes, and if we don't complete the clinical examination, it doesn't matter. We can do it the next day, but we have to be as thorough as we can. And that's the basis of this. Let's be thorough. There's no weakness about this today. Some of it has come to my.
Yes, of course I do a little bit of that and it's exactly what I do there. But let's try to do it in this webinar. So I'll just start now just to recap for everyone, Samir, do you want to just tell the group it's your intermediate case and this gentleman is sitting here, so now he's sitting on his chair, ok? Can you see him sitting there? Yeah, Yeah.
OK and this is real life for all the candidates. OK, so this is the only medication you've taken a good history for five minutes. And I'm telling you as examiners. Yes, Mr mizutani, please carry on with your clinical examination. He's sitting exactly like this. So carry on and see what are you going to say? Yeah, Hi.
I'm assuming it's funny, is it all right if I examine your meat and remove your trousers, socks and shoes and fasten your shoes? And do you have any walking aid? Well, yeah, I resisted. OK, good. So somebody, can I stop you there for a minute? All the candidates, this is just the cap. Like I said, somebody came to my class last week, so it's a good that he started off.
So for everyone. I'm telling you, please accept this is the best opening line for any lower limb case. OK, so for any lower limb case, you're going to sit there and say hello. Don't say your first name or surname, Mr. Please, can I examine you? Don't wait for an answer, but say, is it all right if I examine your left knee?
Please move your trousers, your socks and shoes and pass me your shoes and immediately in the next breath, do you have a walking stick? So this way you will never forget walking it. Yeah, everyone. Yeah know some of you. You carry on that you shoes we did last time, so I don't want to repeat the shoes because it's there in the last clip.
OK OK, so at this stage, I'm here the shoes. You would pick up the shoes and you will describe the shoes and the patient is ready and waiting for you completely exposed with his underwear on. All right. Yes here now. So this carry on. All right. Yes so what are you standing up now?
Yeah OK, what do you want him to do? Yeah so why isn't he standing there? I look at his knee from the front. From the flight and from the back. So while examining it from the front, I look, if there's any threat, if there's any wasting of the quadriceps or are there any cause of sinuses and is there any obvious deformity or shortening, which is apparently OK now for everyone?
We always think that we are, and this is your practice for all of you, that we go through books and like Samir said, he's stopped but something. If you don't mind what I want now, which is the difficulty for all candidates and for you, is whether we should talk or not talk. All right, you agree. That is one of the controversies. And how much should we talk?
Go beyond the inspection now? So from the front? Yeah, imagine this patient has a swelling in. Got a virus, right? You have to imagine some things. It doesn't matter if it's a real patient or not for all other candidates. I want you to speak in a particular manner. So just tell me this.
So imagine this. You've got a swelling in his knee. You go to various of his knee and you've got a midline scar or a knee replacement. Ok? OK. What are you going to do? An inspection from the front? He's got a swelling, which is around his left knee.
He's got a scar, which is healed by primary intention on the anterior aspect of the knee. And there is no sinus and he's got a virus deformity, which is obvious and there is no discrepancy. Moving on to the side, there is a comeback. When you move on to the side, have you given him instructions? I'm moving around him.
I'm asking him to stand there. OK, fine. So let's stop there for just one minute for all the candidates. There's not controversy, but each one of you stick to one thing. You know, you walk around for every patient, which is put me on a hip or you make the patient turn round. The Russians want any tips on this or what you should leave it to them.
Or should we tell them what to do? I personally make the patient. I give a command to the patient to say, face this wall, face that wall, face me. I do it like that. You think you advise them one way or the other? My my preference is the same. To make the patient turn around, you might be in a room, which is very small.
I think it's more difficult for you to get around. And you look awkward as you're trying to move the chair out of the way to get around to turn. That's your view. I think it would look more professional if the patient moves, however, you judge it sometimes by the patient. If you think you can take that patient who is not very cooperative and you have a difficulty moving and think you don't want to waste time with understanding you can move them, but generally is better, more professional to make the patient.
So let's accept what feroz is saying. But let's say 90% of the time, stick to 1. So you've said it very well. I don't mind you moving. It's not hard and fast, but let's imagine somewhere that you are not moving around. What order will you give him now you want? So it's a left knee. So what do you want to do?
Yeah so if you could turn to your right side? Yeah so yeah, so can I stop you there somewhere for all patients and for your information for the candidates, try not to ever say left and right right. Yeah, we say, please face this wall. Yeah, that wall or face me. Yeah, right? And even if you're in the future, telling him to do treadmill test, why are you going to stand on the left and don't say left or right?
It will all be good leg and bad leg? OK, all the candidates. The little small tips like this make you talk much more professionally, ok? Otherwise, you get confused. You say left, he says right. You know you're playing fooling around right. So someone just tell him, please face that. No, please face that wall.
Now he's there standing like that. Yeah, like this. Is the knee visible? Yes yes, sir. Yes, sir. Yes, sir. And from the side, I can appreciate that, that he's got a flexion to form flexion attitude of the left knee and moving on to the back of his knee.
Excuse me, sir, could you turn to that wall? So Yes. So from the back, I there is fullness in the complete fossa with the raising of the hamstring and Solis muscles. So if you could face back looking towards me, please and. I also see the pelvis level is a pelvis is the same level in this girl.
Yeah so some of you, you're not very well. And like I said, I'm just for the others. So what have you done so far? And this, if you want to write down or you want to take some tips because this is not going to be in any textbooks, it's an amalgamation of what is the integral that my way is that when you start from the front, let's start in my mind. I divide my examination of any joint into three parts.
