Elbow structured oral examination question 2

EXAMINER: Look at these radiographs of of the right elbow of a 33-year-old patient and tell me the findings.

CANDIDATE: This plain radiograph of a right elbow shows one loose body in the anterior aspect of the joint.

EXAMINER: What would you like to know if you are allowed to ask only one question?

CANDIDATE: I want to know his presenting symptoms.

EXAMINER: He gets intermittent painful locking symptoms. What is the diagnosis here?

CANDIDATE: Well, he has a loose body in the elbow ...

EXAMINER: Tell me the conditions which produce loose bodies in a joint.

CANDIDATE: Could be post-traumatic, secondary to osteoarthritis, osteochondritis dissecans (OCD) or synovial chondromatosis.

EXAMINER: Now again ... What would you like to know if you are allowed one more question?

CANDIDATE: Did he have any injury in the past?

EXAMINER: No, never ... What is your diagnosis here, keeping in mind that there is only one loose body in the elbow?

CANDIDATE: It could be either secondary to osteoarthritis or OCD and I could rule out post-traumatic cause as he had no injury.

EXAMINER: Can you look at the radiographs again and be more specific? (Showing the X-ray again to the candidate.)

CANDIDATE: I can see only one loose body. There is no calcification in the muscle or capsule.

EXAMINER: What does it tell you?

CANDIDATE: It helps me to rule out myositis ossification and synovial sarcoma.

EXAMINER: I want you to concentrate in the intra-articular pathology and try to narrow down your diagnosis between OCD and osteoarthritis.

CANDIDATE: I would like to know the history of his symptoms and have more investigations to be more specific.

EXAMINER: Well he had unexplained painful elbow which lasted for about 18 months when he was 17 years of age. What do you think is going on with this elbow?

CANDIDATE: It sounds like it may not be osteoarthritis ... it could be OCD.

EXAMINER: If you had been consulting him at the time of initial presentation 16 years ago, what will be your concern?

CANDIDATE: I would ...

TRING...

Was the candidate a happy customer at the end of this viva? Did he lack the knowledge of this subject of loose bodies? Did he use his knowledge appropriately?

EXAMINER: Look at these radiographs of the right elbow of a 33-year-old patient and tell me the findings.

CANDIDATE: This plain radiograph of a right elbow shows wellmaintained joint space with evidence of one loose body in the anterior aspect of the joint.

EXAMINER: What would you like to know if you are allowed to ask only one question?

CANDIDATE: I want to know if this patient had any problem with this elbow in the past.

EXAMINER: Yes, this patient had unexplained painful elbow which lasted for about 18 months when he was 17 years of age. What do you think is going on with this elbow?

CANDIDATE: Well, he could have had osteochondritis dissecans when he was 17, which explains the unexplained pain he had for 18 months and the OCD segment must have separated to form the loose body.

EXAMINER: Do you know a name for OCD of elbow?

CANDIDATE: Yes, Panner’s disease.

EXAMINER: If you had consulted him at the time of initial presentation of OCD, what would you have done and why?

CANDIDATE: I would have performed an MRI scan.

EXAMINER: MRI was not widely available then.

CANDIDATE: Well, I would have performed an elbow arthrogram with contrast to assess if the segment had separated from the base. Also the age at which he presented was not in the favourable range ... that is after the closure of the physis ... therefore I would have followed him clinically more closely.

EXAMINER: This patient unfortunately had only one X-ray at the start of the presentation and as it did not show any obvious pathology, he was discharged from follow-up. What would you like to do now?

CANDIDATE: I would like to know his presenting symptoms. Has he had any treatment so far and what are his expectations?

EXAMINER: He has had no treatment so far. And can you tell me what would be his presenting symptom?

CANDIDATE: I would expect him to have intermittent painful locking of the elbow.

EXAMINER: Yes, that is his symptom. He wants to have something done to prevent these unexpected painful locking episodes.

CANDIDATE: I would perform an arthroscopic removal of the loose body.

EXAMINER: Can you tell me another cause for one or two loose bodies in a joint?

In osteoarthritis the osteophytes can break and present similarly. But the radiograph will show evidence of osteoarthritis.

EXAMINER: If you see multiple loose bodies, what is the diagnosis?

CANDIDATE: Synovial chondromatosis.

