Adult Elective Orthopaedics and Spine
Chapter 7 Shoulder
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Aravind Desai
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Introduction#
A viva examination is like playing a game. The candidate should know the subject well, have a game plan and more importantly should know the opponent. A candidate who manages to answer the higher-order thinking/judgement questions at the end of the viva will make it a rewarding 5 minutes (for both the examiner and candidate) and more importantly will score a 7/8. An examiner relishes a candidate who takes control and makes their life easy.
Again, we must stress the importance of time management in the viva, as you have got only
5 minutes to score either eight or four and time is money! It is important to understand the scenario quickly and progress in the correct direction rather than using guesswork. Avoid talking generally about the shoulder conditions to fill the time if your aim is to score well. Wherever possible support your answer by evidence (quoting literature) as this will get you past a basic pass and on to a higher score. Be careful, however, not to quote unnecessary or irrelevant evidence which will not only irritate the examiners and not score you any extra marks but is rather crass and bovine.
The main aim of this chapter is to express the importance of viva techniques and therefore it is not wrift en as a textbook. Analyse the good as well as the poor techniques illustrated in the scenarios and follow the ones you find most useful.
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Shoulder#
In a shoulder structured oral question try and analyze the question according to its presentation. Broadly, shoulder pathology can be classified as painful, weak, stiff or unstable conditions. Shoulder pathology varies with different age groups and therefore you should have a list of age-related diagnoses clear in your mind, which will be helpful in the viva. There can be overlaps of these conditions, for example a painful stiff shoulder may represent frozen shoulder or acute calcific tendonitis or arthritis. Therefore, candidates should have a list of conditions and one or two classical questions to differentiate one from the other, to lead into the scenario comfortably right from the start.
Some scenarios to remember:
Young patientless than 30 years of age): instability, SLAP lesions.
Middle-aged patient (30–50): impingment, calcific tendonitis frozen shoulder, cuff tears.
Elderly patient (> 50): cuff tear, OA, cuff tear arthropathy.
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Structured oral examination question 1#
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Tuberculosis shoulder
EXAMINER
This is a radiograph of the left shoulder of an 84- year-old lady. Describe the radiograph please (Figure 7.1).
This is a radiograph of the left shoulder of an 84- year-old lady. Describe the radiograph please (Figure 7.1).
CANDIDATE
Well ... Good morning. This is the plain radiograph of an 84-year-old lady’s left shoulder . Anteroposterior (AP) view. There is evidence of joint destruction with loss of articular anatomy ...
Well ... Good morning. This is the plain radiograph of an 84-year-old lady’s left shoulder . Anteroposterior (AP) view. There is evidence of joint destruction with loss of articular anatomy ...
EXAMINER
What do you think is wrong with this shoulder?
What do you think is wrong with this shoulder?
CANDIDATE
Well, to be certain, I need to ask a few questions and examine the patient ...
Well, to be certain, I need to ask a few questions and examine the patient ...
EXAMINER
Go on then and ask some questions.
Go on then and ask some questions.
CANDIDATE
Is she right-handed or left-handed?
Is she right-handed or left-handed?
EXAMINER
Right-handed.
Right-handed.
CANDIDATE
How long has she had a problem with this shoulder?
How long has she had a problem with this shoulder?
EXAMINER
70 years.
70 years.
CANDIDATE
How did the problem start?
How did the problem start?
EXAMINER
It started as a painless lump when she was 14 and a few months later she began to have a discharging sinus that required several joint washouts and medication.
It started as a painless lump when she was 14 and a few months later she began to have a discharging sinus that required several joint washouts and medication.
CANDIDATE
Does she have an active sinus now?
Does she have an active sinus now?
EXAMINER
No, the sinus healed after she underwent shoulder washouts and started her medication and has never recurred.
No, the sinus healed after she underwent shoulder washouts and started her medication and has never recurred.
CANDIDATE
That is good. What are her current problems?
That is good. What are her current problems?