The first is swelling and wasting come together. All right. Yeah Yes. Yes and second, big heading will be scars and sinuses and this headache, deformity, deformity from today onwards. For all of you, whether it's your hip or knee or your shoulder, you will start by saying so somebody, you stay there. You start by saying on his left knee the swelling of his left knee and this swelling and wasting go together and immediately the next word would be there is or there is not quadriceps resting here, right?
And then you'll go into your skull as if you are in the real FR case exam. Yeah, OK, OK. So this is a continuation of imagine you are some here and you've seen a scar in the front of the knee, right? OK and/or it's a scar anywhere in the body. So this is a good shot case. You'll have a scar for nonunion, you'll have a scar somewhere in the humerus, so he's standing in front of you again.
He got a midline scar. Just describe a scar. What do you see about a scar? Yeah, I can see a midline scar on the left knee on the PBS aspect, and the sky is well-healed and no features of acute infection or inflammation. And looking at it seems to be a surgical scar, which is healed by primary intention. And I can't see any features of sinuses or any infections.
I want to visit. I want to pick the I'll talk with the easy talk if I ask any tenderness of regarding the scar. Yeah, don't worry, that was very good at. So coming back to scar for everyone, the way we do scars is that, first of all, describe where in the body it is. So and there are some classic scars. If it's a classic scar, you need to say the name.
But what is your classic scar in the knee called it's a midline incision? Is that correct? Yes and then off in the anterior aspect of the knee, he and it is of 12 centimeters or 14. So we'll talk about the way it lies in the body. If it's a classical skull like a deltopectoral or a bra strap incision or a Yes or a Smith Peterson, you would be saying that directly.
It's a Smith Peterson skull. It's a scar, it's a bra strap. You hear what I'm saying? Yeah, yes, Yes. And now next, you say it is 12 centimeters. Now the next thing for everyone. Just say it's healed throughout its length by primary intention. OK, just use that word.
Suppose it's healed in the pop part by primary intention and a lower part by little puckering. You will say it is healed by primary intention throughout its length, but in the lower end of the scar, I notice it is healed by secondary intention with surrounding redness with sinus or is healed by secondary intention. But there's no sinus and no surrounding it. Don't use the word acute infection and things like that because you're not going to get a patient like that, right?
All you're going to say is, is it got a sinus? Is the surrounding redness? You agree. Yeah, Yeah. So let's use the two words that are sinus, and there's no surrounding redness of the surrounding redness, and it's healed by primary intention or Secretary intention and the name of the scar. Clear OK.
Yeah is that all right? Anything else you'd like to know? Absolutely correct. Keeping it succinct. The only criticism I had before Rajiv was repeated yourself. There was finally healed by the intention. Well, demarcated anterior scar with no signs. That's correct. Exactly that's exactly what we are trying to say, that the words coming out, you have to write down what we are saying and it doesn't matter if me Faraj wants it.
Can you say it in 30 seconds or maybe 10 seconds? Yeah and your words, your writing, your words. So, so write it down and repeat it. And now. Carry on. Imagine that we've done the scar in the stand in you. I can't see a significant left side me, whereas deformity and it's about by inspection. It'll be like 20 degrees, whereas deformity and looking at the lateral view also, there is no worry about.
That's fine. I get this for everyone. I get like, what? What one will agree with me? You said it right, but we can just be very short, very suction. There is various of the left knee compared to the right. Don't worry about using the word significant. Don't worry about using the word 20 degrees.
You can't really measure it. Don't say things which are not true. So my personal opinion would just and don't use the word deformity because it could be attitude, cetera. Right so just say there's a variation of the left knee compared to the right or there's values of the left knee compared to right. And I would not say anything more because you need to move on and you're saying things correctly.
Agree Sean Faris Yes. You have to be very focused again with this one. You might think you have time 5 minutes for examination, but there's very little time and you have to go through it quickly. So be as clear with your instructions, the patient as clear with describing your findings to the examiner.
So there's no, you know, fully understand what you mean, and you don't have to guess what you meant and whether a 15 by 15 is your 20 or 25. So don't get into that yet, right? Happy with that. Yes Yes. OK, now, ajit, what do you want him? Do you want him to turn round? So tell him, given the instructions to face the wall?
Yeah would you mind to turn on this wall, please? OK, now he's now Ajit. He's like this. He's dead. Yeah, Yeah. I can see a flexion deformity compared to the right knee and his ankle is also I can see a little bit transposition escaping. So it could be functionally fine as a position because of his suffering from flexion deformity.
And it's roughly it's about 15 degrees flexion deformity of what? What are you talking about? Knee or the ankle flexion flexion deformity of the knee? OK, fine. So once again, I get very good. I think you picked up two good things with some it did. But the so from the side, everyone, just for everyone. Just to recap again from the side one of my three headings again.
What are the three headings? I have linguistic scars and sinuses and deformity. Right so now you're very right from the side. We are all orthopedic surgeons. We know that 90% of the time there will be no swelling or wasting on the side of the knee. So you didn't mention it, so don't mention it again. You agree that most of the time there'll not be any sort of lateral aspect.
So don't mention it again, but the form of dementia. So once again, what? I'm sorry I missed. What word did you use when you did you say that reflection? What? the affliction flexion deflection attitude, right, so let's use it, deformity, yeah, seriously. Right, so let us all agree. It's not bad.
