Ortho Exam: How to Describe an 84-Year-Old Lady's Shoulder X-ray

Shoulder and elbow structured oral examination question1

EXAMINER : This is a radiograph of the left shoulder of an

84-year-old lady. Describe the radiograph please. (Figure 6.1.)

CANDIDATE : Well ... Good morning.

This is the plain radiograph of an 84-year-old lady’s left shoulder ... anteroposterior (AP) view. There is evidence of joint destruction with loss of articular anatomy.

### EXAMINER : What do you think is wrong with this shoulder?

CANDIDATE : Well, to be certain I need to ask a few questions and examine the patient.

EXAMINER : Go on then and ask some questions.

EXAMINER : Right handed.

### CANDIDATE : How long has she had a problem with this shoulder?

EXAMINER : 70 years.

### CANDIDATE : How did the problem start?

EXAMINER : It started as a painless lump when she was 14 and a few months later she began to have a discharging sinus that required several joint washouts and medication.

### CANDIDATE : Does she have an active sinus now?

EXAMINER : No, the sinus healed after she underwent the washouts and started the medication and has never recurred.

### CANDIDATE : That is good. What are her current problems?

EXAMINER : Well, she has some restriction of movements and therefore visited her GP who performed this X-ray and sent her to you for your opinion.

CANDIDATE : Then I would examine the patient.

EXAMINER : She has 60 of abduction and forward elevation and has very restricted rotations.

CANDIDATE : I would like to know the power of her cuff muscles.

EXAMINER : It is not possible to assess the power as she has very restricted range of movements.

CANDIDATE: Now ...

TRING... ...

EXAMINER : Thank you.

Did this candidate do well? Was there a diagnosis? Was there a discussion about the management? Only a 4 or 5 score would be given as the candidate did not even arrive at a diagnosis and missed all the clues.

A different candidate with the same scenario:

EXAMINER : This is a radiograph of left shoulder of 84- year-old lady. Describe the X-ray please.

CANDIDATE : This radiograph of shoulder anteroposterior ( AP ) view shows evidence of joint destruction and loss of articular cartilage.

### EXAMINER : What do you think is wrong with this shoulder?

### CANDIDATE : This appearance suggests several possible causes such as previous joint infection, trauma or a neurogenic cause. May I know how the problem started?

EXAMINER : Problems started as a painless lump when she was 14 and a few months later she began to have a discharging sinus for which she had several joint washouts and medication.

### CANDIDATE : The presentation sounds like she had a low-grade joint infection. Was there any microbiological investigation performed at the time of the joint washouts?

### EXAMINER : Yes, it was diagnosed as acid-fast bacillus and now what will be your management?

CANDIDATE : Well, I would like to know if she had any reactivation of infection in the last 70 years.

EXAMINER: No.

### CANDIDATE : In that case what is the expectation of the patient?

EXAMINER : The patient does not want any surgical treatment. She wants to know if she can have some injections into her shoulder which can prevent the pain at the extremes of movements.

CANDIDATE : I will be cautious about the intra-articular injections as it can trigger the dormant bacillus and rekindle the infection.

EXAMINER : The patient does not want to take this risk and wants to be left alone.

Thank you.

🎓 Although the viva questions started in the same manner, this candidate with his or her knowledge took the viva to a good level of demonstration of his or her clinical judgement by asking specific questions and had control over the situation. Certainly this candidate deserves a good score.