MED4 Orthopaedics & Traumatology Past Paper PDF 2023-2024

MED4 Orthopaedics & Traumatology End of Module (EOM) Assessment Disclaimer: This source is NOT enough for you to secure a pass in Surg OSCE OnT stations. 1st 2nd 3rd 4th 5t...

MED4 Orthopaedics & Traumatology End of Module (EOM) Assessment Disclaimer: This source is NOT enough for you to secure a pass in Surg OSCE OnT stations. 1st 2nd 3rd 4th 5th 6th 7th 8th 2023-24 Adhesive capsulitis; Sciatica (PID); Knee OA; Osteosarcoma; Adhesive capsulitis; Sciatica (PID); Knee OA; Osteosarcoma; Hip Ulnar nerve Lumber spine Knee Cervical spine Hip Ulnar nerve Shoulder 2022-23 Adhesive capsulitis; Sciatica (PID); Knee OA; Osteosarcoma; Adhesive capsulitis; Sciatica (PID); Knee OA; Osteosarcoma; Hip Ulnar nerve Lumber spine Knee Cervical spine Hip Ulnar nerve Shoulder 2021-22 ???? ????? ??????? Osteosarcoma; Adhesive capsulitis Sciatica (PID); Adhesive capsulitis + Knee OA & Shoulder Hip Ulnar nerve Knee Knee Cervical spine Hip Knee OA (both Hx) impingement 2020-21 2019-20 2018-19 Osteosarcoma; Adhesive capsulitis; Sciatica (PID); Knee OA; Osteosarcoma; Adhesive capsulitis; Sciatica; N/A Ulnar nerve Cervical spine Knee Wrist Lumbar spine Hip Ulnar nerve 2017-18 Adhesive capsulitis; Osteosarcoma; Sciatica (PID); Osteosarcoma; Sciatica (PID); Adhesive capsulitis; Osteosarcoma; OA knee Knee Lumber spine Wrist Ulnar nerve Shoulder Knee Cervical spine Ulnar nerve Physical Examination History Taking 1) Lumbar Spine 1) Adhesive capsulitis Greeting 2) Cervical spine 2) Sciatica (PID) Exposure 3) Hip 3) Osteosarcoma Posture 4) Knee 4) Knee osteoarthritis Compare both sides 5) Wrist Look à Feel à Move 6) Ulnar nerve Timing 7) Shoulder Prepared by Hemato 26’ Physical Examination (Please read it with a grain of salt) A. Lumber Spine Examination B. Cervical Spine Examination 60 years old man with CA prostate surgery done 3 years ago. His pain is not related to Mr Fung, 25/M, was injured in a collision during an RTA. The collision force flexed and ADL. The pain has no radiation, no neurological symptoms, but focal pain of the back. then extended his neck. After some time, he complained of neck pain. He had a spinal decompression surgery done few years ago. (+ LOW, LOA & malaise) 1) Please examine the cervical spine of this patient 1) Do a lumbar spine examination (do not perform neurological examination) 2) No motor or sensory deficit, no need to do upper limb neurological examination 2) What is the most important thing to exclude? Bone metastasis from CA Prostate 3) What X-ray will you order? (3 Views to order: AP, open mouth AP, lateral) 3) What are the other DDx? PID, spinal stenosis, AS, Infection [LOOK for fractures, alignment, soft tissue swelling] Greet the patient and introduce yourself, Consent, HAND HYGEINE Greet the patient and introduce yourself, Consent, HAND HYGEINE Exposure: Entire upper trunk; Posture: Sitting upright at the side of a bed/ on a chair Exposure: WHOLE upper trunk; Posture: Standing in the beginning “I would like to expose the patient’s upper trunk in a sitting position.” Look: Front à Side à Back: Look for asymmetry, scars, misalignment, wasting and scoliosis Look: Front (Torticollis) à Side (lordosis/ kyphosis) à Back (Asymmetry/muscle wasting) Feel (Don’t start from the thoracic region as it is unnecessary; Any pain?) Feel (COMPARE BOTH SIDES!!!) (Any pain? Stand in lateral position and LOOK at the patient!) Palpate along spinous process for tenderness, deviation from midline and stepping Palpate the spinous processes (from C2) for tenderness, deviation from midline, stepping Palpate the paraspinal muscles for spasms; Compare muscle bulk on BOTH SIDES! Start from external occipital protuberance à Ligamentum nuchae & Spinous processes Move (You should observe reduced active ROM) C7 or T1? Only C7 moves when the patient flexes and extends his neck Active Range of Motion (ROM): evenness & smoothness of movement, pain, crepitus Paraspinal muscle + Trapezius (+ SCM): Spasms Ø Lateral Flexion Any mass palpated? Ø Rotation: place hands on pelvis and ask patient to rotate upper torso Move (Ask the patient to sit up straight à Fix shoulders with hands to prevent movement) Ø Extension: “Lean backwards as far as possible” You should observe reduced ROM in all planes!!! [patient can do all movements except flexion] Shoeber Test: sacral dimple (S2) & 10 cm above [just mention it to the examiner] Rotation of cervical spine (90o): “Turn your head to the left / right” Ask the patient to flex forwards, and take note of the change in distance à At least 5 cm increase Lateral flexion (45o): “Touch your ear to your shoulder” Special Tests (NOT required????) [Look at the patient’s face to see if he/she has any pain!] Forward flexion (75o): “Touch your chin to your chest” Straight Leg Raise / Tension Sign: Lie supine à Raise Leg (à Ankle dorsiflexion) Extension (50o): “Look up at the ceiling” Bowstring Sign: Flex knee à Palpate at popliteal fossa (lateral to medial) Do PASSIVE ROM if the patient fails to do ACTIVE ROM; [Additional examination: PR examination/ any lymph node enlargement] Special tests: NOT required as no motor or sensory deficit Prepared by Hemato 26’ C. Hip D. Knee A man is presented with right hip stiffness. A man with injury to his knee during a football game 2 years ago 1) Please examine his range of movement (with the patient’s shorts on). 1) Examine the knee 2) Perform the Posterior and Anterior drawer test 2) Please test whether the patient has flexion contracture. Greet the patient and introduce yourself, Consent, HAND HYGEINE 3) Please perform the Trendelenburg’s test. Exposure: Entire lower limbs; Posture: Lying spine on bed Greet the patient and introduce yourself, Consent, HAND HYGEINE Look: "I would like to examine the patient in standing position for inspection of the knee and the gait LATER" Exposure: Entire lower limbs Feel Posture: Mention the posture for that PE!!! Temperature: using the dorsum of hand on both knees (Compare both sides) [DO NOT WASTE TIME ON ANY INSPECTION OR PALPATION if the instruction didn’t Patella Tap Test OR Fluid Displacement Test: 1) Empty the medial pouch à indicate] 2) Push the fluid to lateral pouch à 3) Observe for any bulging in medial pouch Move [SQUARE THE PELVIS; COMPARE BOTH SIDES] “I’ll measure with a goniometer” Anatomical Landmarks (RUNNING COMMENTARY) Passive Range of Motion (ROM) Ø Anterior: Tibial tuberosity, Patellar tendon, Patellar, Quadriceps tendon Ø Flexion (~130o): Place hand under lumber spine to obliterate lumbar lordosis Ø Medial: Medial femoral & tibial condyle, Medial joint line, semitendinosus + o Ø Abduction (~40 ): Fix pelvis with one hand semimembranosus tendons Ø Adduction (~25o): First abduct the other hip joint Ø Lateral: Lateral femoral & tibial condyle, Head of fibula, Lateral joint line, ITB o o o o o Ø Internal (30 – 40 ) / External Rotation (40 – 50 ): Flex hip joint to 90 Move [Heal buttock distance NOT required] Ø Extension (15o): PRONE position, flex knee joint to 90o then pull up Active Range of Motion (ROM): Flexion (135o – 140o) , Extension (0o) Thomas Test (flexion deformity?): Place hand under lumbar spine to obliterate Passive Range of Motion: Place one hand on patella (Crepitus? Tenderness?) lumbar lordosis à Passively flex the normal hip fully (while also flexing the knee) & Special Test (Perform posterior à anterior; Reason: With PCL injury, starting point is lower) ask the patient to hold the posture with his