I'm not saying it's wrong at all, but just to be safe. Let us all. If you're inspecting, let's use the word attitude. So there's a flexion attitude of his left knee. Are you happy with that traject? Yes OK. So use the word flexion at your left knee and then you go and look down. That his foot and ankle, if the foot and ankle is absolutely flat on the floor, what is the phrase you will use?
Integrate plan degree, so you will. Correct so you will say he's got a flexion attitude of his left knee with a blunt decred foot. Happy with that, everyone and judge it. Yes, Yes. Now, if he had like you saw, he was holding his ankle in. Don't worry about anything about the amount and don't give the explanation. Just say you go to flexion attitude of his left knee with egawa test at his ankle.
Happy with that. Yes repeat it again. Just repeat that statement. He got up. He got it. Here is a flexion at the knee and so forth. Egawa a attitude is it 14 equine? Is the ankle in decline so. Sorry sorry about that.
Its knee is in the flexion attitude and his ankle is in the position. Yeah so and that's all you say and. You agree. Keep it short as well. Absolutely if I was the examiner and you said deformity, the first question I'd say is, how do you know it's a deformity? Fantastic thank you.
Excellent Yeah. You see, so don't get into controversies where you have to get out of it. Happy with that object? Yes yeah, you can. You can always if you say something, but you could always withdraw from it. If you said deformity, you're not sure to say, I'm not sure this deformity.
Maybe I will confirm that with my examination later on. So if you said something and you want to withdraw, withdraw it, you could always do that. Yeah but more importantly, I would just say write down and don't even say anything else, you know? But if you make it my mistake, like I said, just withdraw it. But don't do it as intentional mistake. Just do it that you'll say attitude. And like, if you made a mistake for us is very right.
You can just withdraw whatever you want. No one's going to hold anything against you. And I would say Ajit do not give in a clinical examination. This is, I'm telling you as just direct advice. Please do not give explanations for anything. We do not want explanations unless we ask you as examiners. OK, so you are not to give an explanation that the equine was due to this or the other. If I ask you, please volunteered.
Otherwise, just give your inspector your findings. Happy with that logic. Yes yeah, you're not going to score any more marks because you're losing time and giving me a minute and a half of something which I wasn't on my grid to mark you. You understand this thing. Sinuses and deformity. So say again what you see.
So I cannot see any scars or sinuses. There is no swelling. I can see that he has got his knee in a fixed altitude infection altitude position. Can you say flexion altitude from the back when he was holding his knee in the first position? That's why I said it. No, can't. You can't say that.
You can't see it from the back, right? Yeah so what I'm trying to tell you is just let's go back to just because this is not in any textbook. So anything. What we tend to do like MRC style and we all do it. We try to just repeat the same thing. No scars. No this no that. Try it in your mind.
Compartmentalize again, that on the balance of probabilities at the back of the knee, the correct orthopedic world would be swelling awfulness in the optic fossa. That's what you expect, right? So if you say there is or they know, so let's imagine there is no swelling. So just say there is no fullness in the popular fossa. There's no fullness in the pocket fossa. Now that sounds a little more.
You know that this guy is sounding more knee oriented like a, you know, rather than just saying all this swelling sinus like, that's all I'm saying. And you agree that in my heading, you always whether it's the deltoid or with the humerus, you will always say there's no or there's associated muscle, right? So you can see more fullness in the popple fossa. But I notice this hamstring wasting and this calf wasting right or there.
Yeah, so see it. So there's no for less than the popular fossa, but I notice that they've got some resting in the calf or hamstrings. Do it always have to write it down, you remember? So you always go to the thigh with the hamstrings and we can't see no scars. So let's not say anything about scars. And as you know, there's not much of a deformity you're going to see from the back.
You agree because you already talked about it from the front, so you don't have to say it again. Right? so now you make the patient turn around again in front of you. Not at all, for me. Now you can see the knees now. Yeah now for everyone at this stage, you have to inspect the joint above and the joint below, right?
So they've just verbalize what? How are you going to? You talked about the knee done, the front, back, side very well. And now how are you going? You're going to finish in. Inspection by doing joint and joint below. So how are you going to talk about the pelvis? What are you going to say?
What is the phrase coming out of your mouth? I'm going to say that the pelvis is in the pelvis. Is is it an equal level? Just not. No imagine it's your exam. You're talking to me. And first and 2 on the pelvic is an equal level. I cannot show them the scars that are on the hip. There is the OK.
So what I would just say is that when you talk about inspectorate finding the joint above and joint below, I would really say don't get much into the inspectorate findings of scores unless they of course say it. But the only thing which will most likely be there is the deformity, right? And that's what he said was correct. Just say the pelvis appears symmetrical or your phrase was right, but stick to 1 phrase.
Yeah so what phrase are you going to say? The pelvis? What? what is your phrase? The pelvis is, is at an equal level, equal level. Yeah, now you stick to that, it sounds good. It's your phrase, but don't change it tomorrow to something else. That's what I'm saying. Yeah very, very nice.
And then if you notice scars in the hip, you say, but otherwise, let's not say that. And what about the foot? How are you going to talk about the food? So the feet are at an equal level as well? And I can't appreciate any deformities around the ankle. So in the knee problem, what associated common foot problem would you associate with a bad knee, for example? Let's say it's a 19-year-old girl with a bad knee.
