SlideShare a Scribd company logo
MOCK Clinical
Examnination:
Cerebral Palsy
(long case)
Prof. Anisuddin Bhatti
Dr. Ziauddin University Hospital,
Clifton, Karachi.
Secretary,
Faculty Orthopaedics, CPSP.
Founding Director
PORP Registry, POSP
Focal Person
Ponseti International, Pakistan
Long case: KEY - CONNTEMPORARY
Answers are scored phase-wise on a key.
Excellent, Good, Adequate, Inadequate*, Poor
Examiner 1: [both examiners R Silent Observer]
A. History Taking & Examination: Examinee’s attitude, behavior,
communication skill, clinical examination skill.
B. Presentation skill: Correct history, relevant exam findings, Positive /
negative findings.
C. Order relevant Investigation & justify. He shall be shown that report ,
Xray, MRI, CT etc
D. Differential Diagnosis & confirmation of diagnosis most suitable.
Examiner 2:
A. Management plan. Discussion: What, How, When & When not.
B. Complications. Why & how to manage
C. Recent advances.
* Central Tendency
MOCK:
Case Example
Long case:
Cerebral Palsy
A 9-year-old boy presented with tip toe walking since age 2 years and
having difficulty in walking for the last 3 years. He is able to sit at
ease. Very enthusiastic & cooperative.
Step 1: Ur introduction.
Step 2: Take detailed
relevant history
Q.1. U ask question from patient /
Companion
Q.2. Must NOT Forget to ask Key Q
relevant to problem
Q.2. Key Question
1. Birth history: Liquor aspiration - Birth Asphyxia. Delayed milestones
for one year. mentally alert, Intelligent, he study in class 3.
2. Development history: Walked independently for 6 years, deteriorated
with difficulty in walking, for the last 3 years. He manage his daily
accustomed habits independently.
3. Walking Ability: He is an independent walker, sometimes need
support, when outside [functional walker].
4. Socio-economic status
5. Rehabilitation exercises & facilities services
The Examinee must end his history taking by end of first 10 minutes
Step 3:
Continue
Relevant Q &
perform
Focused
Screening
examination
to reach
MOST
PROBABLE
diagnosis &
functional
disability ?
Q.3. Relevant Question & Focused clinical to reach
most probable diagnosis & functional disability
Exmine to
1. Asses his Gait, Posture, walking ability
2. Type of gait
3. Balance & abnormal spontanous movements
4. Contractures
Q.3. Focused CE:
Gait & Posture again.
Q.3a. What type of gait is this?
Q.3b. What type of walker he is?
Examiner Let examinee to speak freely to justify
Q.3a. Key.
• Spastic Diplegic
• Jump gait / Crouch
• Stable / balanced / Unstable
• Decompensating with Pes Plano-Valgus.. A
Danger sign.
Step 4. Detailed Clinical Examination
Perform multiple clinical test to look for:
• Focus general examination
• Focused systemic examination
• Detalied Regional Examination:
o spasticity,
o hyperreflaxia,
o Contractures: Static & Dynamic
o Specific test relevent to problem
Q.4. Key: Detailed Clinical examination
Detailed clinical Examination. Examinee may narrate his findings
1. In systemic examination he may not have significant abnormality.
2. Focused Neuro - MSK examination: to terform certain clinical
test to evaluate for spasticity & contractures: Dynamic & satatic.
If You have missed few test during your half hour the Examiner may
asks to name such test and perform, not to worry for that.
Plz perform ?? Test OR he just ask how to do and what are pre-
Requisites of that test. OR He may ask you few question to
know ur knowledge & skill.
Be systemic: U wl not loose but win
Follow sequence: General… Systemic … Regional exam
Clinical Evaluation: Tests
Q.6. Which test is
this?
Q.7. What are the
Findings?
Q.8. Is there any flaw
while performing this
test.
Q.6,7,8 Key
Q.6. Thomas test… for Hip Flexion contracture.
FFC
Q.7. Knee cntracture & Hamstring spasticity
Q.8. Flaws: Pillow & Soft bed. Modified
Thomas at edge of bed to exclude Knee
contracture. Not done
Question on Flaws test your knowledge & Skill.
Thomas Test- Modified:
Must to exclude Knee Contracture, avoid flaw
Staheli’s Hip Flexors Stretch test: Hip FFD in CP
More Sensitive test
• More accurate for FFD hip
• Prone position
