1. Orthopaedics for finals
Chris Whelton
ST4 T&O

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

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

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

5. OSCEs
History Station
Examination Station
Xrays
Management Station

6. 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

7. 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

8. 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

9. 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

10. Look Feel Move Special test

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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. Xrays

18. 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

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

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

28. Management

29. 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

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

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