Orthopaedics for finals Chris Whelton ST4 T&O

Aims 40 minutes – not long Signposting and tips MCQ OSCE FY1

Recommended reading I did it 7 years ago Practice OSCEs – speak/listen MCQ read/write

MCQ Oxford handbook clinical specialities Practice timed MCQ questions Learn eponymous syndromes Read the question – underline

OSCEs History Station Examination Station Xrays Management Station

History Usual history Remember RED Flags - general Red Flags Back Pain Hand dominance Occupation Overhead activities Functional level Social level/dependence Athlete Surgical risk – can they get up stairs RED Flags - general Red Flags Back Pain Thoracic pain Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset <20 years or >55 years

History Usual history Remember RED Flags - general Red Flags Back Pain Hand dominance Occupation Overhead activities Functional level Social level/dependence Athlete Surgical risk – can they get up stairs RED Flags - general Red Flags Back Pain Thoracic pain Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset <20 years or >55 years

Examination Wash hands Introduce yourself Check patient names and DOB Explain what you want to do and get consent Mention confidentiality Ask if any discomfort

Gait or function Ask them to walk a few paces Examiner may ask you to move on. Alternatively can mention it and say you will come back at the end In upper limb, consider functional assessment Shoulder and elbow to position hand in space Hands on head Hands behind back. Hand functional assessment part of hand exam

Look Feel Move Special test

Inspection “There is no….” Or There is evidence of ….. Redness Swelling Scars Asymmetry Or There is evidence of …..

Feel Have a method palpating each joint Start with bones One place at a time Don’t say “I’m just going to feel your …..” Press palpate Effusion (Knee) Tenderness Lumps

Move Active first Know your normal ROM Then passive (if active not normal) Shoulder: Abduction, forward flexion, hyperextension, internal and external rotation Elbow: Flex/Ext, pronation/supination Wrist: flex/ext, radial/ulna deviation, circumduction Spine: flex/ext, lateral flexion, rotation Hip: flex/ext, abduction/adduction, internal/external rotation.

Special tests Hand: function, LOOK AT ELBOW, Nerve examination Elbow: golfers and tennis elbow Shoulder: Cuff (SST, IST, Subscap) impingment Spine: Schobers test, sciatic stretch test, myotomes and dermotomes Power, tone, reflexes, coordination, sensation (sharp and soft) Hip: Thomas’ test, trendelenburg sign Knee: ACL, PCL, McMurray’s

Always Check joint above and below NV status Radial: finger ext, wrist ext EI (PIN) Median Intrinsic: Thumb adduciton (LOAF) AIN: FPL Ulna: Intrinsic AbDM

Hand deformity Wasting MCPj: ulnar deviation (RA) PIPj: Bouchard’s Thenar eminence Hypothenar eminence Web spaces MCPj: ulnar deviation (RA) PIPj: Bouchard’s DIPj: Heberdens Stiffness

Xrays

Xray method Have a system Check the patient and the date of the xray Side View Adequacy Mention the obvious abnormality first Look for fractures: Compare sides Follow the cortex Soft tissues

Fractures Bone Location in bone Angulation Translation Articular Proximal/middle/distal third Neck Metaphysis Land marks Angulation Translation Articular Comminution Open?

Xrays Tumours Say you don’t know Radiology report Play it safe

Management

Trauma ABC approach, History inc. hand dominance, social, occupation Examination inc. NV status, open/closed injury Hip fracture DHS Hemi / total hip replacement Fractures Splint in plaster or equivalent, check xray MUA, ORIF, replace

Arthritis Xray findings Conservative treatments Replacement Physio Weight loss Analgesia injections Replacement

Thank you References Samanta et al. “Chronic low back pain.” BMJ 2003;326:535 Google images Orthobullets.com