hands à Observe the contralateral limb for Posterior Sag Test: Flex hip joint & knee joint both to 90o and hold distal leg with one flexion of the hip [then ensure is real hip flexion deformity by pressing down on the hand à Ask the patient to relax & hamstrings relaxed ("放曬啲力落我隻手") à knee; CANNOT press down!] Tibial tuberosity should be anterior to the patella (Same level = +ve) Trendelenburg’s test#: Face the patient à Hold your hands on the patient’s ASIS à Posterior Drawer Test: Flex hip joint and knee joint à Sit on foot à Relax hamstring Place their forearms on you and give support à Ask the patient to stand on one leg & muscles à Apply posterior force to proximal tibia à Excessive laxity/lack of endpoint bend the contralateral knee to 90o backwards Lachman Test: Flex the knee joint to around 15o – 30o à Apply anterior force to proximal tibial & push distal femur down à Excessive laxity/lack of endpoint? Anterior Drawer Test: Similar to posterior drawer test except anterior force applied Prepared by Hemato 26’ E. Wrist F. Ulnar Nerve The patient suffered from a Colle’s fracture in the right wrist 9 months ago and it was Young man hit the elbow. Then have some pain in the elbow and wrist area. subsequently reduced. He returns for his check up for the condition of the wrist. Please 1) Examine the MOTOR function of the Ulnar Nerve perform a physical examination for this follow up and answer the following question: 2) Check the Froment’s Sign 1) What is Colle’s fracture? Fracture of the distal radius in the forearm with dorsal 3) Describe the sensory supply by ulnar (don’t test on this patient) (posterior) and radial displacement (not dislocation!!) of the wrist and hand. Palmar aspect: Volar skin of palm to ulnar 1.5 digits (palmar cutaneous branch + Superficial palmar branch) 2) Is there any residual deformity in the patient? Dinner-fork deformity? Dorsal aspect: Dorsal skin of dorsum to ulnar 1.5 digits (dorsal cutaneous branch) 3) Check the patient’s wrist range of movement 4) Palpate ulnar nerve at the elbow area 4) Check the patient’s wrist power and grip strength. (Findings: Right Claw hand deformity with loss of power of all the test fingers + loss of sensation) Greeting, Consent, HAND HYGEINE; Exposure: Hand + wrist + elbow; Posture: seated with hands on a table Greet the patient and introduce yourself, Consent, HAND HYGEINE Move: Flexion, Extension, Radial/ Ulnar deviation, Pronation/ Supination Exposure: WHOLE upper limb ; Posture: Patient will be seated with the hands on a table / pillow Passive Wrist Extension: Put hands together palm to palm à bring hands as low as possible & keeping palms together Look: Any deformities, discoloration, scars, swelling, muscle wasting or fasciculation? Passive Wrist Flexion: Put hands together dorsum to dorsum à bring hands as high as possible & keeping dorsal hands together Screening Test: Palm down à Wrist extension (Radial nerve: ECRB/L) à Thumb up (PIN: EPL, EPB, APL) Power and Grip strength (For the power, you should comment based on MRC grading.) à Palm up (High median & ulnar nerve: FDS/ FDP) à Thumb opposition (Median nerve: FPB/ OP/ APB) Flexion: Ask patient to put hand on the table with palms facing the ceiling à Ask patient to perform wrist à Okay sign (AIN: FDP-IF/ FPL) à Fingers abduction/ adduction (Ulnar nerve: ADM/ Interossei) flexion, while applying resistance on 2nd & 3rd MC bases à Feel the contraction of FCR at the wrist region. Move (COMPARE BOTH SIDES!!! Start from distal to proximal) Extension: Ask patient to make a fist with palms facing downwards à ask patient to perform wrist extension, Index finger Abduction: 1st dorsal interossei (Stabilize MCP at neutral position) and then also ulnar deviation à Apply