LONG CASE

65 yr old rheumatoid lady, painful R shoulder following a fall, and second problem was pins and needles L little finger

PMH  Bilateral elbow replacements and knee replacements, on methotrexate

History straightforward – take full history, format will be changed tho to 2 x 15 mins cases

Diagnosis – cuff tear right shoulder, cubital tunnel left elbow

Examination of shoulders and elbows, ulnar nerve on left, high v low lesion, neck movements

Discussion

Cubital tunnel, cuff tears, MRI v USS, reverse shoulder, elbow replacements in very general terms, types of shoulder xrays! medication to be stopped before surgery – Grennan paper from wrightington – NOT to be stopped

Nerve conduction studies, treatment of cubital tunnel, ?nerve transposition

SHORT CASES

Lower limb

Knee – pain following TKR – examine knee – got him to stand and walk – looking for thrust – what 2 questions would u ask him? – was pain there following knee replacement and any trauma post fall? – difficult to examine patient as was in pain – told to focus on ligaments – had posterior sag  - what tests would u do – bloods and xr – shown xr – looked like low patella – thought was quads tear – got him to SLR- not quads tear but could hyperextend- DIAGNOSIS – PCL TEAR POST TKR

Asked to examine leg post tibial nailing – shown xrs – had fasciotomy scars and muscle wasting – no active dorsiflexion – had foot drop – how do u know its not a tendon rupture- tested for deep peroneal nerve sensation in web space – was absent- what other nerves supply dorsum of foot- superficial peroneal – what test would u do to determine treatment – test for tib post – functioning – test for other muscle groups – peroneals and plantarflexors – what else would u do – get him to walk – foot drop gait- what else do u look for- AFO orthotic in shoe!

Examine young girls back – café au lait spots – NF – what else do u look for – axillary freckling – how many spots – 6 –what size? Examine gait – look at back – scoliosis – what type – structural v non structural- forward bend test and asked to sit down - look in eyes  - Lisch nodules – iris hamartomas – look in mouth – neurofibroma on tongue! What tests in neurology- upper v lower motor neurone – brisk reflexes – which reflexes best to examine – abdominal – how do u do them?

Upper limb

Examine elbow – scar had replacement – shown xr- types of elbow replacement- lump on elbow – differential – rheumatoid patient – nodule but too big – ?lipoma – was synovial swelling with poly debris!

Examine patient with elbow prosthesis – what is it – how does it work? What has he had done – trans humeral amputation – underlying diagnosis – primary v mets –osteosarcoma- had chondrosarcoma – causes of chondrosarcoma – diaphyseal aclasis – other tumours – olliers – maffuci syndrome-  examine other hand – trigger finger – ask him 1 question – are u diabetic? – treatment – injection or release

Examine hand – garrods knuckle pads – dupuytrens – mcp involvement – treatment – nothing yet – table top test – examine forearm- had AV fistula! – ask him a question – kidney problems- what if PIPJ involvement – problems with tourniquets and surgery – thrombosis

 

VIVAS

TRAUMA

 AP pelvis film with intracapsular hip fracture in 16 yr old – asked for lateral – displaced  - what are u going to do – take to theatre – when? Now – why – any evidence? Is it an emergency? Most important factor in treatment – anatomical reduction – shown post op film – good reduction – what about decompressing capsule – how do u do it? Do u need to? Post op WB status –PWB or toe touch- why?

Gartland 3 supracondylar – management – what do u tell parents – how do u examine nerves – how do u reduce it – what about ulnar nerve symptoms post op – at 6 wks, at 3 mths?

Pathological fracture humerus – metastatic disease – tumours to bone- which ones – how to treat – nail – entry points

Osteoporotic wedge fractures – shown lateral film TL spine – difference between old and new – other tests – bone scan – MRI scan – given dexa scan –what does it show – T  -4.0 – what does it mean – management

Polytrauma patient – given lots films – wanted to know prioritisation of injuries – peg type 3 fracture – stable – pubic ramus fracture – shown CT – sacral ala fracture- undisplaced- stable or unstable?- then shown open tibia – highly comminuted full length – management- if you could nail it how would u do it? Stabilise pelvis before nailing!

Compartment syndrome scenario- how would u do it- full length incisions etc – assessment of patient

HANDS

How do u release trigger finger? Landmarks, structures at risk

Boxers fracture assessment- rotation- what if 50 deg angulation, or 70? Human bite injuries, why r they so serious?

Displaced bony mallet – treatment – how to k wire – key point is joint reduction

Flexor tendon repair – how to do – core sutures – draw it out

PAEDS

Perthes xr- other diagnoses – herring classification – treatment- arthrograms - options – types or osteotomy – at risk signs

Shown XR of coxa vara hip – describe

Selenius graph – types of bowing

Osteochondral lesion talus – management

Forearm XR with osteochondroma – elbow affected also with growth disturbance – general discussion

 

BASIC SCIENCE

Hypertrophic non union v atrophic – bone healing – Perrens theory – factors affecting healing

Bone defects – contained –non contained- bone grafts – types –name osteoconductive agent – ceramic – osteoinductive – BMP

Nerve injuries – types- draw nerve- radial nerve palsy with humerus fracture- time to regenerate 1mm day – how to assess – nerve conduction studies

Anatomy cross sections- thigh- femoral triangle

Principles of lag screw – Herbert screw – differential pitch

Infection – MRSA- laminar flow – types – Howarth  - paper –Lidwell 1982

Henry approach – elbow to wrist, dorsal approach also

Kaplan Meyer Curve

 

ADULT PATH

Spondylolisthesis –types- classification- symptoms – spinal stenosis  v vascular claudication – treatment – nerve root involvement – central v far lateral

Lytic lesion distal tibia – Brodies – treatment- anterior approach to ankle

Rheumatoid foot – treatment- orthotic what type? Surgery, take me thro a stainsby procedure

XR of ank spond – bilateral sacroiliitis – differential – other sero negative arthropathies – management of hip – problems with THR- why do they bleed a lot?

Cavovarus foot – causes- why do they gat clawing? Muscle imbalances – investigations

XR broken DHS plate in curved femur – fatigue failure –cause of femoral bowing – looser zones – osteomalacia  -calcium phosphate metabolism