Shoulder and elbow structured oral examination question2

EXAMINER: Good afternoon. Can you tell me what is going on in this radiograph of the right shoulder (Fig. 6.2.)? This patient had anterior dislocation 2 years ago and has on-going problems.

CANDIDATE: Well this shoulder is reduced congruently. I cannot see any interposition of bony fragments. And I would like to investigate this shoulder with MR arthrogram.

EXAMINER: !! What do you want to rule out?

CANDIDATE: Well the risk of re-dislocation of the shoulder is much higher with anterior dislocation due to labral detachment in younger patients and it could be treated successfully if identified with MR arthrogram.

EXAMINER: This gentleman is claustrophobic!

CANDIDATE: I would talk to the radiologist and anaesthetist to find out if it could be done under sedation.

EXAMINER: The anaesthetist is not happy! And your radiologist suggests an ultrasound examination of the shoulder.

CANDIDATE: Ultrasound examination is not the gold standard examination for labral pathology.

EXAMINER: Well, the patient had only ultrasound examination and it shows a subscapularis tear!

CANDIDATE: There is then a high risk of having damaged the anterior labrum also ... I think I have to speak to the anaesthetist again ...

Another candidate follows this miserable viva of negotiations between anaesthetist and radiologist in the FRCS ortho exam (by the candidate’s own fault).

EXAMINER: Good afternoon. Can you tell me what is going on in this radiograph of the right shoulder? This patient had anterior dislocation 2 years ago and has on-going problems.

CANDIDATE: Thanks. May I know the age of the patient and the nature of the ongoing problem please?

EXAMINER: This 76-year-old gentleman dislocated his shoulder 2 years ago. Now he has got difficulties in overhead activities and we found out that he is claustrophobic!

CANDIDATE: I suspect rotator cuff tear in this age group following dislocation and also there is a risk of infra-clavicular plexus injury following the dislocations, therefore I would like to assess his cuff muscles clinically.

EXAMINER: He has got weakness on internal rotation and the rest of the cuff power is good. Neurologically he is intact.

CANDIDATE: I suspect subscapularis tendon tear from this clinical assessment and I would investigate this shoulder with an ultrasound examination.

EXAMINER: The ultrasound examination shows subscapularis tear, with proximal migration of the tendon by 4 mm.

CANDIDATE: I would like to know, what has been done so far? And what are his expectations?

EXAMINER: Nothing has been done so far. He wants to play golf, which he has not been able to in the last 2 years.

CANDIDATE: Well, I would assess his shoulder arthroscopically and repair his cuff.

EXAMINER: Would you call this a cuff arthropathy as it is going on for 2 years?

CANDIDATE: No. The radiograph does not show any evidence of proximal migration of the humeral head. And the ultrasound scan shows intact supra- and infraspinatus

tendons. To develop cuff arthropathy at least two of the three supports should have been lost.

TRING ...

This candidate knew the importance of age-related pathophysiology and succeeded well in the viva.