EXAMINER
Well she has some restriction of movements and therefore visited her GP, who had performed this X-ray and sent her to you for your opinion.
Well she has some restriction of movements and therefore visited her GP, who had performed this X-ray and sent her to you for your opinion.
CANDIDATE
Then I would examine the patient.
Then I would examine the patient.
EXAMINER
She has 60° of abduction and forward elevation and has very restricted rotations.
She has 60° of abduction and forward elevation and has very restricted rotations.
CANDIDATE
I would like to know the power of her cuff muscles.
I would like to know the power of her cuff muscles.
EXAMINER
It is not possible to assess the power as she has very restricted range of movements.
It is not possible to assess the power as she has very restricted range of movements.
CANDIDATE
Now ... [Bell]
Now ... [Bell]
EXAMINER
Thankyou.
Thankyou.
source p. 430
Figure 7.1 Anteroposterior (AP) radiograph of left shoulder .
Did this candidate do well? Was there a diagnosis? Was there a discussion about the management?
Only a 4 or 5 score would be given as the candidate did not even arrive at a diagnosis and missed all the clues/prompts.
A different candidate with the same scenario:
EXAMINER
This is a radiograph of the left shoulder of an 84- year-old lady. Please describe the X-ray.
This is a radiograph of the left shoulder of an 84- year-old lady. Please describe the X-ray.
CANDIDATE
This is an anteroposterior (AP) radiographic view of the shoulder that shows evidence of joint destruction and loss of articular cartilage.
This is an anteroposterior (AP) radiographic view of the shoulder that shows evidence of joint destruction and loss of articular cartilage.
EXAMINER
What do you think is wrong with this shoulder?
What do you think is wrong with this shoulder?
CANDIDATE
This appearance suggests several possible causes such as previous joint infection trauma or a neurogenic cause. May I know how and when the problem started?
This appearance suggests several possible causes such as previous joint infection trauma or a neurogenic cause. May I know how and when the problem started?
EXAMINER
Her shoulder difficulties beg an as a painless lump when she was 14 years old and after a few months she went on to develop a discharging sinus that required several shoulder joint washouts and medication.
Her shoulder difficulties beg an as a painless lump when she was 14 years old and after a few months she went on to develop a discharging sinus that required several shoulder joint washouts and medication.
source p. 431
CANDIDATE
The presentation sound slik e she had a low-grade joint infection. W as there any microbiological investigation performed at the time of the joint washouts?
The presentation sound slik e she had a low-grade joint infection. W as there any microbiological investigation performed at the time of the joint washouts?
EXAMINER
Yes, it was diagnosed as acid-fast bacillus and now what will be your management?
Yes, it was diagnosed as acid-fast bacillus and now what will be your management?
CANDIDATE
Well, I would like to know if she had any reactivation of infection in the last 70 years?
Well, I would like to know if she had any reactivation of infection in the last 70 years?
EXAMINER
No.
No.
CANDIDATE
In that case what is the expectation of the patient?
In that case what is the expectation of the patient?
EXAMINER
The patient does not want any surgical treatment. She wants to know if she can have an injection in to her shoulder which can prevent the pain at the extremes of movements.
The patient does not want any surgical treatment. She wants to know if she can have an injection in to her shoulder which can prevent the pain at the extremes of movements.
CANDIDATE
I will be cautious about the in tra-articular steroid injections as it can trigger the dormant bacillus and rekindle the infection.
I will be cautious about the in tra-articular steroid injections as it can trigger the dormant bacillus and rekindle the infection.
EXAMINER
OK, the patient comes back to you after 6 months and wants a shoulder joint replacement as her neighbour had one performed for arthritis a few weeks ago and is now pain-free and doing great with her shoulder. The patient wants the same operation. Will you offer her joint arthroplasty?
OK, the patient comes back to you after 6 months and wants a shoulder joint replacement as her neighbour had one performed for arthritis a few weeks ago and is now pain-free and doing great with her shoulder. The patient wants the same operation. Will you offer her joint arthroplasty?
