Shoulder and elbow structured oral examination question5

EXAMINER: Good afternoon. Can you tell me the findings from this radiograph of the left shoulder of a 76-year-old lefthanded fit gentleman? (Figure 6.3.)

CANDIDATE: This anteroposterior view of left shoulder shows no evidence of glenohumeral joint or acromioclavicular joint arthritis. The subacromial space is narrowed with sclerosis of the undersurface of the acromion.

EXAMINER: Would you like any other investigations ... prior to committing yourself with a diagnosis?

CANDIDATE: I would like to have ultrasound of his shoulder ... and may I know his symptoms please?

EXAMINER: The ultrasound, which was requested by his GP, shows torn subscapularis and supraspinatus with massive retraction of the tendons. He has difficulties with overhead activities. Can you tell me what is wrong with this shoulder?

CANDIDATE: From the X-ray ... which shows evidence of impingement by narrowing of the subacromial space, from the ultrasound scan ... which shows evidence of torn subscapularis and supraspinatus tendons and clinically he has got difficulties in overhead activities ...

EXAMINER: Yes, it is a nice summary of the situation ( wasting time)

CANDIDATE: I think he has severe subacromial impingement and secondary cuff tear.

EXAMINER: What would you do for this gentleman?

CANDIDATE: Well, first I would perform a steroid injection into his subacromial space.

EXAMINER: Can you tell me the landmarks and how will you perform the injection?

CANDIDATE: Yes, 2 cm inferior and medial to the posterolateral corner of the acromion, I will direct the needle towards the anterolateral corner of the acromion to be specific into the bursa.

EXAMINER : Is it necessary to be specific in this patient ... he has got a massive cuff tear?

CANDIDATE: ??

EXAMINER: Well, he comes back to clinic in 8 weeks with no difference to his symptoms. Do you have any management plans?

CANDIDATE: I will then perform an arthroscopic debridement of the cuff and bursa and a subacromial decompression.

EXAMINER: !! Thank you.

arrives for the same scenario. EXAMINER: Good afternoon. Can you tell me the findings from this radiograph of the left shoulder of a 76-year-old left- handed fit gentleman? CANDIDATE: This anteroposterior view of the left shoulder shows proximal migration of humeral head with narrowing of the subacromial space and there is no evidence of glenohumeral joint or acromioclavicular joint arthritis. EXAMINER: Would you like any other investigations ... prior to committing yourself with a diagnosis? CANDIDATE: I would like to have an axillary view of his shoulder. EXAMINER: Yes, we have axillary view. What are you looking for?

Do you recognize the candidate’s mistakes? What will you do differently? Did he treat the patient or the investigations? Did he interpret the investigations appropriately? Now the last candidate of the day

CANDIDATE: I am looking for anteroposterior subluxation of the humeral head in the axillary view ... yes, there is anterior subluxation, suggesting torn anteriorly placed subscapularis and from the AP view, the proximal migration of the humeral head suggesting supraspinatus tear ... this gentleman has got established cuff arthropathy.

EXAMINER: What would you do for him?

CANDIDATE: I need to know the patient’s symptoms, what has been done to the patient so far and what are his expectations?

EXAMINER: He has got difficulties in overhead activities. He has had three injections by his GP which has made no difference and being an artist he would like to have reasonable ability to abduct his shoulder to reach for the top of the canvas during painting.

CANDIDATE: Could you please tell me if he has any pain associated with his shoulder abduction?

EXAMINER: No ... not at all

CANDIDATE: I would then offer a reverse-polarity shoulder replacement if he is otherwise healthy and fit for surgery.

EXAMINER: He is very fit. Why do you prefer reverse shoulder to a total shoulder replacement?

CANDIDATE: The reverse shoulder although non-anatomical brings the centre of rotation of the glenohumeral joint medially and thereby increases the moment arm of the deltoid, allowing good abduction of the shoulder.

EXAMINER: Would you not try to repair the cuff prior to this major surgery?

CANDIDATE: No. The radiographs show an established cuff arthropathy and in this situation a rotator cuff repair is not possible.

EXAMINER: Well, we will move on to the next scenario.

Whom do you think played the game well in this scenario? Analyse the candidate’s ability to show their knowledge to the examiner. Learn how not to waste time and not to lower the expectations of the examiner. When the examiner’s expectations go down, the questions may become simpler and the score becomes lower. Show the knowledge appropriately to please the examiner. Make the game interesting for the examiners and you walk away with a good score. Treat each scenario as a separate exam to reach a good overall score. Remember the examiners do not know your previous performance – either good or bad. Therefore forget the previous performance – either good or bad – and move on.