• Pelvis over table edge
Thomas test
Staheli’s
Q.9. Which tests R this.
What R the
Findings.
Any Flaw in
performing
tests?
Q.9. Key
9.A. Combined Abduction test. 700 . Adductors contracture
bilateral.
Flaw: Not significant. Individual side may b done.
9.B. Pop Angle test. +900 . Significant Hamstring contracture /
Spasticity.
Flaw: not significant
9.C. Silverskiold test. Negative. Combined Gastro-Solus
contracture.
Adductor Longus Stretch Test
• Hip abduction angle in Knee extension & flexion
When measurements are same: Adductors tight. Why?
• Hip abduction improves on Knee flexion: Gracilis tight
Same angle
Adductors tight
Abduction
improved
Gracilis is tight
Gracilis spasticity – Phelp’s Test
• Passive abduction with knee in extension.
• Improved hip abduction with knee flexion indicates
Gracilis / medial hamstring tightness. Why?
Popliteal Angle: Normal ranges in Children. Discussion
• 1-3 yrs mean angle 60 [00-150]
• @ 4 yrs mean angle 170 in girls, 270 in boys [50-450].
• >5 yrs mean angle 260 little change [0-50]
• PoP angle of >500 in above age groups indicate abnormal
hamstring tightness.
Katz, Kalman. University Telaviv Israel. J Ped ortho 1992. 12:229-231
POP Angle: Hamstring Stretch Test: Discussion
• Hip flexed to 900 & knee
extend
• Measure Popliteal angle 900
flexion to 00 extension
• Hamstring Shift: Difference
b/t Rt & Lt measurements
00
900
500
Rt
Lt
Achilles Stretch Test: Discussion
Silverskiold test- Gastroc. vs Soleus
“Spastic Gastrocnemius contracture”
Correction of ankle
equinus with
Knee flexion indicates
Predominantly
gastrocnemius
Contracture. Why?
Q.10. Which tests are being performed
What R Findings?
What is wrong in
performing these
tests ?
Q.10.a. Key
10.A. Rectus Strech test: Aly Duncan test.
Pelvis rise on knee flexion.
10.B. Hip Rotation test: Anteversion
Regional MSK Examination
CP Evaluation
Phase 2 Examiner 1
Interactive Discussion
15 minutes
History taking, Art of Presentation,
Findings and Relevant investigations
15minutes presentation by
examinee and interactive
discussion
Q.
Any additional Clinical
tests U Know and
Perform that?
Key
Craig Test: FAV: Trochanteric Prominence Test
• Prone position and knee at 90°
flexion.
• Angle between the vertical line
and long axis of the leg at the
greatest prominence of the
greater trochanter palpated
laterally measures the amount
of FAV.
In recent studies, it has been found that trochanteric prominence test in combination
with hip internal rotation, X-rays is a better predictor of FAV and neck-shaft angle as
compared with computed tomography.
Key. Rotational Malalignment/s
• Foot propagation
angle
• Tibial rotation
Foot – Thigh Angle
Q. Tibial torsion mal-alignment
Thigh foot Angle
• Prone position, knee in 90°
flexion, and neutral ankle
and hind foot position.
• Angle between the thigh
axis and foot axis (axis
between the 2nd and
3rd metatarsals) gives Tibial
torsional measurement
Q.Is there any Advance
Clinical or laboratory
tests available to check
CP Patients Motor
functions & disability?
Q. key Advanced tests
• Foot propagation angle
• Observational Gait Analysis & Video Assisted OGA
• Videographic Gait analysis:
Gait Laboratory test: Computer base gait and indiviual muscle
functions programme, that include:
oEMG Muscle charting.
o3D camera gait analysis.
oFoot pressure Pedography.
Q. Advanced tests:
Repeated examination &
careful analysis of the gait [VAOGA/
Gait laboratory] & posture
and recognition of potential skeletal
changes lead to better judgment
to correct or prevent structural
changes reasonably early i.e before
15 (13) years. (Molnar-Gordon)
Gait Laboratory
Plays important
role in accurate
Judgment
Video Assisted
Observational
Gait Analysis
NED University Gait Laboratory:
Videographic gait analysis
Gait Lab test being performed on patients during CP workshop on
19 March 2011
Gait Laboratory:
PEDOGRAM: Cavovarus & Planovalgus
EMG: Indicating spastic, normal & Weak Muscles
KEY = Interactive discussion
GAIT PATTERNS
• Different Gait patterns observed in CP depends on the
involvement of spasticity or contracture of different muscles:
• Variations relates to topographical type of CP { Hemiplegia,
Diplegia, monoplegia. With or without Ataxia etc}.
• Best seen in contrast between unilateral spastic CP and bilateral
spastic CP.
Key. Spastic Diplegia Gaits:
Four common patterns of gait in spastic Diplegia.
[Rodda et al.]
• Type 1 – True equinus
• Type 2 – Jump gait
• Type 3 – Apparent equinus
• Type 4 – Crouch gait
Q.3c.
Rodda et al. JBJS. 2004
Q.3B Key
Key: Interactive discussion
Waking Pattern
Assessment to Qualify as walker can be made best after the age 7 years. Till than
brain maturation reach to a plateau.
TYPES OF WALKING:
• Walker: when child could walk a minimum of 15 meters without
falling. [Independent walker]
• Functional Walker: when a child could walk only with crutches
[Community walker].
• Non-Walker: when child could walk with aid of mobility device
or only in parallel bars
Phase 2: Examiner 2
Interactive Discussion
15 minutes
Differential Diagnosis & Management Plan
Recent Advance
Differential diagnosis.
• Q. In what pathological status this clinical
condition occurs?
• Q. How would you confirm your best possible
diagnosis?
Key Differential Diagnosis
Cerebarl Palsy,
Spinal Dysraphysm,
Fredrix Ataxia &
Cerebral demyelination syndrome.
Detailed Birth history, Clinical examination, Observational gait analysis,
Video assisted observational gait analysis & Advanced Imaging.
Use Algorythm: Diagnostic Matrix
Q. How can you classify his
functional disability ?
Q. In which functional disability
class (level) he fits & Justify?
Examiner let examinee lets speak freely to justify
Q. Key: Gross Motor Function Assesment
GMFCS
GROSS
MOTOR
FUNCTION
CLINICAL
SCORE:
LEVELS
Q. Key:
Management Plan: 9 yr aged, boy, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Recall findings:
Examiner helps to recall
findings.
1. Functional walker
2. GMFC-2
3. Thomas’s FFC 15-200
4. Combined Abduction 700
5. Phelp’s positive
6. Pop angle +900
7. Silverskiold’s Negative [-150]
8. Pes-planovalgus
9. Ely’s Positive
10. Stable pelvis & Spine
11. Upper limb Normal
12. No neuro deficit
Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.16. What shall be
the objective to
treat him?
Q.17. How shall U
manage him?
Q. Key: management Plan
16. a. Help him to be an independent walker without
support.
b. prevent deterioration of pes planovalgus and
develop crouch gait
17. A. 3-4 weeks pre-operative rehabilitation training exercises /
physiotherapy & Occupational therapy.
B. Exclude structural abnormalities on X-ray.
C. Reconstructive surgery @ Knee & Ankle
C. Postoperative Rehabilitation programmes
Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.18. What shall be
contraindications other
than general well
being?
Q.19. Let us know Ur
plan of Reconstructive
surgery as u decided?
No need to go in
detailes of surgical
steps
Q. Key. Contra Indications & Recon Surgery
Reconstructive surgery is better in Spastic Cerebral palsy, best in
Hemiplegia than diplegia. Before embarking to surgery.
MUST MUST: Exclude Ataxia, chorioform movements & other
abnormal features of basal ganglia involvement.
A. Reconstructive surgery @ Knee & Ankle +/- Hip
Hamstring Fractional Lengthening, Keats transfer to adductor
tubercle, TAL, 1/2 Tibialis Anterior Transfer to neck of talus.
[+/- Adductor Myotomy without Neurectomy]
Postoperative Rehabilitation programmes
Quad strengthening and Gluteal Muscle development excercises.
Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Describe
postoperative
care?
Examiner Let examinee
speak freely
Key. Rehabilitation Programme.
Rehab programme
• Hospital & home bases exercises
• Muscle streghening execrcise
• Occupational therapy
Bracings – Temporary addjuncts
• AFO
• KFO
References
• VCE Guidelines Designed by:
DR. Sirajul Haque Shaikh, Director DME. CPSP, Karachi.
• References:
1. Harless et al 1971
2. Cook et al, 2010.
3. Huang G, Reynolds R, Candler C.
• Clinical Material:
Prof. Anisuddin Bhatti’s collection
• Videos Prepared @ DZUH Clifton, Karachi
Assisted by: Dr. Sadam Mazar Baloch & Dr. Nida Hameed
Mock ExaminationLong case Cerebral Palsy  .pptx