resistance on the ulnar aspect of the 5th MC head Little finger Abduction: Abductor digiti minimi (Stabilize MCP at neutral position) Radial deviation: Ask patient to make a fist with palms facing downwards à ask patient to perform wrist Cross finger sign: 1st volar interossei + 2nd dorsal interossei (CANNOT test POWER!) extension à apply resistance on the radial aspect of the 2nd MC head (since the ECRL attaches to the 2nd MC base) Froment’s Sign: 1st volar interossei + 2nd dorsal interossei + adductor pollicis Ulnar deviation: palms facing upwards with fingers slightly flexed à Ask patient to ulnar deviate, while (Adduct thumb to tightly hold paper à +ve if flexes IPJ of thumb) applying force on ulnar aspect of 5th MC base à Use another hand to palpate tendon (inserts into pisiform) Pollock sign: Flexor digitorum profundus of ring and little fingers Pronation: Ask patient to flex elbow, with palm facing ceiling à Ask patient to perform pronation, while you [Immobilizing the middle phalanx à +ve if reduce power in ring and little fingers] hold onto his hands as if is shaking hands and give resistance Ulnar flexion of wrist: Flexor carpi ulnaris (Apply on volar ulnar aspect of 5th Supination: Ask patient to hold arms out straight, with palms facing the ground à Put one hand at the elbow metacarpal region à contraction of FCU inserting onto pisiform) joint to ensure full elbow extension à Another hand to hold patient’s hand as if is shaking hands & give resistance Special Test: Palpate for ulnar nerve@ (Mass or tenderness) Grip strength: ask patient to hold onto your finger & grip tight prevent you pulling out. Prepared by Hemato 26’ G. Shoulder # Causes of Positive Trendelenburg Test 25 y/o male Plays basketball, multiple episodes of pain over R shoulder in the past year (Pelvis drops on the unsupported side due to abductor mechanism dysfunction) X-ray taken during the episodes (Showing repeated shoulder dislocation) Power failure (Poliomyelitis, Post-surgery superior gluteal nerve damage) Please examine the right shoulder of this patient and do two relevant special tests. Lever Arm failure (Fracture neck of femur) Greet the patient and introduce yourself, Consent, HAND HYGEINE Fulcrum failure (TB hip, Septic hip, Avascular necrosis) Exposure: Entire upper trunk; Posture: Sitting upright at the side of a bed/ on a chair False positives: Gluteal inhibition due to osteoarthritis, rheumatoid arthritis Look (Deformities, Discolorations, Scars, Swelling, Ulcerations, Muscle Wasting, Alignment, Posture) Front: Round contour of deltoid, AC joint, Muscle bulk of Pectoralis major Side: Round contour of deltoid, Anterior shoulder swelling @ Course of the ulnar nerve: Back: Round contour of deltoid, Supraspinatus and Infraspinatus, Inferior tip of Starting from Guyon’s canal (radial border: hook of hamate; medial border: pisiform) scapular (Any scapular winging?), AC dislocation à medial aspect of forearm Feel à cubital tunnel (between the medial epicondyle and the olecranon) Anatomical landmarks: Sternoclavicular joint à Along the clavicle à AC joint à à medial aspect of arm Long head of biceps tendon (anterior to the AC joint), Coracoid process, Supraspinatus à the axilla region attachment (lateral to acromion) Move Forward flexion (~ 180o): Front & Side Backward extension (~ 40o): Front & Side Hand behind head (External rotation with abduction; ~90o): Front & Side Cross Chest Adduction Hand behind Back (Internal rotation with adduction; < 90o): Back Abduction (~160o – 180o): Front & Back *****Passive Range of Motion (ROM): Palpate for crepitus! Forward flexion, External Rotation, Internal rotation (BOTH Abduction and Adduction!!!) Special Tests (For SHOUDLER INSTABILITY) Bonus question: differentiate high and low paralysis claw hand paradox (paralysed Load and Shift Test: Fix the shoulder à Anterior force to humeral head/ glenoid lumbricals intact FDP); Sensory (preservation) Apprehension Test: Abduct shoulder to 90o à Externally rotate shoulder Prepared by Hemato 26’ History Taking (Basically they refry the same surrogate script) A. Adhesive capsulitis B. Prolapsed intervertebral disc (PID)/ Sciatica Patient demographics: Mr. Fung, 56 years old, retired (used to be a driver) Patient demographics: 50/F, low back pain with numbness and radiation, Housewife Chief complaint Chief complaint Ø Site: Right shoulder Ø Site: Low back (Pain in other joints? To rule out inflammatory diseases) Ø Onset: One month ago Ø Onset: 1 week, sudden onset after moving some chairs Ø Character: Aching pain Ø Character: Soreness Ø Radiation: None Ø Radiation: Radiation to L thigh and toe Ø Associated symptoms: Numbness, stiffness (crepitus???) Ø Associated symptoms: Numbness at L thigh and toe, No swelling or bruising Ø Macro time: Constant pain since onset, not gradual or progressive Ø Macro time: 1 week ago, not progressive Ø Micro time: More painful in the morning than night Ø Micro time: more severe in evening Ø Exacerbating factors: Movement in all directions Ø Exacerbating factors: Movement Ø Relieving factors: Rest, Analgesics (minimal effect) Ø Relieving factors: Rest Ø Severity: 7-8/10 in the morning, 5/10 at night Ø Severity: 8/10, not relieved by Panadol Ø Stiffness in shoulder joint? Swelling? Instability? Clicking? Rule out other aetiologies / DDx / Red Flag signs: Rule out other aetiologies / DDx / Red Flag signs: Ø Recent rapid weight loss / night sweats / malaise / cachexia/ fever: None Ø Recent rapid weight loss / night sweats / malaise / cachexia: None Ø Contact with TB patients: None; Trauma: None Ø Fever: None Ø Neurological deficits like weakness in toes, numbness; LL power not affected Ø Contact with TB patients: None Ø No urinary retention/ bladder incontinence Ø Trauma: None (Cannot recall any) PMHx: Not on any medications, NKDA PMHx: Good past health, no chronic illnesses/ drug use, NKDA SHx/ FHx: NSND, Lives with family, Home with lift; Family history unremarkable SHx: Living with wife and son, NSND; FHx: No FHx of malignancies. ADL Assessment: Affect daily activities e.g. walking, carrying heavy things; A little bit ADL Assessment: down, but emotionally stable Ø Can hardly use dominant hand (right hand) e.g. write, brush teeth, comb hair, etc. [May ask you to present your findings if there’s time left] Ø Cannot play ball games (his regular hobby) DDx: Sciatica, caused by spondylolisthesis/ Prolapsed intervertebral disc/radiculopathy Ø Does less household chores 舉高雙手, 換燈膽; Worried (family also worried) [Note: Spondylolisthesis is NOT likely for this age group, but if you are asked to give another diagnosis……] Prepared by Hemato 26’ C. Osteosarcoma D. Knee osteoarthritis A young man/ woman comes to your clinic due to right distal thigh pain.. Prompt: Patient presents with right knee pain. Take a detailed history and give a Take history and give a list of ddx. DDx: 1o tumour Osteosarcoma, Chronic inflammation differential diagnosis. (EXCLUDE GOUT!!!) (finger joint swelling can indicate RA), systemic inflammation (rule out SLE) Patient demographics: Mr. Wong, 55 years old, (Forgot occupation) Patient demographics: 21 years old, university student, right distal thigh pain Chief complaint (Right knee pain) Chief complaint Ø Site: Right knee, localized Ø Site: Right distal thigh Ø Onset: 1 year ago Ø Onset: 6 weeks ago after having a slight rotation of the leg during walking Ø Character: Soreness Ø Character: Dull pain Ø Radiation: none Ø Radiation: None Ø Associated symptoms: