Presentation contain etiology, blood supply of femoral head & neck,pathogenesis ,classification system ,clinical features,diagnosis,managment, pelvic & femoral osteotomies in detail
Presentation contain etiology, blood supply of femoral head & neck,pathogenesis ,classification system ,clinical features,diagnosis,managment, pelvic & femoral osteotomies in detail
Clinical examination skills can be imparted effectively using videos for beds...CIT, NUS
By Naresh Kumar
Background & Purpose
Efforts to impart psychomotor skills through IVLE using McGill Videos have been tried since October 2007 at NUS. The post OSCE survey for year 3 and 4 students in academic year 2008-2009 revealed that it was difficult to use the videos in local context. A common observation arose that there was a need for – ‘standardization of clinical examination techniques’. This study was aimed towards developing a standardised clinical examination video for Orthopaedics and also to prove its effectiveness in standardizing the clinical examination techniques for students and examiners.
Methodology
The steps were as follows:
Production of the standardized video
Video workshop demonstrating clinical examination techniques
Post workshop student feedback
Analysis of feedback
Analysis of workshop attendees vs. non attendees performance in the final phase 3 exam
Results
Out of 260 students, 128 students attended the pre-exam video workshop. The post workshop feedback questionnaire had 6 questions per joint/region. The positive response rate per question was: A-94.5%, B-85.5%, C-84.5%, D 90.9%, E- 95.5%, F- 91.8%.
216 students out of 260 students were examined in the Orthopaedic stations in OSCE. Workshop attendee students scored average 74.01% marks. Non-attendees scored 61.88% marks. Out of 128 workshop attendee students - 37.2% students received positive comments, and 9.1% non-attendees received positive examiner comments.
Conclusions
Psychomotor clinical examination skills in Orthopedics are acquired at the bedside and in the classroom. Clinical standardization can only be achieved by having a standardised video which is available over a common platform i.e. IVLE.
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2. Pathophysiology
• Three major factors cause a child to limp: pain,
weakness, and structural or mechanical
abnormalities of the spine, pelvis, and lower
extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998).
• A normal gait is composed of symmetrical,
alternating, rhythmical motions involving two
phases: stance and swing. The stance phase normally
encompasses 60% of the gait cycle. The type of gait
may be helpful in identifying the etiology of the limp.
3. Some Abnormal Gaits
• An antalgic gait results from pain in one extremity that causes the patient to
shorten the stance phase on that side with a resultant increase in the swing phase.
The most common causes of an antalgic gait are trauma or infection.
• A Trendelenburg gait is a downward pelvic tilt away from the affected hip during
the swing phase as a result of weakness of the contralateral gluteus medius
muscle .The gait disturbance is commonly observed in children with
developmental dysplasia of the hip, Legg-Calves-Perthes disease, or slipped capital
femoral epiphysis. If the involvement is bilateral, a waddling gait results
• A steppage (equinus) gait is a result of the inability to actively dorsiflex the foot,
with exaggerated hip and knee flexion during the swing phase. A steppage gait is
seen in children with neuromuscular diseases (eg, cerebral palsy) that cause
impairment of dorsiflexion of the ankle.
• A vaulting gait occurs when the knee is hyperextended and locked at the end of
the stance phase and the child vaults over the extremity .A vaulting gait is seen in
children with limb length discrepancy or abnormal knee mobility.
• A stooped gait is characterized by walking with bilaterally increased hip flexion A
stooped gait is common in children with pelvic or lower abdominal pain.
• A scissors gait caused due to cerebral palsy , legs cross while walking
• A waddling gait seen in bilateral hip involvement
4. Differential Diagnosis
Age Painful limp Painless limp
1-3yr 1- Infection 1- Developmental
Septic arthritis / dyplasia of the hip
osteomyelitis/ 2- Neuromuscular
cellulitis / synovitis disease
2- Trauma -Cerebral palsy
3- 1ry or metastatic -Muscular dystrophy
neoplasm 3- lower limb length
inequality
5. Differential Diagnosis
Age Painful limp Painless limp
4 - 10yr 1-Infection 1-Developmental dyplasia
2- inflammatory JRA, SLE of the hip
3- Trauma 2- NMD
4- 1ry or metastatic tumor 3- Lower limb length
5- hematological disease inequality
4 –hereditary motor
Hemophilia, SCA,
leokemia sensory neuropathy
charcot’s marrie tooth
6-Legg-Calve-Perthes disease
Disease , Kohler’s (AVN)
6. Differential Diagnosis
Age Painful limp Painless limp
11- 18yr 1-Infection 1- Developmental dyplasia of
2- inflammatory :JRA, SLE the hip
3- Trauma 2- Neuromuscular disease
4-1ry or metastatic tumor Cerebral palsy
5-hematological disease Muscular dystrophy
Hemophilia, SCA, leukemia 3- lower limb length inequality
6-Legg-Calve-Perthes Disease 4- chronic slipped upper
(AVN of femoral head) femoral epiphysis
7-acute slipped upper femoral
epiphysis*
very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position. Often *
painful on internal rotation of the hip. Association with hypothyroidism
7. Differential Diagonsis
• Others: don’t forget to consider:
– Appendicitis with psoas muscle irritation
– Neoplasms- either cause pain or pathological
fractures
– Retroperitoneal neoplasms or infection
– Neuromusculature disorders
8. Approach
• History
• Examination
• Investigation
• Management
9. History
• Age
• Sex
• Onset
• Painful or painless? ( analysis…)
• Acute or chronic
• History of trauma
• Association : Night pain, arthralgia, swelling,
morning stiffness, backache
10. History
• Systemic review
– Recent illness : URTI
– Weight loss, anorexia
– Fever, chills
– Unexplained rash or bruising
– Voiding problem
11. History
• Past history
– Medical : chronic illness
– Drugs : steroids, antibiotic
– Allergies
– Developmental
– Nutritional
– Vaccination ( site, MMR vaccine)
• Family history
– Hemoglobinopathy, CTD, IBD, NMD
• Social history