More Related Content

Similar to Mock ExaminationLong case Cerebral Palsy .pptx

Genetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is tGenetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is t
JeanmarieColbert3
 
ub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdf
ub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdfub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdf
ub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdf
AyalewKomande1
 
Appropriate Outcome Measures for Lower Level Patients
Appropriate Outcome Measures for Lower Level PatientsAppropriate Outcome Measures for Lower Level Patients
Appropriate Outcome Measures for Lower Level Patients
Daniel Woodward
 
Pediatric musculoskeletal examination including P-GALS
Pediatric musculoskeletal examination including P-GALSPediatric musculoskeletal examination including P-GALS
Pediatric musculoskeletal examination including P-GALS
Arnab Nandy
 

Similar to Mock ExaminationLong case Cerebral Palsy .pptx (20)

Ullswater Physio CPD
Ullswater Physio CPDUllswater Physio CPD
Ullswater Physio CPD
 
Developmental dysplasia of hip
Developmental dysplasia of hipDevelopmental dysplasia of hip
Developmental dysplasia of hip
 
Neurological assessment
Neurological assessmentNeurological assessment
Neurological assessment
 
capstoneFINAL
capstoneFINALcapstoneFINAL
capstoneFINAL
 
Special_test_for_all_joints.pdf
Special_test_for_all_joints.pdfSpecial_test_for_all_joints.pdf
Special_test_for_all_joints.pdf
 
Anis bhatti cp1 what, whwn, how, when not
Anis bhatti cp1 what, whwn, how, when notAnis bhatti cp1 what, whwn, how, when not
Anis bhatti cp1 what, whwn, how, when not
 
Knee
KneeKnee
Knee
 
Basic Assessment skills
Basic Assessment skillsBasic Assessment skills
Basic Assessment skills
 
lect 1 Anthropometry -.pdf
lect 1 Anthropometry -.pdflect 1 Anthropometry -.pdf
lect 1 Anthropometry -.pdf
 
Examination Of Spine and it's patholgies
Examination Of Spine and it's patholgiesExamination Of Spine and it's patholgies
Examination Of Spine and it's patholgies
 
meu workshop Osce ospe an introduction
meu workshop Osce ospe an introductionmeu workshop Osce ospe an introduction
meu workshop Osce ospe an introduction
 
Club foot
Club foot Club foot
Club foot
 
Genetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is tGenetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is t
 
Physical & neurological examination
Physical & neurological  examinationPhysical & neurological  examination
Physical & neurological examination
 
OSCE AND OSPE, DIFFERENTIAL SACALE
OSCE AND OSPE, DIFFERENTIAL SACALEOSCE AND OSPE, DIFFERENTIAL SACALE
OSCE AND OSPE, DIFFERENTIAL SACALE
 
The Painful Adult Shoulder: evidence based history, exam and approach
The Painful Adult Shoulder: evidence based history, exam and approachThe Painful Adult Shoulder: evidence based history, exam and approach
The Painful Adult Shoulder: evidence based history, exam and approach
 
ub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdf
ub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdfub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdf
ub-hsped-scoliosis-differential-dx-functional-and-structural-scoliosis.pdf
 
Ep 27 Hobson posture and airway
Ep 27 Hobson posture and airwayEp 27 Hobson posture and airway
Ep 27 Hobson posture and airway
 
Appropriate Outcome Measures for Lower Level Patients
Appropriate Outcome Measures for Lower Level PatientsAppropriate Outcome Measures for Lower Level Patients
Appropriate Outcome Measures for Lower Level Patients
 
Pediatric musculoskeletal examination including P-GALS
Pediatric musculoskeletal examination including P-GALSPediatric musculoskeletal examination including P-GALS
Pediatric musculoskeletal examination including P-GALS
 

More from Anisuddin Bhatti

More from Anisuddin Bhatti (20)

Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptxWhy Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
 
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxPrinciples, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
 
VERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxVERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptx
 
Principles of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxPrinciples of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptx
 
CLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.pptCLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.ppt
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxMock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptx
 
Mock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxMock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptx
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxMock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptx
 
Mock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxMock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptx
 
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsBhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
 
Congenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano ValgusCongenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano Valgus
 
Pakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programPakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention program
 
Post Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbPost Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limb
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limb
 
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxPost Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
 
LCPD Perthes'_ management
LCPD Perthes'_ managementLCPD Perthes'_ management
LCPD Perthes'_ management
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classification
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above
 

Recently uploaded

THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
DR SETH JOTHAM
 
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the HeartCardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
MedicoseAcademics
 

Recently uploaded (20)

Is preeclampsia and spontaneous preterm delivery associate with vascular and ...
Is preeclampsia and spontaneous preterm delivery associate with vascular and ...Is preeclampsia and spontaneous preterm delivery associate with vascular and ...
Is preeclampsia and spontaneous preterm delivery associate with vascular and ...
 
