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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
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?
Q.2. How would you
proceed further to reach
diagnosis?
Q.3. What clinical
Examination you shall do?
q.3a. Perform 2 focused
examination test
virtually or on simulator
Q.3.a. Perform Special
test Virtual / realistic?
What happens when he
stand on right leg?
Q.3.b. Perform Special
test Virtual / realistic?
What happens when he
stand on Left leg?
Q.3.c. Discuss
pathophysiology
of this test?
What does this
test indicate?
What is
Pathophysiol
ogy of this
test
Q.4. Identify test?
• Which test is this?
• How is that being
performed?
• Plz. Perform on IPP
simulator
Q.5. Any more test that help
U in planning of treatment &
why?
Q.6. How R that Performed?
Leg Length Inequality ?
Q6. How to Measure LLD?
Plz make imaginary lines on this slide &
transparency sheet provided.
Q.7. Name the tests.
Leg Length Inequality ?
Q6. Which is what?
Q.7. Name two Other tests.
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
Q.9. Plz advise relevant
investigation with
justification.
Xray in his record @ 2/12 months
He presented @ 6/12m with history &
examination already done as above.
Q.10.
Discussion: 6
years aged
Boy
•Classify paediatric
femoral neck fractures?
•What Complications do
you expect as per types
of injury & explain
reason?
Q.11.
Discussion: 6
years aged Boy
How Type I & II are
managed?
What extra precaution
needed during
treatment in this age
group?
ORIF was done at
6/12m
Xray @9/12m
Findings?
• Plz comment on
fixation.
• What do you expect
with this status
@ 18 m post trauma
i.e 12/12m post fixation.
Implant removed
What are the findings?
What to do now?
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.
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].
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.
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.
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
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.
Q.3.c.i.Key: Trendelenburg’s test:
Pathophysiology
COMPONENTS:
• Lever arms
• Fulcrum
• Power
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.
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
THOMAS TEST: Errors
Avoid Errors:
• Hand under back to
feel back is
straightened
• Exclude Knee
contracture.
• Do modified Thomas
test at edge of bed.
Modified Thomas test:
Q. What test is this?
Modified Thomas
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
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
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.
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.
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
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
.
• 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
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.
Key Q 10.a: Delbet Classification
Delbet-I
a. Without Dislocation
b. With Dislocation
Key Q 10.b: Delbet Type, complication &
reasons
Key Q 11.: Rx Options
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.

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Mock vce lahore 4.8.20 2

  • 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?
  • 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.
  • 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.
  • 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.

Editor's Notes

  1. Key Q1. Interactive Dialogue b/w examiner & examinee. Marks assigned 1/10 [1/10] 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].
  2. Key Q.2. Interactive Dialogue b/w examinee & examiner. He shall ask for clinical examination & special Tests. 1/10 on enumeration & Justification. 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.
  3. Key Q.3. Interactive Dialogue b/w examinee & examiner. He shall ask to Perform clinical examination & special Tests. Mark 1/10 on performance [virtual / realistic] of 2 test. [3/10] 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.
  4. Q.3.a: advised to explain findings in picture and Justify. Trendelenburg test. Pelvis stable when he stand on right Explains why that happens so Examiner continue interactive dialogue for pathophysilogy of Trendelenbur test.
  5. Q.3.b: advised to explain findings in picture and Justify. Trendelenburg test. Pelvis stable when he stand on right Pelvis droops down on right, when he stand on Left Explains why that happens so Examiner continue interactive dialogue for pathophysilogy of Trendelenbur test.
  6. Q3cKey: examiner & examinee continue interactive dialogue Explains why pelvis droops on rightwhile standing on left Discuss pathophysiology of Trendelenburg: Lever arm, Fulcurum & Power
  7. Interactive dialogue Hug Oven Thomas Test. Explains how is that performed Prerequisites … procedure to perform
  8. Bryant’s Traingle …. Shortening above & below trochanter LLD: apparent & True
  9. LLD measurement: Measure Apparent length Squaring pelvis and measure True lengths
  10. LLD measurement: Measure Apparent length Squaring pelvis and measure True lengths Bryant’s Block test
  11. Key Q8. Differential diagnos on clinical Judgment & advise relevant investigation with justification. Marks 1/10 [5/10] D/D: Frx NOF, Cong Coxa vara, Tuberculous hip, ABC/UBC NOF with frx, acetabulum frx Most possible: Frx NOF malunion, TB hip
  12. Key Q9. 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.
  13. Transcervical Delbet II, Delayed Union
  14. Delbet 2 Malunion / Nonunion collapsed Neck of femur
  15. ORIF with possible wedge osteotomy Gap at fRx site may cuase problem Scre should have been Parralel
  16. Non-Union AvN, absorption of neck …. MRI Rx: Preserve Femoral head
  17. Klisic’s Test performed similarly with 3 fingers