CANDIDATE
Again, I would be cautious to do so. I will certainly investigate her in terms of infective and inflammatory markers. I understand the principles of management of this case with the potential risk of recurrence of deep infection. This case will potentially require a biopsy, discussion with a microbiologist as part of an MDT meeting andas taged procedure. If active infection was present a two-stage procedure should be performed. The first stage would involve humeral head resection and insertion of an an tibiotic-impr egnated cement spacer. Multiple tuberculosis drug therapy for several months. I would biopsy the shoulder again and if it was negative for infection I would proceed with the second stage. I would prefer to use a reverse shoulder replacement in this pa tientas there is likely to be extensive destruction of the rotator cuff. I would counsel the patient that the surgery was likely to be protracted and drawn out as active TB of the shoulder needs to be eradicated before undertaking the second stage. I would warn her of the risk of further reactivation and reoccurrence of infection in the future.
Again, I would be cautious to do so. I will certainly investigate her in terms of infective and inflammatory markers. I understand the principles of management of this case with the potential risk of recurrence of deep infection. This case will potentially require a biopsy, discussion with a microbiologist as part of an MDT meeting andas taged procedure. If active infection was present a two-stage procedure should be performed. The first stage would involve humeral head resection and insertion of an an tibiotic-impr egnated cement spacer. Multiple tuberculosis drug therapy for several months. I would biopsy the shoulder again and if it was negative for infection I would proceed with the second stage. I would prefer to use a reverse shoulder replacement in this pa tientas there is likely to be extensive destruction of the rotator cuff. I would counsel the patient that the surgery was likely to be protracted and drawn out as active TB of the shoulder needs to be eradicated before undertaking the second stage. I would warn her of the risk of further reactivation and reoccurrence of infection in the future.
EXAMINER
Would you offer her a one-stage procedure if active TB infection was present?
Would you offer her a one-stage procedure if active TB infection was present?
CANDIDATE
I am aware of a few case reports in which a primary single-stage cementless hemiarthroplasty has been performed for active TB with satisfactory results reported at 5 years, but I would prefer a more cautious approach and opt for a two-stage procedure [1].
I am aware of a few case reports in which a primary single-stage cementless hemiarthroplasty has been performed for active TB with satisfactory results reported at 5 years, but I would prefer a more cautious approach and opt for a two-stage procedure [1].
EXAMINER
The patient does not want to take this risk and wants to be left alone. Thankyou. Although the viva questions started in the same manner, this candidate with his/her knowledge took the viva to a good level of demonstration of his/her clinical judgement by asking specific questions and had control over the situation Certainly, this candidate deserves a good score.
The patient does not want to take this risk and wants to be left alone. Thankyou. Although the viva questions started in the same manner, this candidate with his/her knowledge took the viva to a good level of demonstration of his/her clinical judgement by asking specific questions and had control over the situation Certainly, this candidate deserves a good score.
source p. 432
Reference#
1. Lue namS, Kosiyatrakul A. Immediate cementless hemiarthroplasty for severe destructive glenohumeral tuberculous arthritis . Case RepOrt hoped. 2013;2013:426102.
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Structured oral examination question 2#
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Rotator cuff tear
EXAMINER
Good afternoon. Can you tell me what is going on in this radiograph of the right shoulder (Figure 7.2)? This patient had anterior dislocation 2 years ago and has ongoing problems.
Good afternoon. Can you tell me what is going on in this radiograph of the right shoulder (Figure 7.2)? This patient had anterior dislocation 2 years ago and has ongoing 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 an MR arthrogram.
Well, this shoulder is reduced congruently. I cannot see any interposition of bony fragments. And I would like to investigate this shoulder with an MR arthrogram.
EXAMINER
What do you want to rule out?
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.
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!
This gentleman is claustrophobic!