What would she probably have in a foot and ankle? So she could have a collapsed argument, she might have that very likely flat feet. Yes, you agree with that. Yes well, so and so therefore you can say I notice that the feet are satisfactory and there's no particular collapse. Arch you know, that's what you're looking for, right, Debbie.
So we've done that. Have you done your inspection now? What you want him to do is you want done, you've done your inspection very well. And we either nod or we don't not. But you've said all this. What do you want to do now? Can you take a few steps for me and turn around and walk towards the wall and come back towards the office again?
OK, so what is the exactly like this? I know it is a little difficult. He's standing so far from the camera. I give him instruction. Give me clear instruction. What do you want? Can you turn it on and walk towards the wall and then come back and walk towards me?
What it. Yeah so I can appreciate that he's working with little, as demonstrated by a short stance phase. OK, carry on. What do you want to do? He's walking toward you.
You told him to walk towards you, walking towards you and you stop. Stop no, please. Yeah and then what do you want him to do? OK, so I've already verbalized that he's walking with the gait. And can you lie down for me in the couch, please? Very good. Thank you.
Just a point for you. You did it very well. So please understand this is exactly what I want everyone to do. Control the situation and swan for us. All examiners will tell you. You want to see you control the situation? All right, we do not want. It's not your being arrogant.
You want to control it like you did. You decide that this guy walk in the room or not if there's a chair in the place? Please go and move the chair. If there's an examiner there, please tell the examiner, please move away. You're very clear instructions to him. Yes, please walk. What I tend to do is I tend to make you start going as far away from the patient as you can.
Don't make him turn and walk away. That's confuses him. Please walk towards me. That's the best advice to give. Walks towards me. And when he comes as close to you, say, please turn around and walk towards that wall, right? Like you said, and go from the side and watch him and then don't talk to the examiner during that time.
Because if you start using words like repulsion and this and that, what will happen is that this guy is walking around the room, not knowing what to do. So you finish this walking. Tell him, thank you very much. Lie on the couch. Look at the examiner and say he got up and told you get a puppy. Yeah, so do that.
Repeat again. Just say walk to us just to tell him he's not there, but just say, what are you going to say? Walk to us or walk towards me. So can you please walk towards me and then walk towards the wall? Then turn around, give him clear instructions. I want to see that turn round, so look towards me. Turn around and walk towards the wall.
Yeah, and you're going from the side. And then what are you going to tell him? Thank you very much. Thank you very much. Lined on the couch and then immediately look at Sean and tell him this patient. This patient has an end target, right? But you can't take your time in this. You have to be very quick.
Yeah so but the next advice to you for the clinical and is I'm telling you as I've done, you know, I've given my course for 10 years. I've been with Kevin Sherman. I've been all the examiners in the short case or in the intermediate case, your marking is just identification of a gait pattern. Your theory about whether it's a foot propulsion, whether it is a short stepping gait, that description is going to be tested on your Viva station.
OK, so I don't want any of you all to go into this long spiel about this is they're short that unless you're asked if you are, say it that way, just identify it like you did, ok? And for us, that is my view. I don't know. Other people may not agree, but I think that is perfect. I think I just want to say, sorry, Sean, go ahead, Sean. Go ahead. I'm no after you first.
So please, no. Just a simple thing I want to say. You can't show that obviously to you this video conference. But I would recommend that if you are describing deformity of any part that you, your eye side should be at the level of that part. So if you describing a knee, you bend down actually to the level of the knee you're describing your hips, you bend down to the level of the hips where you look at it just so of examine that it's like a driving test.
You're showing them bending down or you squatting down to that level as you're describing the deformity. Absolutely, Yeah. In terms of as just one other thing about when you're describing the gait, steps and things like that, you can get yourself into a lot of trouble in a clinical scenario. Just use succinct words just like we talked about in the scar.
Just this is the normal, normal heel to toe pattern or normal antalgic gait. Leave it. Don't explain it. Don't do anything. Because that's if the examiners want you to describe it. That's where the marking is. They're asking you guys move on to the rest of the exam. Thank you, swan.
Thanks Thanks for clarifying that it is something which you agree. All the candidates are always worried. You're always saying, let's say this more because I'll be impressing them. Believe me, you're not because you're going to say something wrong, because you're so stressed. I want you for five minutes. I just want you to describe just the gait pattern.
Like Sean says, one is an traject. Just tell me what you mean by until you get that is a short. It means that the stance phase is shorter, so let's keep it that simple. One that it stands for is shorter. What is the second most communist or we? So just give me one at Brandenburg Gate. OK, so now please tell me and my co examiner, what do you understand about Brandenburg Gate gait as you are examining the objective mechanism?
up the mechanism includes the pivot, which is a giant, the lever, which is the building structures, the head and neck and the muscles that we through this medium. Mm-hmm So you cross the patient first to stand on the bad side? Mm-hmm So I mean, it's just kind of look on the bad side. Yeah so where the patient stands on the stand, on the good side stands on the good side, the opposite sides pelvis tends to get down, but that's prevented by the intellectual objective mechanism.
And as a result, the contralateral pelvis lifts up. Whereas the patient, when the patient stands on the bad side, the contralateral pelvis dips down due to gravity. I mean, what you said was right, I would say try for a clinical scenario. When we ask you when you say it was a treadmill, birgit, I'll ask you why you don't have to go into the explanation. If you don't mind Ranjit about the pivot something, just say when a patient stands and a little tip to every candidate in yourself.