None Ø Associated symptoms: No redness or hotness; Swelling is present!!! (growth Ø Macro time: progressively worse compared to 1 year ago in size, texture of mass) Ø Micro time: worse at night, especially after walking (Early morning stiffness?) Ø Macro time: Pain progresses more severe gradually in 6 weeks. Ø Exacerbating factors: walking Ø Micro time: Especially painful during evening. Pain wakes patient at midnight. Ø Relieving factors: rest Ø Exacerbating factors: Moving from rest Ø Severity: from 7/10 after walking to 3/10 at rest, 3/10 no matter what 1 year ago, Ø Relieving factors: Rest used paracetamol to relieve pain but of little use Ø Severity: Patient’s severity grading of 7-8/10 (previously 5-6/10) Rule out other aetiologies / DDx / Red Flag signs: Rule out other aetiologies / DDx / Red Flag signs: Ø Recent rapid weight loss / night sweats / malaise / cachexia: None Ø Poor appetite, weight loss around 6-8 pounds and fatigue in past 6 weeks Ø Fever: None Ø Fever: None Ø Contact with TB patients: None Ø Contact with TB patients: None Ø Trauma: None Ø Trauma: Denies any slip, fall and any other trauma PMHx: Good past health; Chronic diseases: None; No Bone deformity; No chronic PMHx: Good past health; No significant past medical Hx and surgery. NKDA; Taking drug use except recent paracetamol use (dosage? administration?) ; NKDA analgesics but poor response to it. (Dosage? Administration?) SHx: Lives with wife and son & NSND // FHx: unremarkable SHx: NSND, Worry about poor financial status, hobby: hiking ☹, family relationships? ADL Assessment: FHx: No family history of leg pain and malignancies Ø Can walk but significantly less; Can walk less steps; Can walk unaided ADL Assessment: Cannot walk > 4-5 mins, independent lifestyle, no assistance needed Ø Hobby: hiking and is no longer able to do so, but is not particularly affected Prepared by Hemato 26’ Framework (History Taking) [GREETING and SELF-INTRODUCTION] 1) Patient demographics: Name, Age, Occupation 2) Chief complaint (SOCRATES) Site Onset [Ask the patient what he/she was doing] Character: Dull? Sharp? Soaring? Radiation: Location [Is the pain referred from other site? e.g. from abdomen / chest / neck?] Associative symptoms: Swelling, Stiffness, Crepitus? Erythema and swelling of joints? 紅腫熱痛 Time: Macro time/ Micro time [when it is most painful, the corresponding score and frequencies] Exacerbating factors/ Relieving factors Trauma Severity [Scaling should be out of 10, remember to tell patient] Infection: Fever, Night sweat, TB contact 3) Rule out other aetiologies / DDx / Red Flag signs: Recent rapid weight loss (STATE how many kg across how many weeks!!!) / night sweats / malaise / cachexia/ fever Neoplasm: LOA, LOW, Malaise, Cachexia Contact with TB patients; Trauma; Steroid use Inflammation: Joint pain/ stiDness? Steroid use Neurological deficits like weakness & Urinary retention/ bladder incontinence if you suspect sciatica!!! 4) PMHx: Chronic illness? Chronic drug use? Previous surgeries? History of malignancies (Do not say 循例問 unless your examiner is Dr. Fried rice)? Drug allergy? 5) SHx: Smoking (How many packs? How often?); Drinking (TYPE of alcohol? Quantity? Frequency?); Family members (Relationship with them? Financial status? Are they worried?) 6) FHx: Any family history of malignancies? Any family members presented with similar problems? 7) ADL assessment: remember to be specific to the patients. Ø Handedness [if upper limb is involved!!!] Ø Household chores e.g. 舉高雙手, 換燈膽; Teenagers ask about going to school → PE lessons okay? Ø Walking and social life of patients à Living independently? Need assistance to complete daily tasks? Ø Hobbies? How does the patient feel about it? Prepared by Hemato 26’