Past exams

Belfast 2012

Intermediate cases usually start with a brief GP letter

Upper limb and spine:

I was given this letter
16 yr old girl, GP is concerned about increasing curvature of her back please proceed.
This was likely to be adolescent idiopathic scoliosis. The important points in history and examination were to rule out any sinister features. History was the most important feature and I discussed why I was not concerned about this girl. I got to demonstrate very little of clinical examination. It was important in examination to start off with sagittal and coronal balance as well as shoulder and pelvic position and leg length discrepancy. Then show Adam's forward bend test. I was stopped here. What would I want next? X-ray of course. I was shown a PA spine ( remember they are PA and NOT AP) and we discussed Cobb's angle and end vertebra, neutral vertebra etc. Finally we discussed likleyhood of progression and indications for surgery.

Lower limb: no letter

I found a gentleman lying in bed, he had previous problem with his right leg and had many operations ( looked like PFFD), ignore them please, his problem is now the left knee, take a history and proceed.

This was a straight forward varus knee. Very risky as this is bread and butter. Be on your guard when you have common cases. The margin of error is almost nil (you can get maximum 6, one slip and you get 5).

This gentleman had a medial menisectomy scar, it was essential not to miss this and to take pertinent history.

For examination I got him to stand and attempt to walk.We discussed the x-ray and I stated off with conservative treatment with physio and analgesics first. Generally this is the safe approach but you have to be careful how you phrase it. He had significant OA and I was challenged : do you think this will work. I immediatley backtracked saying that I would offer this but bring him for early review and have low threshold for offering surgery.

Short cases:

Upper limb:

Middle aged gentleman, seated, told that he had right wrist pain.

I had an immediate hunch that a middle aged man with atraumatic wrist pain was Kienbock's. It was important to start systematically with inspection, I demonstrated gross restriction in ROM, then on palpation ASB was non-tender but mid-dorsal wrist was tender (diagnosis confirmed).

Young girl, asked to examine her left shoulder.

I thought instability, she had signs of multidirectional instability. I was then asked to demonstrate Beighton's score.

Elderly gentleman, seated, with hands rested on his laps, asked to comment on his hands, had obvious fixed flexion deformity and multiple previous scars.

This was examination of inspection. Important point was that he had very fine scars of previous surgery and also previous skin graft. I missed the skin graft as it was very fine and in the finger cleft but he had an obvious scar in his forearm which I picked up.

Lower limb:

Elderly gentleman, obvious LLD, prompted to ask 3 relevant questions regarding his condition and proceed:

I wanted to know if he was born with it to which he said no, next Q, any childhood fever and any previous surgery, both yes. I got him to stand up and inspected the hip: obvious scar: diagnosis confirmed: hip fusion due to childhood infection, was asked to confirm this, got him to lie down for Thomas' test, FFD, no hip mvt.

Elderly lady, seated, examine her legs please. On standing up clear planovalgus deformity, what do you do next, single limb toe stance, what next? Checked if heel was correctable, next? demonstrated relationship of forefoot to hingfoot on correction of heel valgus, any thing else? checked for ankle ROM and TA tightness.

Middle aged lady, scarring in both legs, asked to ask questions for 30 secs and then proceed. Q to confirm post- traumatic OA from ligamentous instability, got to do little of examination. Examiners had lost interest.

Trauma viva:

30 ish female, closed displaced shortened fracture clavicle: always ask for complementary views, I only saw the AP view but this was a comminuted displaced fracture and unlikley to do well conservtively. I knew the recent Mike McKee systematic review and argued my case for conservatie treatment but I think the right approach would have been to ask for axillary views at the outset and offer surgery.

Mangled leg, plantar sensation intact, reduced pulse. When examiner mentions intact plantar sensation with a mangled leg it is likley they are leaning towards limb salvage. Know MESS score well, I mentioned it but did not know the score in detail. The examiner kindly allowed me to get away with it by mentioning an alternative score: Ganga hospital score that I knew better. It is useful to know of and be able to cite LEAP trial.

Periprosthetic fracture knee, has THR proximally: what to do? avoid stress riser: give LISS plate.

80ish lady, fall,neck pain, lateral view c spine: x-ray was normal, however, with that history even if x-ray was normal one should be suspicious of fracture and ask for peg views. I did and was shown a CT scan with odontoid peg fracture.

Luxatio-erecta shoulder

Central fracture dislocation hip:

manage according to BOAST guidelines, give skeletal traction via distal femur ( not tibia), ask for fine cut CT scan. It showed bicolumnar acetabular fracture as well as femoral head fracture. Although different surgical approaches are described Ganz approach is, I think, more appropriate for bicolumnar fracture as it affords 360 degree views. It has the added benefit of being simpler than other approaches, a single approach, and preserves femoral head blood supply.I mentioned Ganz approach and was asked to describe the approach.

Hand and paediatrics:

Hand
Radio-carpal fracture dislocation: how to manage

Thorn injury 2/7 old, now painful swollen finger, presents at 2 AM: a clear case of pyogenic flexor tenosynovitis: arrange for immediate drainage.

Capitellar fracture: displaced, how to manage: surgery, what instruction do you give to nurse: bring out headless compression screw.

Paeds

You are on-call and get call to see this new born( pic of feet) what to do: club feet.

Both bones forearm fracture, displaced, how to manage? as an aside can you guess age: roughly by number of ossified carpal bones.

6 yr old with hip pain, x-ray pelvis ( Perthe's).

Basic science:

Articular cartilage diagram, function, diff with age, structure etc
Nerve injury:
Survival curve
Pic of broken knee implant
Pic of ORIF forearm and nail humerus in same screen, what is the significance of the difference in type of fixation and how will it affect healing?
Dissection of the posterior aspect of the gluteal region.

Adult pathology:

X-ray with osteolytic lesion distal tibia
Painful resurfacing hip
Genu valgum
LBP: red flags x-ray TL spine partial collapse with winking owl sign
Young pt with painful leg, x-ray: sunray appearance
OA ankle