Always, if you're going to explain something difficult, could be walking. Length of the nail could be a tension man principle. Just say what happens normally in life. OK, so just tell the examiner. When the patient stands on the normal hip, the pelvis of the other side lifts up, and that is normal. You agree. Yes in about five seconds, I've said what you said when a patient stands on a normal hip.
The pelvis of the other side raises that is normal. Then say when the patient stands on the bad hip, the pelvis of the other side sags. This is the basis of the treadmill test. And if I ask you what happens, then you explain. Right? Yes. Now what is the third commonest or to mitigate it? Yeah let's be simple, and let's stick to bilateral trade, which is called whatling.
Get everyone happy. Yeah, that's a common gait we see in the older population, right? So a person walking towards us waddling, you say this is a waddling gait. Potentially this could be a bilateral trade. You're talking sense. Yeah fourth will be a short legged right. That's what he said.
Yes, please tell me. What do you understand about short legged short luggage means when the patient walks, he would tilt towards the lateral side? Mm-hmm What do you mean by oscillator? Yeah, the short lived side. But like you said, keep your right. You're very right. But if you keep to the same nomenclature, when the patient stands on the affected hip, the only way you can get that hip down to get his foot planted it is that pelvis dips down.
That's what you're trying to say. That's true. Yeah, that's what. So stick to the same nomenclature when the patient stands on the affected hip or the bad hip, the pelvis will group down on that side, and that is called a short leg, which is exactly the opposite of a general. Yeah, that's a short leg.
51 high stepping gait. Yeah so high stepping gait is in common is in good drop. Yeah so you have to have a high clearance. And now if you're asking, you have just finished. If you are doing well, what are the three other cerebral palsy gets? You got a strange gait. Yeah, good one. Scissoring slap lesion.
Then you get crouching, crossing it. Yeah, and third. Windswept, OK, so everyone, so I'm just giving you a little gait patterns, because if you get a difficult patient, you just say these gait patterns here. So we finish the fight so that five orthopedic gates and Tajik Milberg bilateral training bug, short leg and high stepping or foot drop.
Then I divide my mind into three cerebral palsy will be where you have tightness of the adaptors. I can be a crouching and that crouching could be flexion at the hip flexion of the knee with or without Equinix at the ankle clip. And then you can have a wind-swept wins by means latching on one side and values on the other. Yes, or windpipe. And just to finish two or three neurological gait patterns.
Common neurological gait that. Parkinson's, what does a get in parkinson's? I got a certificate. A shot, shot shot, stepping it or shuffling it. Yeah second is a. So let's get production, get in, hemiplegia, Yeah. OK and then what do you get which you're going to get in a spine case?
What are the common spine cases going to be? But it's going to be a collapse with. But what do you get, what do we get a posterior column sign problem? What will the gait of a posterior column problem be? A proper Section will be lost. So will. Broad basket. OK, yeah, so what I'm trying to say is we all know it, but if we can identify it for a patient, we are very confident now.
So you have 10 kids, so you are really looking forward to a lower limb. It could be spine, hip, knee. You're going to see it in any course you go to now in any exam you do now say this is the case. I don't think any more gates there are strong any more gates you want to talk about, which are coming up next. Pretty much covers everything.
The reality is, if you're short, if you can't get the words, just describe what they're doing. Yeah, absolutely. Yes, I have a question. So the gave you just name what it is, and then move on. That's that's all that's required that I'm most of the time. If it's a very clear gait like an Intel or a peel-back or a foot drop, why did you say what it is?
Then if I ask you or one of us, ask us examiners, explain it. Otherwise move on. Control it because it's your intermediate case. You've said it and you've moved on. That's what I'm trying to tell all of you. This is the only time when you actually have control, and if you don't take that control, you're open. Unicef, the control say, yeah, this is it. You're going to.
Until you get these, please lie down and then charge towards him and do the line on examination. So therefore there's no chance of him to ask you anymore. But if you stutter. And this guy is walking around in his underpants, they're going to ask you something more. You see what I'm trying to say? You control it for that time. I just want to say, yes, absolutely.
It's your station. You need to control it. The examiners might not always guide you through. And if you say something about gait and they dragon about gait gate, yeah, you're not going to pass that because you still have to do all inspection. You have to move. have to feel the joint. You have to discuss the management.
You have to do all of that. There are tick boxes for each one of these. And if it is a short case, it's possibly just about gait. It could be, but that case will never be just about gait. If you stuck on gait, you're not going to get anywhere. Even if the examiner wants to keep talking about gait. You try to move on. Yeah, absolutely efficient. Yeah hi, how are you?
Hi, Mr. Yeah treat this like this if you are in real exam. Yeah, OK, so take it seriously. Yeah, Yeah. Now you want to just recap you had finished your gait better, and now you've told the patient to lie down as you ask, do I know you've done it with me before? But do you want to do something next or are you lying down next? What will you do next to everyone?
So once the patient won. Yes, he's variously partially improved after lying down. No, you want to do lying down or do you want to do sitting? You know, do you want to make the patients sit and do sitting tests or do you want to do lying down? And no, I would like it is his comfort. Probably he is comfortable by sitting like that, so I would sit him like that, you know, lie him, lie down flat.
No, what I meant is that you want. I know you want him to do sit on the side of the couch or you want to lie down. I would for him to lie down. Yeah light up. So just what I'm trying to tell all the other candidates is that at this stage, there's always a controversy that when you finish your gate, people make the patient, sit on the chair or they make the patient, sit on the side of the couch and they do Sitting Test next.