This is a good example of using your knowledge appropriately. Compare these two candidates. Candidate 2 has made life easier by being specific and appropriate on every opportunity available

Elbow structured oral examination question 2

EXAMINER: Look at these radiographs of of the right elbow of a 33-year-old patient and tell me the findings.

CANDIDATE: This plain radiograph of a right elbow shows one loose body in the anterior aspect of the joint.

EXAMINER: What would you like to know if you are allowed to ask only one question?

CANDIDATE: I want to know his presenting symptoms.

EXAMINER: He gets intermittent painful locking symptoms. What is the diagnosis here?

CANDIDATE: Well, he has a loose body in the elbow ...

EXAMINER: Tell me the conditions which produce loose bodies in a joint.

CANDIDATE: Could be post-traumatic, secondary to osteoarthritis, osteochondritis dissecans (OCD) or synovial chondromatosis.

EXAMINER: Now again ... What would you like to know if you are allowed one more question?

CANDIDATE: Did he have any injury in the past?

EXAMINER: No, never ... What is your diagnosis here, keeping in mind that there is only one loose body in the elbow?

CANDIDATE: It could be either secondary to osteoarthritis or OCD and I could rule out post-traumatic cause as he had no injury.

EXAMINER: Can you look at the radiographs again and be more specific? (Showing the X-ray again to the candidate.)

CANDIDATE: I can see only one loose body. There is no calcification in the muscle or capsule.

EXAMINER: What does it tell you?

CANDIDATE: It helps me to rule out myositis ossification and synovial sarcoma.

EXAMINER: I want you to concentrate in the intra-articular pathology and try to narrow down your diagnosis between OCD and osteoarthritis.

CANDIDATE: I would like to know the history of his symptoms and have more investigations to be more specific.

EXAMINER: Well he had unexplained painful elbow which lasted for about 18 months when he was 17 years of age. What do you think is going on with this elbow?

CANDIDATE: It sounds like it may not be osteoarthritis ... it could be OCD.

EXAMINER: If you had been consulting him at the time of initial presentation 16 years ago, what will be your concern?

CANDIDATE: I would ...

TRING...

Was the candidate a happy customer at the end of this viva? Did he lack the knowledge of this subject of loose bodies? Did he use his knowledge appropriately?

EXAMINER: Look at these radiographs of the right elbow of a 33-year-old patient and tell me the findings.

CANDIDATE: This plain radiograph of a right elbow shows wellmaintained joint space with evidence of one loose body in the anterior aspect of the joint.

EXAMINER: What would you like to know if you are allowed to ask only one question?

CANDIDATE: I want to know if this patient had any problem with this elbow in the past.

EXAMINER: Yes, this patient had unexplained painful elbow which lasted for about 18 months when he was 17 years of age. What do you think is going on with this elbow?

CANDIDATE: Well, he could have had osteochondritis dissecans when he was 17, which explains the unexplained pain he had for 18 months and the OCD segment must have separated to form the loose body.

EXAMINER: Do you know a name for OCD of elbow?

CANDIDATE: Yes, Panner’s disease.

EXAMINER: If you had consulted him at the time of initial presentation of OCD, what would you have done and why?

CANDIDATE: I would have performed an MRI scan.

EXAMINER: MRI was not widely available then.

CANDIDATE: Well, I would have performed an elbow arthrogram with contrast to assess if the segment had separated from the base. Also the age at which he presented was not in the favourable range ... that is after the closure of the physis ... therefore I would have followed him clinically more closely.

EXAMINER: This patient unfortunately had only one X-ray at the start of the presentation and as it did not show any obvious pathology, he was discharged from follow-up. What would you like to do now?

CANDIDATE: I would like to know his presenting symptoms. Has he had any treatment so far and what are his expectations?

EXAMINER: He has had no treatment so far. And can you tell me what would be his presenting symptom?

CANDIDATE: I would expect him to have intermittent painful locking of the elbow.

EXAMINER: Yes, that is his symptom. He wants to have something done to prevent these unexpected painful locking episodes.

CANDIDATE: I would perform an arthroscopic removal of the loose body.

EXAMINER: Can you tell me another cause for one or two loose bodies in a joint?

In osteoarthritis the osteophytes can break and present similarly. But the radiograph will show evidence of osteoarthritis.

EXAMINER: If you see multiple loose bodies, what is the diagnosis?

CANDIDATE: Synovial chondromatosis.

This is a good example of using your knowledge appropriately. Compare these two candidates. Candidate 2 has made life easier by being specific and appropriate on every opportunity available