DIGITAL RADIOGRAPHY-SABBU KHATOON .pptx
DIGITAL RADIOGRAPHY-SABBU KHATOON  .pptxDIGITAL RADIOGRAPHY-SABBU KHATOON  .pptx
DIGITAL RADIOGRAPHY-SABBU KHATOON .pptx
 
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDFNCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
 
Final CAPNOCYTOPHAGA INFECTION by Gauri Gawande.pptx
Final CAPNOCYTOPHAGA INFECTION by Gauri Gawande.pptxFinal CAPNOCYTOPHAGA INFECTION by Gauri Gawande.pptx
Final CAPNOCYTOPHAGA INFECTION by Gauri Gawande.pptx
 
Compare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from homeCompare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from home
 
Why invest into infodemic management in health emergencies
Why invest into infodemic management in health emergenciesWhy invest into infodemic management in health emergencies
Why invest into infodemic management in health emergencies
 
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
 
Aptopadesha Pramana / Pariksha: The Verbal Testimony
Aptopadesha Pramana / Pariksha: The Verbal TestimonyAptopadesha Pramana / Pariksha: The Verbal Testimony
Aptopadesha Pramana / Pariksha: The Verbal Testimony
 
Arterial health throughout cancer treatment and exercise rehabilitation in wo...
Arterial health throughout cancer treatment and exercise rehabilitation in wo...Arterial health throughout cancer treatment and exercise rehabilitation in wo...
Arterial health throughout cancer treatment and exercise rehabilitation in wo...
 
180-hour Power Capsules For Men In Ghana
180-hour Power Capsules For Men In Ghana180-hour Power Capsules For Men In Ghana
180-hour Power Capsules For Men In Ghana
 
Cardiovascular Physiology - Regulation of Cardiac Pumping
Cardiovascular Physiology - Regulation of Cardiac PumpingCardiovascular Physiology - Regulation of Cardiac Pumping
Cardiovascular Physiology - Regulation of Cardiac Pumping
 
Introducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European UnionIntroducing VarSeq Dx as a Medical Device in the European Union
Introducing VarSeq Dx as a Medical Device in the European Union
 
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the HeartCardiac Impulse: Rhythmical Excitation and Conduction in the Heart
Cardiac Impulse: Rhythmical Excitation and Conduction in the Heart
 
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
 
Couples presenting to the infertility clinic- Do they really have infertility...
Couples presenting to the infertility clinic- Do they really have infertility...Couples presenting to the infertility clinic- Do they really have infertility...
Couples presenting to the infertility clinic- Do they really have infertility...
 
MALE REPRODUCTIVE TOXICITY STUDIES(Toxicokinetics).pptx
MALE REPRODUCTIVE TOXICITY STUDIES(Toxicokinetics).pptxMALE REPRODUCTIVE TOXICITY STUDIES(Toxicokinetics).pptx
MALE REPRODUCTIVE TOXICITY STUDIES(Toxicokinetics).pptx
 
Relationship between vascular system disfunction, neurofluid flow and Alzheim...
Relationship between vascular system disfunction, neurofluid flow and Alzheim...Relationship between vascular system disfunction, neurofluid flow and Alzheim...
Relationship between vascular system disfunction, neurofluid flow and Alzheim...
 
𝕔ALL #𝕘IRLS Service in Jaipur %(8901183002)# Jaipur #𝕔ALL #𝕘IRLS
𝕔ALL #𝕘IRLS Service in Jaipur %(8901183002)#  Jaipur #𝕔ALL #𝕘IRLS𝕔ALL #𝕘IRLS Service in Jaipur %(8901183002)#  Jaipur #𝕔ALL #𝕘IRLS
𝕔ALL #𝕘IRLS Service in Jaipur %(8901183002)# Jaipur #𝕔ALL #𝕘IRLS
 
Young at heart: Cardiovascular health stations to empower healthy lifestyle b...
Young at heart: Cardiovascular health stations to empower healthy lifestyle b...Young at heart: Cardiovascular health stations to empower healthy lifestyle b...
Young at heart: Cardiovascular health stations to empower healthy lifestyle b...
 
Scientificity and feasibility study of non-invasive central arterial pressure...
Scientificity and feasibility study of non-invasive central arterial pressure...Scientificity and feasibility study of non-invasive central arterial pressure...
Scientificity and feasibility study of non-invasive central arterial pressure...
 