Is that right? Well, it. Most people do that. My advice to everyone is that sitting tests are only important for mainly patellar framework. They are very difficult tests to do. And in my AIIS and in my way of doing things, I put on the special tests and a 70-year-old man. You're not going to get much information from sitting so late.
I advise that. Do sitting later on. All right. So let's all agree that we lie down and do the lying down test next. And what Walid was trying to say, if it's a knee, the patient does not have to be flat as a pancake. You can be sitting uncomfortable with some pillows, but he's on the bed.
Now, while it is now lying like that, you can see the knee. I know it's difficult for you to do palpation now, but what are you going to say? How are you going to start now? So my first phrase his yeah, his virus needs is improved or immunity. So thank you a little for everyone. All the other candidates write this down as you noticed the minute you finished your gait and you make the patient lying down.
Your mind goes into a blank. You agree. Your mind goes in a blank. That's life because you're doing something different. So you have to have some phrases which make you kick start your mind. So for me, the best phrase which you just go on is that there's only one inspectorate finding which will change by lying down to standing.
And what is that? Is your value. So varies. So when the patient lies down, just look at them and say, Yes. The various of his left knee has improved or the variance of the left knee has remained the same. That kick starts your mind. And next, we'll go into what? So what do you want to do next?
Will you tell me what can I do it for? You know, I'm going to touch you need by the back of my hand? Yeah so what are you looking for next temperature? Yeah OK. Now this is difficult. What I would like now is the time where if you were in real life, you as a candidate, well, it would have been actually doing things. You cannot do it to this patient. So in your heading would be temperature.
Is that right? Really, that's what you're saying. Yes OK. So for everyone, what I would do is I would say thank you very much. And I'll tell the patient, and this is what I'll do. I'll put both my hands like that. Thank you. And if the knee was warmer, I would tell the examiner the left knee is warmer than the right level it.
Yes so at the same time, now we have this controversy in inspection, we decided how much to talk and not talk. Now, when we come to the painting, which we are going to start now, let us be very clear that don't listen to people who have told you. Go on talking. Go and talk. You cannot do both things correctly at the same time, and please decide all the candidates.
Are you talking to the patient or are you going to talk and verbalize a statement, right? But at no times are you going to mumble about anything, so if you're going to talk to the patient? So I'll tell you how to do it. So what did you do in your first and you make a statement left me is warmer than the right next? What do you want to do? Now I'm going to bend your knee.
I'm going to move your knee. Let's bend it together, right? Fantastic so I'm doing that for you over there. OK that's right. Now, what do you want to do? Now I'm going to feel around your knee where my finger is. Is that sore? Yeah now I'm moving to the inside. The inside, if you join, is that so?
Yes, that's fine. And what about the medial ligament, the femur attachment, the midline? Good That's right. I know it's difficult. Yeah, it's great. What about the outside of your joints? This point is, is that hurt? Yes, fine. What about the back of your knee?
Is that toll now, OK, I'm going to move you on. Let's do it together. I'm going to move your kneecap outside feeling underneath. Is that so? No now I'm going to move it in. Is that soil? Yes likely look fantastic. Thank you very much.
Just for everyone. What I've done and what Walid is very clearly demonstrated that we all agree that his focus was who? Who do you think his focus was? He was completely the patient. And I want all of you to realize that there's only one important person is like Walid was completely bothered about only the patient. If you're an empowered patient, especially for 10 minutes, there has to be a complete rapport and the talk has to be with the patient.
Ok? you have now. So let me just recap how I will do it, which Walid did so for everyone. If you are going to move a limb, it could be the knee. It could be the hip, it could be the shoulder where you want the hip or the need to be. And you tell the patient we will move the knee together. Happy with that.
So I tell the examiner or the patient, I'm just going to bend your knee. Let's bend it together. OK, so this means he's not fighting you. I don't want anyone to do any palpation of the knee in the extension. It has to be done in a degree of flexion. All right. Well, you agree with that.
Yes, sure. Now I divide my palpation into three parts. There's a front of the knee, which is your anterior aspect. There's a medial, there's a lateral and there's a back. So let's repeat again. There's an extended slap mechanism. There's a medial, there's a lateral and the back. So I'm going to start by telling the patient, please let me know where my thumb is.
I want to be very clear. And what am I pressing here? Well, it is. The tibial is the front of me, which is the tibial tuberosity. Yeah, right? Yes well, and I'm feeling now just for everyone. What I'm feeling is the less is the pole of the patella suggestive of patella tendinitis. OK then I go up and I feel the top of the patella, what is that for?
Well, it is a quadriceps infection. Yes so what is that? What, what are the diagnosis? It'll be quadriceps tendonitis. I'm looking for clinical scenarios, you see. And then if I feel a gap, I'm going to say there's a gap palpable, which could be all quadriceps rupture, which is a common short case, right?
So it's like starting in the front of the knee. You see, just what this is for everyone is that's all. No, no. Is this all is? That's all. Yeah and oh, there's a gap there. You see what I'm trying to say. got that part down then because the camera is facing here and next go. But let's do laterally.
Let's see. This is that's all. And you see that well for us. Are you seeing that? Yes yes, very clear. Is that. So and this soul? And then this bone is important for me. Is that what am I indirectly telling the examiner?
Well, it is a fibular head lateral collateral ligament. Correct? and is that so? No, no. So what have I done? So the lateral side is the entry of lateral middle lateral posterior lateral attachment of the ligament and femoral attachment and then the same on the inside left to the inside.
