Elbow structured oral examination question 3
Elbow structured oral examination question 3
EXAMINER: What do you see in this radiograph of a 67- year-old lady’s right elbow? (Figure 6.4.)
CANDIDATE: This radiograph shows extensive erosion of the articular cartilage which has involved both ulnohumeral and radiocapitellar joints. The radial head is dislocated and the elbow articulation is aligned only with ulna and humerus. There is peri-articular osteopenia. There is no subchondral sclerosis or osteophytes.
EXAMINER: What could be the cause?
CANDIDATE: It is characteristic of inflammatory arthropathy and I suspect rheumatoid arthritis. It is a flail elbow.
EXAMINER: Indeed this lady has had RA for the last 34 years. What would you like to do for her?
CANDIDATE: I want to know her presenting symptoms from this elbow. What has changed now to think about doing something about this elbow now? What has been done to this elbow so far? What are her expectations?
As an RA patient she has many joint problems and recently she is finding lack of strength in her right upper limb to do day-to-day activities. She has had no specific elbow treatments. She wants to do her normal household activities.
CANDIDATE: I would specifically assess her elbow stability and range of movements. And more importantly check her hand function with regards to any tendon ruptures and posterior interosseous nerve function.
EXAMINER: She has no valgus and varus stability but good range of active and passive movements. Hand function is also good. Now how will you differentiate between PIN palsy and extensor tendon rupture?
CANDIDATE: Well if there is no active extension of the fingers at MCP joint and tenodesis test is showing no passive extension of finger at MCP joint on passive flexion of wrist, then the diagnosis is extensor tendon rupture. If the tenodesis test produced passive extension at MCP joint then the diagnosis is PIN palsy. But I will cautiously assess the other tendons supplied by PIN prior to making final diagnosis as in RA patients both can exist together.
EXAMINER: What will be your management plan?
CANDIDATE: It is a multidisciplinary approach with reconsultation with rheumatologists and assessment by occupational therapists. I would initially offer her an elbow brace.
CANDIDATE: If she is fit for a general anaesthetic, I will do a to assess the atlanto-axial joint and obtain an anaesthetic opinion. EXAMINER: Finally, what happens to juvenile rheumatoid joints? CANDIDATE: Contrasting to adult RA, juvenile RA produces stiff joints. Who had the control in this viva? Did this candidate get the questions he played for? Was his technique good? Did he not manage to get a bonus question? Would you be happy if you were the candidate of this scenario? Would you have played it any better? Now the next candidate approaches this table. |
EXAMINER: She comes back after 3 months and says the brace has improved her life quality to some extent but finds it difficult as it gets wet in the kitchen and she still has difficulties in the shower as she could not wear it in the shower.
EXAMINER: What do you see in this radiograph of a 67-year-old lady’s right elbow?
CANDIDATE: This radiograph shows extensive erosion of the articular cartilage which has involved both ulnohumeral and radiocapitellar joints. The radial head is dislocated and the elbow articulation is aligned only with ulna and humerus.
EXAMINER: What could be the cause?
CANDIDATE: It is characteristic of inflammatory arthropathy and I suspect rheumatoid arthritis. It is a flail elbow.
EXAMINER: Indeed this lady has had RA for the last 34 years. What features in the radiograph made you rule out osteoarthritis?
CANDIDATE: In osteoarthritis there will be joint space narrowing, subchondral sclerosis, subchondral cysts and osteophytes. This radiograph does not show these features.
EXAMINER: What is the bone quality here?
CANDIDATE: ... The bone appears to be osteopenic ... could be disuse from pain or the disease process itself.
EXAMINER: Now, what would you do for her?
CANDIDATE: I need to know the history of presenting complaints and I would examine the elbow.
EXAMINER: She recently finds her right upper limb weak affecting her day-to-day activities. In the examination there is valgus/varus instability.
CANDIDATE: It is an unstable elbow from advanced RA.
Therefore I would do a total elbow replacement for her.
EXAMINER: Is there anything you would consider prior to surgery?
CANDIDATE: Well, I can try a splint if she is willing to try ...
EXAMINER: She comes back after 3 months and says the brace has improved her life quality to some extent but finds it difficult as it gets wet in the kitchen and she still has difficulties in the shower as she could not wear it in the shower.
CANDIDATE: Then I will proceed with the total elbow replacement.
EXAMINER: Which nerve specifically would you like to assess in the RA elbow especially prior to total elbow replacement?
CANDIDATE: Posterior interosseous nerve as it can be affected by the synovial swelling/dislocation of the radiocapitellar joint. EXAMINER: What would be the findings if she has PIN palsy?
CANDIDATE: There will be no active extension of the fingers at the level of MCP joints.
EXAMINER: Do you know any other cause for the inability to extend MCP joints?
CANDIDATE: Yes, progressive rupture of extensor tendons called Vaughn–Jackson syndrome.
EXAMINER: Is there any concern regarding this RA patient undergoing general anaesthesia?
CANDIDATE : These patients can have lung fibrosis ... apart from this, yes ... of course I will perform a c-spine X-ray to see the stability of atlanto-axial joint.
EXAMINER : Thank you.
Did he not answer all the questions? Did he not possess theknowledgeofthesubject?But,didhegainthecontrol of this viva? Did he ever lead the examiner to the next question? Or did the examiner have to guide him with leading questions? Would he ever get a score of 8 ?
