Mock Virtual Clinical examination on long case delivered through zoom.us @ CPSP lahore on 4.8.2020. Describe how to give long case in Covid situation without a real patient.

1. MOCK VCE:
LONG CASE
ANISUDDIN BHATTI
Dr. Ziauddin University Hospital
Clifton, Karachi
Pre-Exam Mock-CPSP Lahore. 4.8.2020
Thankx to organizers & Trainees
for gracious Invitation
Specially Dr. Zahid Malik

2. Look at this picture of
8 year-aged boy
• He fell from 5feet height [Tree]
6/12m back.
• Pain & Antalgic limp Left leg
Q.1 What additional
questions You would like
to ask & why?

3. Q.2. How would you
proceed further to reach
diagnosis?

4. Q.3. What clinical
Examination you shall do?

5. q.3a. Perform 2 focused
examination test
virtually or on simulator

6. Q.3.a. Perform Special
test Virtual / realistic?
What happens when he
stand on right leg?

7. Q.3.b. Perform Special
test Virtual / realistic?
What happens when he
stand on Left leg?

8. Q.3.c. Discuss
pathophysiology
of this test?
What does this
test indicate?
What is
Pathophysiol
ogy of this
test

9. Q.4. Identify test?
• Which test is this?
• How is that being
performed?
• Plz. Perform on IPP
simulator

10. Q.5. Any more test that help
U in planning of treatment &
why?
Q.6. How R that Performed?

11. Leg Length Inequality ?
Q6. How to Measure LLD?
Plz make imaginary lines on this slide &
transparency sheet provided.
Q.7. Name the tests.

12. Leg Length Inequality ?
Q6. Which is what?
Q.7. Name two Other tests.

13. Q.8. What differential diagnosis
You would suggest?
Recall Findings:
• 6m-old H/O fall
• Antalgic Limp left hip
• Positive Trendelenburg
• Positive Thomas Test 150
• LLD 1.5cm True. Apparent
• Bryant’s.. Shortening above
trochanter.
What are two most possible diagnosis

14. Q.9. Plz advise relevant
investigation with
justification.

15. Xray in his record @ 2/12 months

16. He presented @ 6/12m with history &
examination already done as above.

17. Q.10.
Discussion: 6
years aged
Boy
•Classify paediatric
femoral neck fractures?
•What Complications do
you expect as per types
of injury & explain
reason?

18. Q.11.
Discussion: 6
years aged Boy
How Type I & II are
managed?
What extra precaution
needed during
treatment in this age
group?

19. ORIF was done at
6/12m
Xray @9/12m
Findings?
• Plz comment on
fixation.
• What do you expect
with this status

20. @ 18 m post trauma
i.e 12/12m post fixation.
Implant removed
What are the findings?
What to do now?

21. Discussion
i. 6m-old H/O fall
ii Antalgic Limp left hip
iii. Positive Trendelenburg
iv. Positive Thomas Test 150
LLD 1.5cm True. Apparent
v. Bryant’s.. Shortening
above trochanter.

22. Q.1. Key: Detailed hidtory:
Marks: 1/10 on taking & presentation skill [1/10]
• Interactive Dialogue b/w examiner & examinee.
• 1. Was he able to stand & bear weight after injury? Not able to do say.,
Taken to local bone setter.
2. How he was managed than till date? Potters treatment with alternate day
lubricant, wooden strips splintage to left hip and non weight bearing.
3. Was he taken to hospital / Orthopod? Yes at two months after injury. X-ray
was taken and was advised non-weight bearing
4. Personal history: Do he have any history of fever, cough or other major illness
before this injury? None, not at all.
Did he had complete vaccination proptocol including BCG? Yes, total
protocol followed.
5. Family history: No. of Family members {6], Any chronic Illness in parents &
siblings [none].

23. Q.2. Key: Clinical Examination
Marks 1/10 on enumeration & Justification. [2/10]
Interactive Dialogue b/w examinee & examiner.
He shall ask for clinical examination & special Tests.
•General & systemic Examination. Posture ?, Gait ?, Sitting ability ?,
ability to Get up to couch,
•Trendelenburg test?, Deformities / contracture .. Hip/knee ?
•Thomas test ?, Limb length Discrepancy & Telescope Test?
• He may be asked to justify .. Why he needs to do above tests.

24. Q.3. Key: Performing examination virtualy / silulator
Mark 1/10 on performance [virtual / realistic] of 2 test. [3/10]
Interactive Dialogue b/w examinee & examiner. He shall ask to Perform
clinical examination & special Tests.
•General & systemic examination: examiner may dialogue and may
inform “there is no Significant abnormality.
•Locomotor MSK Examination & neurology.
•Special test: Trendelenburg test?, Deformities / contracture ..
Hip/knee ? Thomas test ?, Limb length Discrepancy & Telescope Test?
• He shall be asked to explain the findings in presented pictures or
perform a test on simulator [examiner / assistant] minimum two
tests.

