Common OSCES for Muskuloskeletal system for finals

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Common OSCES for Muskuloskeletal system for finals

• Shila Begum
• FY1 Orthopaedics

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Outline

• Check list of what to go through once before
  exams
• 3 OSCES that have come up in the past
• Full explanations and answers
• Extra Bits
• List of previous OSCES
• Questions

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Orthopaedics and Rheumatology Check List

• Examination of bones and joints
• Back
• Shoulder
• Elbow
• Hand and Wrist
• Hip
• Knee
• Ankle and foot
• GALS screen

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Xrays- Recognition of

• OA
• RA (remember atlanto axial subluxation)
• Gout
• Fractures (neck of femur, common forearm and
  wrist, shoulder)

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History taking /presentation and basic knowledge
of

• Bone pain e.g back ache
• RA
• OA
• Septic arthritis
• Gout and Pseudogout
• Osteomyelitis
• Ankylosing Spondylitis
• Psoriasis
• SLE
• Vasculitis
• Systemic sclerosis
• Fibromyalgia
• Pagets

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OSCE 1

• 2010 OSCE Day 1
• Please examine this patients back and present
  your findings and differential diagnoses

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• Alcogel hands
• Smile and Introduction
• Explain and consent
• Pain
• Look ( Spinal deformities, asymmetry, muscle
  wasting)
• Feel ( Spinous processes, SIJ, paraspinal
  tenderness,T1 prominent)
• Move (cervical-4, thoracic-1, lumbar 4)
• Special Tests (Schobers test, SLR, )
• End of exam (examine above and below joint,
  neuro, gait, pr exam)

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Schober's test When the spine flexes, the
distance between each pair of vertebral spines
increases. Schober's test can be used to provide
a quantitative evaluation of flexion of the
lumbar spine A tape with a 15 cm mark is placed
vertically in the midline upwards from the level
of the dimples at the level of the posterior
superior iliac spines). Mark the skin at 0 and
at 15 cm and then ask the patient to flex as far
forward as they can Record where the 15 cm mark
on the skin strikes the tape. The increased
distance along the tape is due only to flexion of
the lumbar spine and is normally about 6-7 cm
(less than 5 cm should be considered as
abnormal)

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• Present your findings
• This is a 45 year old man.
• On general inspection he looks well and
  comfortable.
• On examination of his back there is obvious
  scoliosis and scaring in the mid thoracic region
  with evidence of loss vertebral body space. On
  flexion there were prominent thoracic vertebral
  process.
• On palpation there were no tenderness over the
  spinous processes or paraspinal areas
• On movement there was limited forward flexion of
  approximately 50 expected, limited thoracic
  movements and normal lateral flexion.
• These findings are consistent with
• Qns asked-
• What else can cause this?
• How could this be managed?

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• Answer- Deforming scoliosis secondary to
  infection
• The infective cause was TB of the thoracic
  vertebral bodies
• Was treated with removal of the infected
  vertebral bodies, giving rise to a scoliosis,
  scaring and shortened thoracic area of the back.
• Also looked very abnormal as all normal anatomy
  was now moved up a few places and diaphragm was
  higher, lungs were higher up, ribs looked
  abnormal
• Differential diagnoses
• Congenital scoliosis (Failure of formation or
  segmentation
• Idiopathic (seen in infants and adolescents)
• Neuromuscular (neuropathic, myopathic cerbral
  palsy or muscular dystrophy)
• Syndromic- marfans
• Other (tumour, infection, trauma)

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• Management
• Conservative- Treat symptoms- pain, mechanical
  brace
• Surgery- Deformity correction- spinal fusion and
  stabilisation
• Just need to know the principles of
  management ie split into conservative and medical
  (non surgical) and surgical treatments.
• Questions?

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OSCE 2

• Please examine this patients hips and interpret
  this radiograph.

