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Orthopaedics for finals
Chris Whelton ST4 T&O
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Aims 40 minutes – not long Signposting and tips MCQ OSCE FY1
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Recommended reading I did it 7 years ago Practice OSCEs – speak/listen
MCQ read/write
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MCQ Oxford handbook clinical specialities Practice timed MCQ questions
Learn eponymous syndromes Read the question – underline
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OSCEs History Station Examination Station Xrays Management Station
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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
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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
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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
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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
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Look Feel Move Special test
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Inspection “There is no….” Or There is evidence of ….. Redness
Swelling Scars Asymmetry Or There is evidence of …..
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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
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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.
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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
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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
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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
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Xrays
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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
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Fractures Bone Location in bone Angulation Translation Articular
Proximal/middle/distal third Neck Metaphysis Land marks Angulation Translation Articular Comminution Open?
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Xrays Tumours Say you don’t know Radiology report Play it safe
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Management
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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
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Arthritis Xray findings Conservative treatments Replacement Physio
Weight loss Analgesia injections Replacement
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Thank you References Samanta et al. “Chronic low back pain.” BMJ 2003;326:535 Google images Orthobullets.com
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