Mock ExaminationLong case Cerebral Palsy .pptx

  • 1. MOCK Clinical Examnination: Cerebral Palsy (long case) Prof. Anisuddin Bhatti Dr. Ziauddin University Hospital, Clifton, Karachi. Secretary, Faculty Orthopaedics, CPSP. Founding Director PORP Registry, POSP Focal Person Ponseti International, Pakistan
  • 2. Long case: KEY - CONNTEMPORARY Answers are scored phase-wise on a key. Excellent, Good, Adequate, Inadequate*, Poor Examiner 1: [both examiners R Silent Observer] A. History Taking & Examination: Examinee’s attitude, behavior, communication skill, clinical examination skill. B. Presentation skill: Correct history, relevant exam findings, Positive / negative findings. C. Order relevant Investigation & justify. He shall be shown that report , Xray, MRI, CT etc D. Differential Diagnosis & confirmation of diagnosis most suitable. Examiner 2: A. Management plan. Discussion: What, How, When & When not. B. Complications. Why & how to manage C. Recent advances. * Central Tendency
  • 4. A 9-year-old boy presented with tip toe walking since age 2 years and having difficulty in walking for the last 3 years. He is able to sit at ease. Very enthusiastic & cooperative. Step 1: Ur introduction. Step 2: Take detailed relevant history Q.1. U ask question from patient / Companion Q.2. Must NOT Forget to ask Key Q relevant to problem
  • 5. Q.2. Key Question 1. Birth history: Liquor aspiration - Birth Asphyxia. Delayed milestones for one year. mentally alert, Intelligent, he study in class 3. 2. Development history: Walked independently for 6 years, deteriorated with difficulty in walking, for the last 3 years. He manage his daily accustomed habits independently. 3. Walking Ability: He is an independent walker, sometimes need support, when outside [functional walker]. 4. Socio-economic status 5. Rehabilitation exercises & facilities services
  • 6. The Examinee must end his history taking by end of first 10 minutes
  • 7. Step 3: Continue Relevant Q & perform Focused Screening examination to reach MOST PROBABLE diagnosis & functional disability ?
  • 8. Q.3. Relevant Question & Focused clinical to reach most probable diagnosis & functional disability Exmine to 1. Asses his Gait, Posture, walking ability 2. Type of gait 3. Balance & abnormal spontanous movements 4. Contractures
  • 9. Q.3. Focused CE: Gait & Posture again. Q.3a. What type of gait is this? Q.3b. What type of walker he is? Examiner Let examinee to speak freely to justify
  • 10. Q.3a. Key. • Spastic Diplegic • Jump gait / Crouch • Stable / balanced / Unstable • Decompensating with Pes Plano-Valgus.. A Danger sign.
  • 11. Step 4. Detailed Clinical Examination Perform multiple clinical test to look for: • Focus general examination • Focused systemic examination • Detalied Regional Examination: o spasticity, o hyperreflaxia, o Contractures: Static & Dynamic o Specific test relevent to problem
  • 12. Q.4. Key: Detailed Clinical examination Detailed clinical Examination. Examinee may narrate his findings 1. In systemic examination he may not have significant abnormality. 2. Focused Neuro - MSK examination: to terform certain clinical test to evaluate for spasticity & contractures: Dynamic & satatic. If You have missed few test during your half hour the Examiner may asks to name such test and perform, not to worry for that. Plz perform ?? Test OR he just ask how to do and what are pre- Requisites of that test. OR He may ask you few question to know ur knowledge & skill.
  • 13. Be systemic: U wl not loose but win Follow sequence: General… Systemic … Regional exam
  • 14. Clinical Evaluation: Tests Q.6. Which test is this? Q.7. What are the Findings? Q.8. Is there any flaw while performing this test.
  • 15. Q.6,7,8 Key Q.6. Thomas test… for Hip Flexion contracture. FFC Q.7. Knee cntracture & Hamstring spasticity Q.8. Flaws: Pillow & Soft bed. Modified Thomas at edge of bed to exclude Knee contracture. Not done Question on Flaws test your knowledge & Skill.
  • 16. Thomas Test- Modified: Must to exclude Knee Contracture, avoid flaw
  • 17. Staheli’s Hip Flexors Stretch test: Hip FFD in CP More Sensitive test • More accurate for FFD hip • Prone position • Pelvis over table edge Thomas test Staheli’s
  • 18. Q.9. Which tests R this. What R the Findings. Any Flaw in performing tests?
  • 19. Q.9. Key 9.A. Combined Abduction test. 700 . Adductors contracture bilateral. Flaw: Not significant. Individual side may b done. 9.B. Pop Angle test. +900 . Significant Hamstring contracture / Spasticity. Flaw: not significant 9.C. Silverskiold test. Negative. Combined Gastro-Solus contracture.
  • 20. Adductor Longus Stretch Test • Hip abduction angle in Knee extension & flexion When measurements are same: Adductors tight. Why? • Hip abduction improves on Knee flexion: Gracilis tight Same angle Adductors tight Abduction improved Gracilis is tight
  • 21. Gracilis spasticity – Phelp’s Test • Passive abduction with knee in extension. • Improved hip abduction with knee flexion indicates Gracilis / medial hamstring tightness. Why?
  • 22. Popliteal Angle: Normal ranges in Children. Discussion • 1-3 yrs mean angle 60 [00-150] • @ 4 yrs mean angle 170 in girls, 270 in boys [50-450]. • >5 yrs mean angle 260 little change [0-50] • PoP angle of >500 in above age groups indicate abnormal hamstring tightness. Katz, Kalman. University Telaviv Israel. J Ped ortho 1992. 12:229-231
  • 23. POP Angle: Hamstring Stretch Test: Discussion • Hip flexed to 900 & knee extend • Measure Popliteal angle 900 flexion to 00 extension • Hamstring Shift: Difference b/t Rt & Lt measurements 00 900 500 Rt Lt
  • 24. Achilles Stretch Test: Discussion Silverskiold test- Gastroc. vs Soleus “Spastic Gastrocnemius contracture” Correction of ankle equinus with Knee flexion indicates Predominantly gastrocnemius Contracture. Why?
  • 25. Q.10. Which tests are being performed What R Findings? What is wrong in performing these tests ?
  • 26. Q.10.a. Key 10.A. Rectus Strech test: Aly Duncan test. Pelvis rise on knee flexion. 10.B. Hip Rotation test: Anteversion
  • 28. Phase 2 Examiner 1 Interactive Discussion 15 minutes History taking, Art of Presentation, Findings and Relevant investigations
  • 29. 15minutes presentation by examinee and interactive discussion
  • 30. Q. Any additional Clinical tests U Know and Perform that?
