Elbow structured oral examination question 5

Elbow structured oral examination question 5

EXAMINER: I have a problem with my left elbow. Proceed.

CANDIDATE: Well, I want to know your age, hand dominance, your occupation and the nature of your problem please.

EXAMINER: I am 47, a right-hand dominant mechanic and in certain positions my elbow pops which is painful.

CANDIDATE: Is the popping sensation on the inner side or outer side of your elbow?

EXAMINER: The outer side ... yes, my thumb side.

CANDIDATE: Did you ever have any problem in your elbow as a child?

EXAMINER: I had problems as a child in my right elbow, but now my right side is fine. My left side, although I did not have any problem as a child, 3 years ago I had a simple dislocation.

CANDIDATE: What problem did you have on the right side?

EXAMINER: My older sister pulled me by my right hand and my elbow became painful and the doctor had manipulated my elbow and told my parents not to let anyone pull me by my hand. And he said it was a pulled elbow ... where the radial head pops out.

CANDIDATE: I want to check if you have general joint laxity.

EXAMINER: No I am rather stiff. What do you think is wrong with my left elbow?

CANDIDATE: I think radial head dislocations ... probably secondary to annular ligament insufficiency secondary to the dislocation. In what position do you get this popping sensation?

EXAMINER: Whenever I push myself off the chair with my arm.

CANDIDATE: I would like to perform an X-ray of your elbow to assess the radial head.

EXAMINER: The X-ray is normal. Can you tell me about the ligaments around the elbow?

CANDIDATE: Sure. There are two main groups of ligaments, medial and lateral collateral ligaments. MCL has three bundles: anterior, posterior and transverse bands. LCL has lateral ulnar collateral ligament (LUCL), annular ligament, radial collateral ligament and accessory collateral ligament.

EXAMINER: Have you heard of postero-lateral rotatory instability of the elbow?

CANDIDATE: ...

Did the candidate reach the diagnosis? Did he understand the clues given by the examiner? The next candidate arrives.

EXAMINER: I have a problem with my left elbow. Proceed.

CANDIDATE: Well, I want to know your age, hand dominance, your occupation and the nature of your problem please.

EXAMINER: I am 47, a right-hand dominant mechanic and in certain positions my elbow pops with pain.

CANDIDATE: Have you ever injured your left elbow in the past? And in what position are you feeling the popping sensation in the elbow?

EXAMINER: Well, I had a simple dislocation of my left elbow 3 years ago which was reduced in A&E. Now whenever I push myself off a chair using my arm I get this sensation.

CANDIDATE: I would like to have a quick assessment of your elbow.

EXAMINER: What would you like to test?

CANDIDATE: I want to perform the pivot-shift test to assess the lateral ulnar collateral ligament.

EXAMINER: If the pivot-shift test is positive, what is your diagnosis?

CANDIDATE: Postero-lateral rotatory instability of the left elbow.

EXAMINER: I had been told that I had ‘pulled elbow’ on the other side as a child. Could this be the same?

CANDIDATE: No, usually the pulled elbow settles as the child grows and you had a definite injury to the left elbow.

What could you do to me to prevent these unpleasant episodes?

CANDIDATE: I need to perform an MRI scan to confirm injury to LUCL and to see if the injury to the ligament is intra-substance or from the origin to decide on the treatment. And did you have any recent X-rays?

EXAMINER: My X-rays were normal. If the MRI scan shows injury to the LUCL, how will you manage this problem?

CANDIDATE: If the LUCL is avulsed from the origin or insertion and the ligament itself is healthy, it could be re-attached to the bone using bone anchors. It may not be possible in your case as the injury was 3 years ago. My main inclination is to reconstruct the LUCL using palmaris longus tendon or triceps fascia.

Did this candidate manage to please the examiner? Which candidate you would prefer to treat your elbow?

The examiner’s aim is all about finding out, can I let this candidate be my consultant. As you would like to win the patient’s confidence while consulting in the clinics, it is vital to win the examiner’s confidence in each and every scenario by showing adequate knowledge expressed with correct technique.