Shoulder and elbow structured oral examination question3

EXAMINER: This is a radiograph of right shoulder of a lady who has got severe pain in her shoulder. Anything you find interesting? (Figure 6.2.)

CANDIDATE: Well ... No not really ... I cannot see any abnormal or disease process in this radiograph.

EXAMINER: She is in your clinic referred by her GP. What would you like to do for her?

CANDIDATE: I want to get history ... then to examine the patient ... to decide on the management plan.

EXAMINER: Go ahead.

CANDIDATE: In the history I will first find out her age, job and dominant side ... and how and when the problem started.

EXAMINER: She is 45, right-hand dominant and does clerical work. The pain started 8 months ago when she was reaching out for the seat belt in her car.

CANDIDATE: The age and history suggest probable frozen shoulder ... I will proceed with the examination.

Figure 6.2

Anteroposterior (AP) radiograph right shoulder.

EXAMINER: She has got global restriction of her movements.

CANDIDATE: That confirms frozen shoulder. So ...

EXAMINER: What do you want to do?

CANDIDATE: I would offer intra-articular steroid injection for her shoulder and also advice on stretching exercises by physiotherapists.

EXAMINER: She has already had three intra-articular steroid injections and regular physiotherapy from her GP practice.

CANDIDATE: Well in that case I would advise her to have manipulation under anaesthesia or arthroscopic arthrolysis.

EXAMINER: What will you specifically offer the patient?

CANDIDATE: mmm ... MUA.

EXAMINER: The patient wants to know the risks associated with MUA.

CANDIDATE: Well apart from the anaesthetic risks, there is a risk of fracturing the humerus as it can be osteopenic from disuse ... also the risk of recurrence.

EXAMINER: If the bone fractures, what will be the management?

CANDIDATE: It is like any fracture. Can be treated in a cast or operated.

EXAMINER: The patient decides now to leave it alone.

CANDIDATE: I will then convince her to have an injection today and review her situation in 12 weeks.

Do you think this candidate impressed the ( patient ) or the examiner, with this simple shoulder scenario? Before we look at the next candidate, think how you would approach this differently!

EXAMINER: This is a radiograph of right shoulder of a lady who has got severe pain in her shoulder. Anything do you find interesting?

CANDIDATE: Yes, this radiograph is essentially normal. May I know the age of this patient and does she suffer from diabetes or thyroid-related problems?

EXAMINER: Well she is 45 and she has hypothyroidism. Is there anything else would you like to examine other than her shoulders?

CANDIDATE: Yes, I would like to look at her hand to see if she has any evidence of Dupuytren’s contracture as it has some association with frozen shoulder.

EXAMINER: She is in your clinic referred by her GP. What would you like to do for her?

CANDIDATE: I want to know the history and examination findings.

EXAMINER: She is right-hand dominant and does clerical work. The pain started 8 months ago when she was reaching out for the seat belt in her car. She has got global restriction of her movements.

CANDIDATE: Does this pain affect her sleep? What is the range of her external rotation?

EXAMINER: Yes, she struggles to sleep at night and her ER is only to neutral position. What would you like to do for her?

CANDIDATE: I want to know what has been done to her so far and what is her expectation?

EXAMINER: She has had three intra-articular injections and physiotherapy from her GP practice. She wants to be able to wash and dress herself independently.

CANDIDATE: Well, I would like to offer her either manipulation under anaesthesia or arthroscopic capsular release, explaining the advantages and disadvantages of both procedures and the importance of immediate post-intervention physiotherapy, and make her understand the disease process of frozen shoulder so that the patient could have a realistic expectation of the treatment process.

EXAMINER: The patient understands your explanation very well and wants to have the key-hole surgery. What will you do in arthroscopic capsular release?

CANDIDATE: The anterior capsule release especially at the rotator interval, followed by middle glenohumeral ligament release and the release of coracohumeral ligament. Inferior capsule will be stretched by manipulation ... this is my preference as the arthroscopic release of inferior capsule carries a small risk of damaging axillary nerve.

EXAMINER: Thank you.

When the examiner sensed an ability, a small extra challenge was given – anywhere else you want to examine? And the candidate was able to demonstrate his or her knowledge – association with Dupuytren’s contracture – the candidate would have been given an extra point for these smart moves.