CANDIDATE
I would talk to the radiologist and anaesthetist to find out if it could be done under sedation.
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.
The anaesthetist is not happy! And your radiologist suggests an ultrasound examination of the shoulder.
CANDIDATE
Ultrasound examination is not the g old standard examination for labral pathology.
Ultrasound examination is not the g old standard examination for labral pathology.
EXAMINER
Well, the patient only had an ultrasound examination and it shows subscapularis tear!
Well, the patient only had an ultrasound examination and it shows 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 ...
There is then a high risk of having damaged the anterior labrum also ... I think I have to speak to the anaesthetist again ...
source p. 435
Figure 7.2 Anteroposterior (AP) radiograph of shoulder.
Another candidate follows this miserable viva of negotiations between anaesthetist and radiologist in the FRCS ortho exam (by the candidate’s own fault). The candidate fails to start with the fundamental questions of age, how and when it happened and current problems and patient expectations, etc. This makes the entire viva go in the wrong direction and leads to a failing scenario.
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 ongoing problems.
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 ongoing problems.
CANDIDATE
Thanks. May I know the age of the patient and the nature of the ongoing problem, please?
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 has got difficulties in overhead activities and we found out that he is claustrophobic!
This 76-year-old gentleman dislocated his shoulder 2 years ago. Now 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 als other e is a risk of infraclavicular plexus injury following the dislocation therefore, I would like to assess his cuff muscles clinically.
I suspect rotator cuff tear in this age group following dislocation and als other e is a risk of infraclavicular plexus injury following the dislocation therefore, I would like to assess his cuff muscles clinically.
source p. 436
EXAMINER
He has got weakness on internal rotation and r est of the cuff power is good. Neurologically he is intact.
He has got weakness on internal rotation and r est of the cuff power is good. Neurologically he is intact.
CANDIDATE
I suspect rotator cuff tear from this clinical assessment and I would investigate this shoulder with an ultrasound examination as he is claustrophobic. Ideally, I would have preferred an MRI scan to look for any fatiy a trophy changes in the cuff, which could be detrimental in considering any repair of the cuff tear.
I suspect rotator cuff tear from this clinical assessment and I would investigate this shoulder with an ultrasound examination as he is claustrophobic. Ideally, I would have preferred an MRI scan to look for any fatiy a trophy changes in the cuff, which could be detrimental in considering any repair of the cuff tear.
EXAMINER
The ultrasound examination shows full-thickness cuff tear of 4 mm with retraction.
The ultrasound examination shows full-thickness cuff tear of 4 mm with retraction.
CANDIDATE
I would like to know, what has been done so farAnd what are his expectations?
I would like to know, what has been done so farAnd what are his expectations?
EXAMINER
Nothing has been done so far. He wants to play golf, which he has not been able to do in the last 2 years.
Nothing has been done so far. He wants to play golf, which he has not been able to do in the last 2 years.
CANDIDATE
Well, I would assess his shoulder clinically to assess for any weakness, stiffness and deltoid muscle compensation before considering any intervention as its going on for 2 years and he is elderly. Although it could be a traumatic t ear secondary to dislocation, quite often it could be over a degenerative tear.
Well, I would assess his shoulder clinically to assess for any weakness, stiffness and deltoid muscle compensation before considering any intervention as its going on for 2 years and he is elderly. Although it could be a traumatic t ear secondary to dislocation, quite often it could be over a degenerative tear.
EXAMINER
Would you call this cuff arthropathy as it is going on for 2 years?
Would you call this 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.
No. The radiograph does not show any evidence of proximal migration of the humeral head.
EXAMINER
What will you do? How will you manage this patient?
What will you do? How will you manage this patient?
CANDIDATE
I will explain to the patient that options are both non-operativ e (Deltoid rehab, physiotherapy) or operative management (arthroscopic/mini-open cuff repair – both techniques have equally good results) with caution as evidence suggests/reports up to 30% re-rupture rates in people above 65 years of age. [Bell] This candidate knew the importance of age-related pathophysiology and succeeded well in the viva.