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• Interpret this radiograph

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• Alcogel hands
• Smile and introduction
• Explain and consent
• Pain
• General Inspection- pt well/unwell
• Look- (Standing) symmetry, pelvic tilt,
  deformities,muscle wasting, scars, true and
  apparent leg length, get them to walk.
• Feel- tenderness greater lesser trochanter,
  ischial tuberosities
• Move- active and passive- flexion, extension, in
  and ex rotation, ab/aduction
• Special Tests- Trendelenburgs, Thomas

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• Trendelenburg Sign (not test!)
• Stand on one leg for 30 seconds each.
• Illiac crests should be level.
• If the hip falls on that side, then adductors are
  weak on the opposite side.
• (As the adductors on the opposite side are not
  strong enough to hold the contralateral hip
  against gravity)

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• Thomas test
• CI-?
• Test for fixed flexion deformity of Hip
• How-
• Place one hand in lumber back,
• Patient brings both knees upto chest. Extend one
  leg fully. One hand should be on opposite hip
  ASIS to stabilise.
• If patient cannot extend leg straight then FFD of
  hip.

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• This is a pleasant 86 year old lady.
• On general inspection she looks well
• On closer inspection of the hip there appeared to
  be no obvious deformities of the hip apart from
  some quadriceps muscle wasting. Gait appeared
  normal.
• There were no leg length discrepancy.
• There appeared to be some tenderness to deep
  palpation of the greater trochanters.
• Movements were reduced in all areas, notably
  internal rotation. SLR was intact.
  Trendelenburgs test was negative however Thomas
  test was positive.
• These findings are consistent with typical OA of
  the hips, most likely bilateral.
• I would also like to examine the neurovascular
  status, and the joints above and below.

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• This is a radiograph of Mrs A.
• Taken on 27/10/2010
• AP Radiograph of both hips
• Film appears adequate as does resolution
• Obvious abnormalities are at the joint of the
  femoral head meeting the acetabulum on both sides
• I can see
• Definite joint space narrowing
• Sclerosis (the white bits)
• Osteophytes (bony formation)
• I would also expect to see subchondral cysts with
  better resolution radiograph.
• These findings are consistent with moderate
  bilateral degenerative osteoarthritis of the hips.

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• Questions?

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OSCE 3

• Please examine this patients hands and
  discuss investigations and management options.

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• Alcogel hands
• Smile and introduction
• Explain and consent
• Pain
• General inspection-looks well,unwell
• Look- color,swellings, deformity,wrist, muscle
  wasting,nails
• Feel-wrist, MCP, PIP, DIP for tenderness(blanch
  skin), crepitus-open and close fist fully, feels
  tendon sheath.
• Move-active and passive,make a fist,extension,
  flexion, ad/abduction
• Other-median nerve-push against vertical thumb
• radial nerve- push against extended
  fingers
• ulnar nerve- froments test- grip paper
  between palm and thumb
• Neurovascular status

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• This is a 85 year old pleasant gentleman.
• On general inspection he looks well
• Obvious abnormalities-
• Symmetrical deforming polyarthropathy.
• There is MCP swelling and pip swelling, MCP
  deviation, volar displacemnt of the wrist, z from
  deformity of thumb and squaring of base of thumbs
  and both boutonniere and swan neck deformities.
  Small muscle wasting of both hands
• On palpation there were no tenderness or pain
  found which means there is no active synovitis.
• Movements were very limited
• Neurovascular intact
• These findings are consistent with RA
• I would also like to examine the joint above
  and do a full systemic examination for further
  manifestations of the disease.

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• Questions asked
• What investigations would you do?
• What are the different management options for
  this disease?
• What x-ray findings would you find?