  • 31. Key Craig Test: FAV: Trochanteric Prominence Test • Prone position and knee at 90° flexion. • Angle between the vertical line and long axis of the leg at the greatest prominence of the greater trochanter palpated laterally measures the amount of FAV. In recent studies, it has been found that trochanteric prominence test in combination with hip internal rotation, X-rays is a better predictor of FAV and neck-shaft angle as compared with computed tomography.
  • 32. Key. Rotational Malalignment/s • Foot propagation angle • Tibial rotation Foot – Thigh Angle
  • 33. Q. Tibial torsion mal-alignment Thigh foot Angle • Prone position, knee in 90° flexion, and neutral ankle and hind foot position. • Angle between the thigh axis and foot axis (axis between the 2nd and 3rd metatarsals) gives Tibial torsional measurement
  • 34. Q.Is there any Advance Clinical or laboratory tests available to check CP Patients Motor functions & disability?
  • 35. Q. key Advanced tests • Foot propagation angle • Observational Gait Analysis & Video Assisted OGA • Videographic Gait analysis: Gait Laboratory test: Computer base gait and indiviual muscle functions programme, that include: oEMG Muscle charting. o3D camera gait analysis. oFoot pressure Pedography.
  • 36. Q. Advanced tests: Repeated examination & careful analysis of the gait [VAOGA/ Gait laboratory] & posture and recognition of potential skeletal changes lead to better judgment to correct or prevent structural changes reasonably early i.e before 15 (13) years. (Molnar-Gordon) Gait Laboratory Plays important role in accurate Judgment Video Assisted Observational Gait Analysis
  • 37. NED University Gait Laboratory: Videographic gait analysis Gait Lab test being performed on patients during CP workshop on 19 March 2011
  • 38. Gait Laboratory: PEDOGRAM: Cavovarus & Planovalgus EMG: Indicating spastic, normal & Weak Muscles
  • 39. KEY = Interactive discussion GAIT PATTERNS • Different Gait patterns observed in CP depends on the involvement of spasticity or contracture of different muscles: • Variations relates to topographical type of CP { Hemiplegia, Diplegia, monoplegia. With or without Ataxia etc}. • Best seen in contrast between unilateral spastic CP and bilateral spastic CP.
  • 40. Key. Spastic Diplegia Gaits: Four common patterns of gait in spastic Diplegia. [Rodda et al.] • Type 1 – True equinus • Type 2 – Jump gait • Type 3 – Apparent equinus • Type 4 – Crouch gait
  • 41. Q.3c. Rodda et al. JBJS. 2004 Q.3B Key
  • 42. Key: Interactive discussion Waking Pattern Assessment to Qualify as walker can be made best after the age 7 years. Till than brain maturation reach to a plateau. TYPES OF WALKING: • Walker: when child could walk a minimum of 15 meters without falling. [Independent walker] • Functional Walker: when a child could walk only with crutches [Community walker]. • Non-Walker: when child could walk with aid of mobility device or only in parallel bars
  • 43. Phase 2: Examiner 2 Interactive Discussion 15 minutes Differential Diagnosis & Management Plan Recent Advance
  • 44. Differential diagnosis. • Q. In what pathological status this clinical condition occurs? • Q. How would you confirm your best possible diagnosis?
  • 45. Key Differential Diagnosis Cerebarl Palsy, Spinal Dysraphysm, Fredrix Ataxia & Cerebral demyelination syndrome. Detailed Birth history, Clinical examination, Observational gait analysis, Video assisted observational gait analysis & Advanced Imaging. Use Algorythm: Diagnostic Matrix
  • 46.
  • 47. Q. How can you classify his functional disability ? Q. In which functional disability class (level) he fits & Justify? Examiner let examinee lets speak freely to justify
  • 48. Q. Key: Gross Motor Function Assesment GMFCS
  • 50. Management Plan: 9 yr aged, boy, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Recall findings: Examiner helps to recall findings. 1. Functional walker 2. GMFC-2 3. Thomas’s FFC 15-200 4. Combined Abduction 700 5. Phelp’s positive 6. Pop angle +900 7. Silverskiold’s Negative [-150] 8. Pes-planovalgus 9. Ely’s Positive 10. Stable pelvis & Spine 11. Upper limb Normal 12. No neuro deficit
  • 51. Management Plan: 9 yr aged, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Q.16. What shall be the objective to treat him? Q.17. How shall U manage him?
  • 52. Q. Key: management Plan 16. a. Help him to be an independent walker without support. b. prevent deterioration of pes planovalgus and develop crouch gait 17. A. 3-4 weeks pre-operative rehabilitation training exercises / physiotherapy & Occupational therapy. B. Exclude structural abnormalities on X-ray. C. Reconstructive surgery @ Knee & Ankle C. Postoperative Rehabilitation programmes
  • 53. Management Plan: 9 yr aged, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Q.18. What shall be contraindications other than general well being? Q.19. Let us know Ur plan of Reconstructive surgery as u decided? No need to go in detailes of surgical steps
  • 54. Q. Key. Contra Indications & Recon Surgery Reconstructive surgery is better in Spastic Cerebral palsy, best in Hemiplegia than diplegia. Before embarking to surgery. MUST MUST: Exclude Ataxia, chorioform movements & other abnormal features of basal ganglia involvement. A. Reconstructive surgery @ Knee & Ankle +/- Hip Hamstring Fractional Lengthening, Keats transfer to adductor tubercle, TAL, 1/2 Tibialis Anterior Transfer to neck of talus. [+/- Adductor Myotomy without Neurectomy] Postoperative Rehabilitation programmes Quad strengthening and Gluteal Muscle development excercises.
  • 55. Management Plan: 9 yr aged, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Describe postoperative care? Examiner Let examinee speak freely
  • 56. Key. Rehabilitation Programme. Rehab programme • Hospital & home bases exercises • Muscle streghening execrcise • Occupational therapy Bracings – Temporary addjuncts • AFO • KFO
  • 57.
  • 58.
  • 59. References • VCE Guidelines Designed by: DR. Sirajul Haque Shaikh, Director DME. CPSP, Karachi. • References: 1. Harless et al 1971 2. Cook et al, 2010. 3. Huang G, Reynolds R, Candler C. • Clinical Material: Prof. Anisuddin Bhatti’s collection • Videos Prepared @ DZUH Clifton, Karachi Assisted by: Dr. Sadam Mazar Baloch & Dr. Nida Hameed