I will explain to the patient that options are both non-operativ e (Deltoid rehab, physiotherapy) or operative management (arthroscopic/mini-open cuff repair – both techniques have equally good results) with caution as evidence suggests/reports up to 30% re-rupture rates in people above 65 years of age. [Bell] This candidate knew the importance of age-related pathophysiology and succeeded well in the viva.
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Structured oral examination question 3
EXAMINER
This is a radiograph of the right shoulder of a lady who has got severe pain in her shoulder. Do you find anything interesting ( Figure 7.3a)?
This is a radiograph of the right shoulder of a lady who has got severe pain in her shoulder. Do you find anything interesting ( Figure 7.3a)?
CANDIDATE
Well ... No not really ... I cannot see any abnormality or disease process in this radiograph. I would like to see a lateral radiograph of her shoulder. I can’t see anything abnormal here either.
Well ... No not really ... I cannot see any abnormality or disease process in this radiograph. I would like to see a lateral radiograph of her shoulder. I can’t see anything abnormal here either.
EXAMINER
She is in your clinic referred by her GP. What would you like to do for her?
She is in your clinic referred by her GP. What would you like to do for her?
CANDIDATE
I want to get the history ... then examine the patient ... to decide on the management plan.
I want to get the history ... then examine the patient ... to decide on the management plan.
EXAMINER
Go ahead.
Go ahead.
CANDIDATE
In the history I will first find out her age, job and dominant side ... and how and when the problem started.
In the history I will first find out her age, job and dominant side ... and how and when the problem started.
EXAMINER
She is 45, right-hand dominant and does clerical work. The pain started 8 months ago when she was reaching out for the seatbelt in her car.
She is 45, right-hand dominant and does clerical work. The pain started 8 months ago when she was reaching out for the seatbelt in her car.
CANDIDATE
The age and history suggest probable frozen shoulder ... I will proceed with the examination.
The age and history suggest probable frozen shoulder ... I will proceed with the examination.
EXAMINER
She has got global restriction of her movements.
She has got global restriction of her movements.
CANDIDATE
That confirms frozen shoulder. So ...
That confirms frozen shoulder. So ...
EXAMINER
What do you want to do?
What do you want to do?
CANDIDATE
I would offer intra-articular steroid injection for her shoulder and also advise stretching exercises by physiotherapists.
I would offer intra-articular steroid injection for her shoulder and also advise stretching exercises by physiotherapists.
EXAMINER
She has already had three intra-articular steroid injections and regular physiotherapy from her GP practice.
She has already had three intra-articular steroid injections and regular physiotherapy from her GP practice.
CANDIDATE
Well in that case I would advise her to have manipulation under anaesthesia (MU Aor arthroscopic arthrolysis.
Well in that case I would advise her to have manipulation under anaesthesia (MU Aor arthroscopic arthrolysis.
EXAMINER
What will you specifically offer the patient?
What will you specifically offer the patient?
CANDIDATE
mmm ... MUA.
mmm ... MUA.
EXAMINER
The patient wants to know the risks associated with MUA.
The patient wants to know the risks associated with MUA.
CANDIDATE
Well apart from the anaesthetic risks, there is a risk of fracturing the humerus as it can be osteopenic from disuse ... also the risk of recurrence.
Well apart from the anaesthetic risks, there is a risk of fracturing the humerus as it can be osteopenic from disuse ... also the risk of recurrence.
EXAMINER
If the bone fractures, what will be the management?
If the bone fractures, what will be the management?
CANDIDATE
It is like any fracture. Can be treated in a castor operated.
It is like any fracture. Can be treated in a castor operated.
EXAMINER
The patient decides now to leave it alone.
The patient decides now to leave it alone.
source p. 438
CANDIDATE
I will then convince her to have an injection today and review her situation in 12 weeks.
I will then convince her to have an injection today and review her situation in 12 weeks.
