Orthopedic Teaching Cases 2022, Dec, 06 | 12:00 am

Elbow structured oral examination question 4

Elbow structured oral examination question 4

EXAMINER: Good morning. Here are the radiographs of a righthand dominant 43-year-old man’s right elbow. Tell me the findings. (Figure 6.5.)

CANDIDATE: Good morning. These radiographs show narrowing of joint space on both ulnohumeral and radiocapitellar joints with subchondral sclerosis and cysts and medial, anterior and posterior osteophytes suggesting osteoarthritis. Has he had any previous injury to this elbow?

EXAMINER: Well he had a dislocation of this elbow 8 years ago which was reduced in A&E and as he improved to full function in 8 weeks he was discharged from the fracture clinic. Now over the last 3 years he has got problems with this elbow. What would you advise for this patient?

CANDIDATE: I want to know his present symptoms. How much does it affect his job? What are the treatments he has had so far? And what is his expectation?

EXAMINER: This elbow is affecting his job as he has got restricted movements – flexion extension from 50 to 110 and supination is only to 40. He had a few intra-articular injections by his GP. He wants to have more movement in the elbow.

CANDIDATE: He has got post-dislocation osteoarthritis with stiffness. He is not presenting with pain as a main symptom. Therefore I would like to perform an arthroscopic debridement/arthrolysis of his elbow.

 

 

Figure 6.5 Anteroposterior (AP) radiograph right elbow.

EXAMINER: Can you show me the arthroscopic portals in this elbow picture?

CANDIDATE: (Marking and talking to the examiner.)

Direct lateral portal:

At the centre of a triangle defined by the lateral epicondyle, the radial head and the olecranon. This is frequently used as the initial entry portal to inflate the joint with saline.

Anterolateral portal:

1 cm distal and 1 cm anterior to the lateral epicondyle, between the radial head and the capitellum. This gives good access to the anterior aspect of the joint.

Anteromedial portal:

2 cm distal and 2 cm anterior to the medial epicondyle. This is often created using an

 

‘inside out’ technique by cutting down onto the tip of the arthroscope inserted using the anterolateral portal.

Proximal medial portal:

2 cm proximal to the medial epicondyle along the anterior surface of the humerus towards the radial head.

Direct posterior portal:

1.5 cm proximal to the tip of the olecranon. Access to olecranon fossa.

Posterolateral

Access to radiocapitellar joint.

portal:

Is the benefit of the debridement permanent?

CANDIDATE: No, it is not ... and varies between individuals.

EXAMINER: Patient wants to know if there is any procedure which can provide long-lasting benefit.

CANDIDATE: The longer-lasting result can be achieved by a total elbow replacement ... But as this patient is only 43 and he is a manual worker and his dominant elbow is affected with osteoarthritis, I would not advise a total elbow replacement at this moment as the TERs do not have long life expectancy in young osteoarthritic patients.

TRING ...

Would you handle this scenario differently? How much will you score this candidate? Was his knowledge sufficient and well presented? Now a confidentlooking candidate approaches the table.

EXAMINER: Good morning. Here are the radiographs of a righthand dominant 43-year-old man’s right elbow. Tell me the findings.

CANDIDATE: The radiographs show advanced osteoarthritis of his dominant elbow.

EXAMINER: Correct. What would be your advice to this patient?

CANDIDATE: It depends on if he has pain, stiffness, difficulty with his job and also depends on his expectations.

EXAMINER: Pain is not a main issue here. This elbow is affecting his job as he has got restricted movements – flexion extension from 50 to 110 and supination is only to 40. He wants to have more movement in the elbow.

CANDIDATE: I will initially inject his elbow with steroids and send him for stretching physiotherapy.

EXAMINER: Patient has had a few injections already and also physiotherapy from his GP and therefore he prefers to have a more definitive procedure.

CANDIDATE: Well, if the injections have been tried without any success, I would advise a total elbow replacement.

EXAMINER: Is there anything you could offer prior to TER?

CANDIDATE: (Suddenly losing confidence.) Probably an attempt at manipulation under anaesthesia ...

EXAMINER: Is MUA and passive stretching of a stiff elbow good advice?

CANDIDATE: ... perhaps not ... as there is a small risk of myositis ossification.

EXAMINER: In the last 30 years ... the number of implanted TERs is in decline. Why?

CANDIDATE: ...

EXAMINER: Well, 20 to 30 years ago the TER was commonly used for which group of patients?

CANDIDATE: Rheumatoid patients, and it has declined as rheumatoid patients are better treated now and we do not see advanced joint pathology in this group of patients.

EXAMINER: What is the clinical finding in an advanced RA elbow?

CANDIDATE: Arthritis affects the entire joint, the ligament stability is also lost as RA is primarily a soft tissue problem and the radial head dislocates and the elbow becomes flail.

EXAMINER: Have you seen flail RA elbow recently?

CANDIDATE: No, I haven’t seen any which have progressed to radial head dislocations ... instead the appearance we see now is more like osteoarthritis.

EXAMINER: Does this modification of disease pathology have anything to do with declining number of implanted TER?

CANDIDATE: Yes, the TER failed earlier in this group.

EXAMINER: This is because we are treating stable diseasemodified osteoarthritic RA elbows, with the implant designed to treat flail elbows.

CANDIDATE: ...

EXAMINER: Would you like to offer anything else prior to TER for this young manual worker?

CANDIDATE: An arthroscopic washout?

EXAMINER: Is there any ...

TRING ...

Did the confident start last long? Was the knowledge adequate to handle this scenario? Would you like to be this candidate on the day of exam?