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• Investigations- FBC, ESR, CRP, RH F, Anti CCP
  antibodies (specific 98, sensitive 80)
• Radiographs
• X-ray findings in RA-
• Symmetrical soft tissue swellings around MCP, PIP
• Narrowed joint space
• Bony erosions at mcp, pip
• Peri-articular erosions
• Osteopenia
• Mal-alignment of bones

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• Management RA
• Medical-
• Drug therapy (DMARDs- methotrexate,
  sulfasalazine, Anti-inflammatory and analgesia)
• Exercise
• Joint injections or aspiration
• Making lifestyle changes that can ease the
  condition
• Managing pain
• Physical rehabilitation
• Surgical-
• If medical approaches do not control the
  symptoms, surgery may be needed. Available
  surgical procedures include
• Arthroplasty, in which parts of the joint are
  replaced with artificial parts. This may be done
  if there is joint damage that limits the movement
  of the joint
• Total joint replacement. This is typically done
  with the hip and knee
• Fusion of joints, so that the damaged parts are
  not moving against each other

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• Last Bits
• Atlanto axial subluxation-
• Rupture of transverse ligament. This ligament
  holds the adonatoid process in check, separates
  it from the spinal cord.
• Tears in- sudden flexion or RA
• C1 slips forward onto C2. Shown by a gap between
  anterior arch of atlas and adenatoid process.
• Need 2 lateral views- In flexion and extention
• CT of cervical vertebrae

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Atlantoaxial subluxation

• Lateral radiograph of the neck with the head in
  flexion shows an increased distance between the
  anterior border of the dens and the posterior
  border of the anterior tubercle of C1 (blue line)
  
• The red line above should smoothly connect all of
  the white lines of each vertebral body but
  clearly is directed posterior to the spinolaminar
  white line of C1 (green arrow) since C1 is
  subluxed forward on C2.

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2 Classifications to know

• Webers Ankle
• Gardens Proximal Hip

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• Weber Classification for Ankle

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Weber classification for ankle fractures

• The Weber ankle fracture classification is a
  simple system for classification of lateral
  malleolar fractures, relating to the level of the
  ankle joint, and determining treatment.
• type A
• below level of the ankle joint
• tibiofibular syndesmosis intact
• usually stable occasionally nonetheless
  requires an open reduction and internal fixation
  (ORIF)
• type B
• at the level of the ankle joint, extending
  superiorly and laterally up the fibula
• tibiofibular syndesmosis intact or only partially
  torn,
• variable stability
• type C
• above the level of the ankle joint
• tibiofibular syndesmosis disrupted
• medial malleolus fracture
• unstable requires ORIF

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Gardens classification for Neck of femur
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• Garden Classification for Proximal Femur
• The Garden classification of proximal femoral
  fractures is the most widely used, and is useful
  as it it is both simple and predicts the
  development of AVN.
• Garden stage I  undisplaced incomplete,
  including valgus impacted fractures.
• Garden stage II  undisplaced but complete
  fracture
• Garden stage III  complete fracture,
  incompletely displaced. Risk AVN.
• Garden stage IV  complete fracture, completely
  displaced. Risk Of AVN.

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• SUMMARY
• ALCOGEL, INTRODUCTION, SOUND CONFIDENT
• WITH EXAMINATIONS-
• LOOK
• FEEL
• MOVE
• SPECIAL TESTS
• DIFFERENTIALS- GO THROUGH SURGICAL SEIVE (even if
  you have no idea!)

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OSCES in the past

• Examine the knee.
• Very Straight forward station. Asked to examine a
  real patients knee, told that there
• will be an x-ray to interpret and that you will
  be asked about management options.
• Male patient had bilateral osteoarthritis which
  was obvious on examination and had
• barn door x-ray changes.
• 2009
• Examination of patients with stable chronic
  disease Mind and
• Movement - Hip exam and Pelvic Radiograph
• This was a nice station with plenty of time at
  the end. Exam was on a student
• normal. I made patient walk and did
  trendelenbergs before examination of hip. Then
• we were given an x-ray which was bilateral OA of
  hips and sclerotic changes in
• spine. I was additionally wary of an abnormality
  in the left hip that could have been
• an intracapsular fracture I said this to the
  examiner and he questioned me further.
• What are the changes that suggest OA and why due
  you say about the fracture? I
• said the characteristic changes of OA and just
  commented on the asymmetry of the
• appearance of the femur necks. He seemed happy
  and said I would make a good
• FY1 Dr (always a nice comment!) I still do not
  know if there was a fracture, I know at
• least one person in the same cycle as me had also
  thought that there was something
• unusual about the left neck of femur, I think the
  OA was the main point though.