So what am I doing here by 800? Yes Yep. Medial and posterior. And then the attachments of the. Collateralized debt. So see how particularly about the tenderness, then. Not not bad debt. Thank you. And then I straighten the knee and just can see what I'm doing.
I'm going to move your kneecap. Just tell me where my finger is. Is that so? I'm taking the latter facet. I'm moving only in words with my think that's all there. Yes, that's the media facet. Yeah, so we've done tenderness and it's been so thorough in 20 seconds and you've done as you do it. Stick way.
But Mr Murdoch's trying to show us the certain buttons that could be reproducible easily for everyone. And yeah, and Thanks for that for us. Sure so now we are on to the next part, which is we've done temperature, we've done tenderness right now. What in your heading is going to be next for you? So the next thing will be I will go for the look, feel and move then.
Yeah so you've done your look, you've done your feel. And are you going to movements right now for move? Yes OK, now remember, Sean raised a very important point. What is one thing? He said something very correct that he would do swelling tests before tenderness. And he would do he did it for a particular reason. Also that if you're going to do movements next, a large swelling may impair.
Maybe the cause of your movements are correct. So now is the time. Unfortunately, Sean, where I would do the swelling test, you see. So I've just changed it one not for any reason, just to be slick. So it's easier to do the tenderness first. That's all. That's true.
Yeah so I'm just I would advise you before you move, let's do swelling tests. All right. OK, so imagine let's bend up the knee. Now or now you take control. You tell me what you want to do for the swelling test. What do you want me to do? And I'll do it for you. What is the swelling interest?
Can you leave your knee flat? OK, she's down now. What do you want to do? Thank you very much. Now I am going to see the looking from the top to hold the suture pouch. Exactly so and then I'm going to move swipe from medial aspect. Yes and then and then a swipe from the lateral aspect and then see the bulge on the medial aspect.
Fantastic fantastic. What do you want to call this test? This sweet test, yeah, right. So very good, you said it like that, and I'm telling everyone that all these tests, you can call it swipe test, you can call it feeling test, you can call it whatever test you want. They are all the same. The principle is, and I'm telling you what I see happening very often is that when you ask people to do these tests, Amjad said it very right what he would do.
But I'm telling you, I see everyone doing this. They come there. They're very stressed. They start doing this. They start just massaging the knee in different directions, not really doing it with any purpose. So let's all do this test together. Let's watch. The first thing for this test is what am I doing?
I'm making sure that I get all the fluid into the knee, so my hand is on the quadriceps, right? By push down on the Super suprapatellar pouch. I'm just all right. Yes, correct. I don't want your hand. Your hand cannot be stabilizing the patella, right? Because otherwise the patella does not move clear right now when you did your test, right?
What is a swipe test important for? Is it for a small effusion or moderate infusion or a large infusion? It's for small and moderate effusion. So most of the time is for small one, and you agree it's a difficult test to do. So my advice to you object is let's do the patella tap test first.
OK OK. So when you do a patella tap test, guide me through the same thing. So my hand is here. Yeah? so your approach? Yeah and then what then I just push on the patella and tap on the patellar like I'm doing now. I couldn't see it.
I go on the other side. Yes, that would be better. Thank you very much, Mr. Yeah Yes. We can see now clearly sorry about not wanting the patella, but here my hand. Yeah and that right? OK and that's your patella. My advice to everyone is just do whatever. Tap first.
So you're going to do it. Imagine if it's positive. I want you to verbalize it so you can get. But before you do that, are you going to dial things like Sean said, are you going to tell, what are you going to tell the patient? So I will get a resonance. So in this test, I'm going to hold your leg from the top there.
Let me know if I cause you any pain. OK, I just want to be able to afford your tie and I'm going to top on your kneecap. You'll have to say so much. That's what I'm trying to tell you now. You don't have to go so much to just say, I'm going to do a test, I'm going to hold your tie and let's do that. OK, now what is it?
Do I want your hands to be removed from this? I don't want to just go and do this, and I don't want you to look at the examiner because who's the most important person? The patient? Right? yeah, I'm looking at you now, but seen the screen, but otherwise I do this. This watch you can examine and tap was positive.
So I want that manner to be done. So your first patient, you finished the test. Your hands are away. Look at the examiner immediately as possible. All right. OK imagine if the patella tap was negative, you were force through your next test, which is your swipe test that I'll do again. I don't keep my patient, Mr Mehta.
I'm just going to do one more test. I'm going to squeeze your card right? Then in my mind, I just move. See what I'm doing. I move the leg outwards, so my AIIS are looking at the medial side of the knee, right? And what do I do, I empty the Mediasite like this very clearly. And then you can wait for it to feel which is called the filet desk or the typekit along by swiping on the outside is a very simple thing to do, right, like you said.
Is that correct? Yes, that's exactly it. OK so this is for everyone to repeat. The simple way of doing it is squeeze the quadriceps, get the fluid into the propeller pouch. Your mind's eye is moving a little, so you're going to see they're empty the inside and help along by swiping on the outside. And that's your feeling.
Yes and the third test is victory finding. So what I would have said, suppose it was a short case. Like you remember, Farah said that supposedly sometimes focusing on short case only on swelling, for example. What is your first finding of a swelling of a small failing? What would be the inspector refining of that? So swelling or waiting? Yeah, you can. What the word would be that when you bend the knee like this and you're looking from the front, you will say there is obliteration of the furrows on either side of the patella tendon, you see.