Editor's Notes

  1. 1. Birth history: Liquor aspiration Birth Asphyxia. Delayed milestones for one year. Intelegent. 2. Development history: Walked independently for 6 years, deteriorated with abnormal Gait for the last 3 years. He manage his daily accustomed habbits independently. 3. He is an independent walker with a Jump gai, sometimes need support, when outside.
  2. Exmine for Gait, Posture, walking ability multiple clinical test to look for soasticity, hyperreflaxia, Contractures:static & dynamic.
  3. 3. Spastic Diplegia. 4. By GMF Assesment: Print key as on next slide 5. GMFL: II (Walks with Jump gait BUT supported
  4. Thomas test… Hip contracture Knee cntracture … Hamstring spasticity Flaws: Pillow & Soft bed. Modified thomas at edge of bed to exclude Knee contracture.
  5. Detailed clinical Examination Focused MSK examination to terform certain clinical test o evaluate for spasticity & contractures: Dynamic & satatic
  6. 1. Clinical video based analysis of Gait & Posture.
  7. Detailed clinical Examination Focused MSK examination to terform certain clinical test o evaluate for spasticity & contractures: Dynamic & satatic
  8. 1. Cerebarl Palsy, Spinal Dysraphysm, Fredrix Ataxia & Cerebral demyelination syndrome. 2. Detailed Birth history & clinical examination. [Print two slides as key]
  9. 3. Spastic Diplegia. 4. By GMF Assesment: Print key as on next slide 5. GMFL: II (Walks with Jump gait BUT supported
  10. 16. a. Help him to be an independent walker without support. b. prevent deterioration of pesplanovalgus and develop crouch gait 17. A. 4-6 weeks pre-operative rehabilitation training exercises / physiotherapy & Occupational therapy B. Reconstructive surgery @ knee & ankle C. Postoperative Rehabilitation programmes