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• Examination of a patient with chronic stable
  disease Mind and
• Movement Rheumatoid hands (Spotter)
• This was a spotter but an examination was
  necessary, as well as a diagnosis and
• discussion about management for the marks. Was
  asked what else I would like to
• examine (feet) and about cervical spine exactly
  which joint is affected.
• Knee exam - on a real patient. OA. and then shown
  x-ray of knee with OA on
• medial side of joint. Examiner asks about
  management and advice for pt.
• Knee Examination and then x-ray interpretation.
• A patient with bilateral knee replacements. She
  had scars on both knees. Attempted
• a knee examination but she wasnt very
  cooperative and one of her knees was really
• sore! Bit of a dodgy station!
• I then had to look at a knee x-ray (obviously not
  hers) with OA changes so listed
• them and then spoke about the management of OA
  (conservative, medical and
• surgical management seemed to do the trick!)
• Rheumatoid hands - Patient had textbook RA hands.
  Had to examine her and
• discuss extra-articular features and management.
• psoriasis - asked to examine the patients
  hands/arms/nails. then asked regarding
• differentials and management of psoriasis
• Dupuytren's

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• Psoriasis
• Card said "You are going to meet a patient with a
  skin condition"
• - Inside - Barn door Psoriasis on his knees and
  elbows, which I said - examiner
• asked if there was anything else you'd look at -
  my mind threw a blank - he said what
• about the hands - I spotted onycholysis straight
  away - was gearing to up to give a
• flawless answer on the non-dermatological
  associations but instead the examiner
• asked me about treatments, which threw me. I gave
  the usual conservative, medical,
• surgical framework and struggled to elaborate. In
  the last 15 seconds the examiner
• asked me about complications - started to chat
  about stigma, flaky clothes and then
• time ran out, before I could mention those
  associations I had outlined in my head.
• Knee exam. Asked to describe each test and what I
  was looking for. I was stopped
• after every movement so the station didnt flow.
  Patient had mild antalgia with
• reduced function. He also used a walking stick
  which was with him. All else was
• normal.
• Whats the diagnosis OA or referred pain from
  the hip. It was OA, but he was
• pleased i mentioned referred pain.
• Student Reports on Finals 2008 Manchester
• Psoriasis. Describe the lesions and their
  location. Told to look at hands which had
• nail pitting and onycholisis.

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• RA
• Again, a good thorough history is required. My
  patient was a farmer so his life was
• affected and he was forced into retirement. Ask
  about function and ADLS.
• Questions by the examiner?
• What makes you think its RA? His chronic
  history, joint distribution and the
• inflammatory nature of the swellings/pain.
• How would you diagnose? History and Examination.
  Also do Rh factor just for the
• sake of it and ESR levels in active disease plus
  Xray of the joints.
• What would the Xray show? Subluxation,
  Osteopenia, Loss of joint space, Erosions,
• Soft tissue swelling.
• What other DMARDs do you know of apart from
  sulphasalazine and methotrexate?
• Gold, penicillamine and azathioprine.
• How would you treat severe disease or flare up's?
  Joint debridement, steroid
• injection or basic NSAIDs if it's a flare up.
  Also joint replacement for severe RA.
• What conservative steps can be taken? Physio,
  splints and aids to help with ADL.

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• QUESTIONS??

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• GOOD LUCK!!