Isn't that a small, subtle sign of a swelling? Yeah so repeat it. Yes, there the obliteration of the various on each side of the tendon. All you can say, there's fullness on either side of the patellar tendon. Use whatever phrases you all are happy with. But stick to 1 phrase, yeah, OK. And then you will say, thank you, Mr Mehta.
I want to keep your knees straight and then you do your Patel attack. Then you do your swipe test. Yeah, OK. Yeah lovely. Good so you see, we spend so much time, but what me and for us and Sean have tried to do is try to say, forget about textbooks, forget about videos. It's whether it comes out of your mouth, the correct words and whether you can control right.
Which you have is the principle, isn't it? Obviously, you could read books about clinical examination, but this is how you should perform in the fastest exam. It's very specific. Can I ask you, Mr maximus? They've been asked about examining the normal limb in the exam. Yeah, for comparison, I know the books say this is the standard way of examining you examine the normal limb.
But again, this is exam specific scenario here and exam. I think if you start examining the normal limb, you have no time left to examine the. Yeah, I agree. And I like this is a common question. Everybody asked me in my course, and I can tell you guarantee that why are you worried about things which are not a worry for the examiner? Truly, they're worried for some reason.
Every candidate is mortally worried about that. But like we've said, if you start doing what we've done, so let's say you start on the abnormal on your bad leg like we've done for 10 minutes and we moved on. There's no place so far of doing anything to the normal limb. You agree everyone. There's no place when we have to do things like ACL, which we'll come to next time, then I'll tell you how I do it, and that's the only time that you may have to compare.
And that's when all of us can chip in as to where should we compare or not? Yeah, but for normal things, no. And even for ACL, I would do the abnormal limb. And if it is positive, I know it's positive. You know, I don't have to do the abnormal. So the answer is the correct answer is just forget about the normal limb concentrate with perfect technique on your bad limb.
And that's enough. Nothing more. I think that's what self-assurance I've done. The chatter is in Sichuan. Absolutely I think it's a case by case, isn't it? But I'm thinking exam. So there's to my thinking, there's only one useful reason to examine the other side in a five minute examination.
It's to compare if you've got an abnormality, which is bilateral or not. So for example, PCL rupture, rupture, ACL injury, ligament injury you're comparing what is the normal side for that patient to the other side is. So please tell the candidates that this is. Don't worry about it. It's not an issue whatsoever. I mean, if you would compare anyway during your inspection because you need something.
Exactly, exactly. Clinical examination. Again, I'm thinking if there is a patient, I think mainly ligament problem. If they are ladies, young ladies, they're thinking of ligament laxity or hyper mobility, then yes, examine that the other limb. But otherwise, I don't think, for example, the question on how much we talk to the patient and how much we talk to the examiners while doing this, it's very clear on this.
So let's all Mustafa. It's a very common question. As we've said in inspection, we have to say something and I. We knew that three phrases to say, right, and that could be anywhere in the body, so you were talking about a delta. You see the swelling in the deltoid region or supersprint is wasting, et cetera, and deformity, et cetera. You see all that.
You cannot keep quiet. You agree. You have to talk. The problem happens when you are doing. Tenderness in tenderness as one and everyone else says we will be concentrating on the patient only because that's the most important person. So you have to have a complete rapport with the patient, is it does it hurt here?
Does it hurt there? Does it here and do not try to tell the examiner while you're having a rapport with the patient that you have a medical axilo tenderness level, you're going to get it completely wrong. Just finish your tenderness with a complete focus on the patient, then look at the examiner and tell him, he admitted your NIPE tenderness with collateral tenderness and then move back to the patient.
Again, the focus I'm telling you that is probably the most for average person, but all of us are average. None of us are people who have these skills where we can talk and do everything perfectly. So for average person, the only way you can execute a correct tenderness is to rapport with the patient and then look at the exam and tell him your tenodesis when you go to special tests.
Once again, the most important is do the test with a rapport with the patient. Just tell him, I'm going to hold your leg, do your collateral, and then I tell them I drop the leg and then tell the examiner. There was reaction to the collateral ligament trying to explain the test at the same time as doing the test, 90% of people will get it wrong and get it perfectly. It's fine. If you it wrong, you're going to get wrong.
That's my. Not only will you get it wrong, but you'll miss of the non-verbal cue the patient is giving you. Absolutely so if you're trying to tell the examiner the collateral ligament is and you're still painting it as you're looking at the examiner, you've missed the patient's face. And the first Warning sign, the patient is in pain. Thank you, John, and I'm telling you, all of you, all your go to a number of people will tell you that they're not wrong.
The gold standard is to do everything, but we don't have the skills to do it. And like you said, you're going to miss the important points. So please accept do the test with a patient and then look at the examiner and tell them your result. OK, you agree. Should we give it a data format for from now on which one? And for us, that's the way. Yeah, that's very good.
That's good, very good way. And we could use the same methods in examining other joints also. Absolutely going through the knee and a lot of details step by step. So I think we covered the history in details. We covered the inspection gate, shoe examination and patient swelling and sweating, swelling, checking for the swelling and effusion.
So that's all covered now with the knee. We obviously still more to do with the knee examination movements. Next time will be movements and special tests, and we are done exactly one session and then we can have other sessions to reinforce this. For example, one, if you can show us, I can do hip again, you know, things like that. So we cover clinical art.
We had 67 people registered for today. Thanks everyone, particularly to those who came forward to talk. And I hope you. I'm sure you will all benefit from this in a way or another.
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