Elbow structured oral examination question 3
EXAMINER: What do you see in this radiograph of a 67- year-old lady’s right elbow? (Figure 6.4.)
CANDIDATE: This radiograph shows extensive erosion of the articular cartilage which has involved both ulnohumeral and radiocapitellar joints. The radial head is dislocated and the elbow articulation is aligned only with ulna and humerus. There is peri-articular osteopenia. There is no subchondral sclerosis or osteophytes.
EXAMINER: What could be the cause?
CANDIDATE: It is characteristic of inflammatory arthropathy and I suspect rheumatoid arthritis. It is a flail elbow.
EXAMINER: Indeed this lady has had RA for the last 34 years. What would you like to do for her?
CANDIDATE: I want to know her presenting symptoms from this elbow. What has changed now to think about doing something about this elbow now? What has been done to this elbow so far? What are her expectations?
As an RA patient she has many joint problems and recently she is finding lack of strength in her right upper limb to do day-to-day activities. She has had no specific elbow treatments. She wants to do her normal household activities.
CANDIDATE: I would specifically assess her elbow stability and range of movements. And more importantly check her hand function with regards to any tendon ruptures and posterior interosseous nerve function.
EXAMINER: She has no valgus and varus stability but good range of active and passive movements. Hand function is also good. Now how will you differentiate between PIN palsy and extensor tendon rupture?
CANDIDATE: Well if there is no active extension of the fingers at MCP joint and tenodesis test is showing no passive extension of finger at MCP joint on passive flexion of wrist, then the diagnosis is extensor tendon rupture. If the tenodesis test produced passive extension at MCP joint then the diagnosis is PIN palsy. But I will cautiously assess the other tendons supplied by PIN prior to making final diagnosis as in RA patients both can exist together.
EXAMINER: What will be your management plan?
CANDIDATE: It is a multidisciplinary approach with reconsultation with rheumatologists and assessment by occupational therapists. I would initially offer her an elbow brace.
CANDIDATE: If she is fit for a general anaesthetic, I will do a to assess the atlanto-axial joint and obtain an anaesthetic opinion. EXAMINER: Finally, what happens to juvenile rheumatoid joints? CANDIDATE: Contrasting to adult RA, juvenile RA produces stiff joints. Who had the control in this viva? Did this candidate get the questions he played for? Was his technique good? Did he not manage to get a bonus question? Would you be happy if you were the candidate of this scenario? Would you have played it any better? Now the next candidate approaches this table. |
EXAMINER: She comes back after 3 months and says the brace has improved her life quality to some extent but finds it difficult as it gets wet in the kitchen and she still has difficulties in the shower as she could not wear it in the shower.
EXAMINER: What do you see in this radiograph of a 67-year-old lady’s right elbow?
CANDIDATE: This radiograph shows extensive erosion of the articular cartilage which has involved both ulnohumeral and radiocapitellar joints. The radial head is dislocated and the elbow articulation is aligned only with ulna and humerus.
EXAMINER: What could be the cause?
CANDIDATE: It is characteristic of inflammatory arthropathy and I suspect rheumatoid arthritis. It is a flail elbow.
EXAMINER: Indeed this lady has had RA for the last 34 years. What features in the radiograph made you rule out osteoarthritis?
CANDIDATE: In osteoarthritis there will be joint space narrowing, subchondral sclerosis, subchondral cysts and osteophytes. This radiograph does not show these features.
EXAMINER: What is the bone quality here?
CANDIDATE: ... The bone appears to be osteopenic ... could be disuse from pain or the disease process itself.
EXAMINER: Now, what would you do for her?
CANDIDATE: I need to know the history of presenting complaints and I would examine the elbow.
EXAMINER: She recently finds her right upper limb weak affecting her day-to-day activities. In the examination there is valgus/varus instability.
CANDIDATE: It is an unstable elbow from advanced RA.
Therefore I would do a total elbow replacement for her.
EXAMINER: Is there anything you would consider prior to surgery?
CANDIDATE: Well, I can try a splint if she is willing to try ...
EXAMINER: She comes back after 3 months and says the brace has improved her life quality to some extent but finds it difficult as it gets wet in the kitchen and she still has difficulties in the shower as she could not wear it in the shower.
CANDIDATE: Then I will proceed with the total elbow replacement.
EXAMINER: Which nerve specifically would you like to assess in the RA elbow especially prior to total elbow replacement?
CANDIDATE: Posterior interosseous nerve as it can be affected by the synovial swelling/dislocation of the radiocapitellar joint. EXAMINER: What would be the findings if she has PIN palsy?
CANDIDATE: There will be no active extension of the fingers at the level of MCP joints.
EXAMINER: Do you know any other cause for the inability to extend MCP joints?
CANDIDATE: Yes, progressive rupture of extensor tendons called Vaughn–Jackson syndrome.
EXAMINER: Is there any concern regarding this RA patient undergoing general anaesthesia?
CANDIDATE : These patients can have lung fibrosis ... apart from this, yes ... of course I will perform a c-spine X-ray to see the stability of atlanto-axial joint.
EXAMINER : Thank you.
Did he not answer all the questions? Did he not possess theknowledgeofthesubject?But,didhegainthecontrol of this viva? Did he ever lead the examiner to the next question? Or did the examiner have to guide him with leading questions? Would he ever get a score of 8 ?