25. Q.3.a.Key: TRENDELENBURG TEST (right side)
• Examinee Explain findings in picture and Justify.
OR perform Trendelenburg test.
• The patient stands on the normal [Right]: leg his
trunk inclines towards the same side, and the
pelvis tilts and is stabilized towards the same side
causing the other buttock to rise.
• Note the position of the glutei folds. The right hip
is stable, no drooping of pelvis on left…….test is
negative on this side.
Exeminer ask why that happens so… Pathophysiology

26. Q.3.b.Key: TRENDELENBURG TEST: (left side)
• Then patient then stands upon the
affected [left] side.
• The stabilizing mechanism has failed
and the buttock on the opposite side
droops downwards; the left hip is
unstable: the test is positive on left.

27. Q.3.c.i.Key: Trendelenburg’s test:
Pathophysiology
COMPONENTS:
• Lever arms
• Fulcrum
• Power

28. Q.3.c.ii.Key: pathophysiology- TRENDELENBURG TEST:
• The cause of failure in this case
is due to subluxation of the hip
joint so the fulcrum for the
action of the pelvi-femoral
muscle is lost.
The cause of failure in this case
is due to # Nonunion of the hip
joint so the Lever arm for the
action of the Pelvi-femoral
muscle is lost.

29. Q.4 Key: Hug Owen Thomas Test
Demonstrates:
“Hidden / obscure Fixed Flexion Deformity”
• How to perform [on simulator or Video/photo]
• What R Prerequisites: Flat top, no pillow, hand
under back
• How to eliminate knee contracture: Modified
test.
• True & False contractures: Relax IT Tract, check
for Iliopsoas / Orthrois .. No rotational ROM
• Errors: not doing modified, soft bed & pillow

30. THOMAS TEST: Errors
Avoid Errors:
• Hand under back to
feel back is
straightened
• Exclude Knee
contracture.
• Do modified Thomas
test at edge of bed.

31. Modified Thomas test:

32. Q. What test is this?
Modified Thomas

33. Bryant’s Triangle
Shortening may
occur either above
or below the greater
trochanter, i.e. in
the femoral neck
and hip joint, or
below it.
• Assessment of relation b/w Ant. Sup Iliac Spine & tip of G trochanter
• Base of triangle is a guideline to N-S angle, normally nearly Isosceles triangle
Klisic’s Test with 3 fingers

34. Bryant’s Triangle
• True Shortening indicated
by diminished base of
triangle.
• Trochanter lies almost
vertically below ASIS.
• Can be measured by
palpation by thumb + 2
fingertips [Klisic’s Test] &
compared two sides
simultaneously

35. BRYANT’S TRIANGLE: Klisic's Test.
• In practice, Bryant’s triangle
does not require to be
marked out, but is readily
assessed by palpation with
the thump on the anterior
superior iliac spine and
fingertips on the top of the
greater trochanter, the two
sides being simultaneously
compared.

36. Leg Length Inequality
Measurements?
Procedure & Prerequisites
• Wide variety of causes.
• In its simplest form, it is due to
shortening in any part of one leg,
or lengthening in any part of the
other.

37. Leg Length Inequality: Block test
When the patient stands
erect, the pelvis is tilted due
to shortening of the left leg.
A block of 5 cm underneath
the left leg squares the
pelvis, indicating true
deference in the length of
the legs.
5cm block underneath left leg squares pelvis, indicating TRUE difference

38. Apparent lengthening
due to Left leg abduction contracture, right leg is measured in same
degree of abduction, lengths are seen to be equal
Leg length inequality may
be apparent only:
• fixed adduction
deformity at the hip
causes shortening,
• fixed abduction causes
apparent lengthening

39. .
• This child has a fixed abduction deformity
of the left hip caused by muscle
contracture following poliomyelitis.
• There is apparent lengthening of the left
leg.
• When the right leg is measured in the
same degree of abduction as the left, the
leg lengths are seen to be equal.
PELVIS SQUARING:
Right leg is measured in same
degree of abduction, lengths are
seen to be equal
Apparent LLE/D
Apparent LLD

40. Key Q9: Xray
• Advise relevant investigation with
justification. Marks 1/10 [5/10]
• Xray, Tc99, CT/MRI .. To confirm
diagnosis & +/- AVN, Hip status
• Clinical lab test. CBC, ESR, CRP,
Test for possile GA.
• X-ray @2/12m
Transcervical Delbet II,
Delayed Union
• Xray @ 6/12m
Delbet 2 Malunion /
Nonunion collapsed Neck of
femur.

41. Key Q 10.a: Delbet Classification
Delbet-I
a. Without Dislocation
b. With Dislocation

42. Key Q 10.b: Delbet Type, complication &
reasons

43. Key Q 11.: Rx Options

44. Key Q 12. Further treatment… after AVN & collapsed
Femoral Neck. EXTRA MARKS
• Xray @ 9/12m
oORIF with possible wedge
osteotomy
oGap at frx site may cuase
problem
oScre should have been Parralel
• Xray @ 18/12M
oNon-Union
oAvN, absorption of neck …. MRI
• Rx Options:
oPreserve Femoral head
oWait & Eatch
oTreat as Perthes
oVascularised Fibular graft.