Common OSCES for Muskuloskeletal system for finals

1. Common OSCES for Muskuloskeletal system for finals Shila Begum FY1 Orthopaedics

2. 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

3. Orthopaedics and Rheumatology Check List • Examination of bones and joints • Back • Shoulder • Elbow • Hand and Wrist • Hip • Knee • Ankle and foot • GALS screen

4. Xrays- Recognition of: • OA • RA (remember atlanto axial subluxation) • Gout • Fractures (neck of femur, common forearm and wrist, shoulder)

5. 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 • Paget’s

6. OSCE 1 • 2010 OSCE Day 1 • Please examine this patient’s back and present your findings and differential diagnoses

7. 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)

8. 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)

9. 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?

10. 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)

11. 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?

12. OSCE 2 • Please examine this patients’ hips and interpret this radiograph.

13. Interpret this radiograph

14. 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’

15. 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)

16. 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.

17. 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.

18. 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.

19. Questions?

20. OSCE 3 Please examine this patients’ hands and discuss investigations and management options.

22. 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

23. 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.

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

25. 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

27. 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

28. 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

29. 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.

30. 2 Classifications to know • Webers Ankle # • Gardens Proximal Hip #

31. Weber Classification for Ankle #

32. 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

33. Gardens classification for Neck of femur #

34. 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.

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

36. OSCES in the past • Examine the knee. • Very Straight forward station. Asked to examine a real patient’s 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.

37. 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 wasn’t 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 • - Card said "You are about to meet a patient regarding their hands" • - Inside - The guy had barn-door Dupuytren's, which I said, and then I looked, felt • and moved the hands (when I started moving the joints he said "they're normal, you • can skip that" - the examiner asked me if there was anything else - I looked again, • really carefully this time, but I couldn't really find anything blatantly obvious, which I • said - he asked what else I would look for in the hands - I said stigmata of liver • disease - he asked about treatment - I said conservative, medical, surgical and then • awkwardly elaborated on these.

38. 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. • What types of Psoriasis do you know? Nail, pustular and flexural. • What can cause the rash to appear? Alcohol, geneteic, stress, infections etc. • How would you treat? Conservative was to avoid precipitants and reassurance. • Medical was steroids, bone marrow suppressants as its an auto-immune disease and • phototherapy.

39. 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.

40. QUESTIONS??

41. GOOD LUCK!!