Figure 7.3a AP radiograph of left shoulder .
Figure 7.3b Axillary view of left shoulder .
Do you think this candidate impressed the (patient or) the examiner with this simple shoulder scenario? Before we look at the next candidate, think how you would approach this differently!
EXAMINER
This is a radiograph of the right shoulder of a lady who has got severe pain in her shoulder. Do you find anything interesting?
This is a radiograph of the right shoulder of a lady who has got severe pain in her shoulder. Do you find anything interesting?
CANDIDATE
Yes, this radiograph is essentially normal. May I know the age of this patient and does she suffer from diabetes or thyroid-related problems? Was there any history of trauma?
Yes, this radiograph is essentially normal. May I know the age of this patient and does she suffer from diabetes or thyroid-related problems? Was there any history of trauma?
source p. 439
EXAMINER
Well, she is 45 and she has hypothyroidism. Is there anything else would you like to examine other than her shoulders?
Well, she is 45 and she has hypothyroidism. Is there anything else would you like to examine other than her shoulders?
CANDIDATE
Yes, I would like to look at her hand to see if she has any evidence of Dupuytren’s contracture as it has some association with frozen shoulder.
Yes, I would like to look at her hand to see if she has any evidence of Dupuytren’s contracture as it has some association with frozen shoulder.
EXAMINER
She is in your clinic referred by her GP. What would you like to do for her?
She is in your clinic referred by her GP. What would you like to do for her?
CANDIDATE
I want to know the history and examination findings.
I want to know the history and examination findings.
EXAMINER
She is right-hand dominant and does clerical work. The pain started 8 months ago when she was reaching out for the seatbelt in her car. She has global restriction of her movements.
She is right-hand dominant and does clerical work. The pain started 8 months ago when she was reaching out for the seatbelt in her car. She has global restriction of her movements.
CANDIDATE
Does this pain affect her sleep? What is the range of her external and internal rotation?
Does this pain affect her sleep? What is the range of her external and internal rotation?
EXAMINER
Yes, she struggles to sleep at night and her ER is only to neutral position and she cannot get her hand to her back to do up her clothes. What would you like to do for her?
Yes, she struggles to sleep at night and her ER is only to neutral position and she cannot get her hand to her back to do up her clothes. What would you like to do for her?
CANDIDATE
I want to know what has been done for her so farand what is her expectation.
I want to know what has been done for her so farand what is her expectation.
EXAMINER
She had three intra-articular injections and physiotherapy from her GP practice. Shew ants to be able to wash and dress herself independently.
She had three intra-articular injections and physiotherapy from her GP practice. Shew ants to be able to wash and dress herself independently.
CANDIDATE
Well, I would like to offer her either manipulation under anaesthesia or arthroscopic capsular release, explaining the advantages and disadvantages, benefits and risks of both procedures and the importance of immediate post intervention physiotherapy and make her understand the disease process of frozen shoulder so that the patient could have a realistic expectation of the treatment process.
Well, I would like to offer her either manipulation under anaesthesia or arthroscopic capsular release, explaining the advantages and disadvantages, benefits and risks of both procedures and the importance of immediate post intervention physiotherapy and make her understand the disease process of frozen shoulder so that the patient could have a realistic expectation of the treatment process.
EXAMINER
The patient understands your explanation very well and wants to have the keyhole surgery. What will you do in arthroscopic capsular release?
The patient understands your explanation very well and wants to have the keyhole surgery. What will you do in arthroscopic capsular release?
CANDIDATE
The anterior capsule release especially at the rotator interval, followed by middle gleno- humeral ligament release and the release of the coraco-humeral ligament. The inferior capsule will be stretched by manipulation ... this is my preference as the arthroscopic release of inferior capsule carries a small risk of damaging the axillary nerve.
The anterior capsule release especially at the rotator interval, followed by middle gleno- humeral ligament release and the release of the coraco-humeral ligament. The inferior capsule will be stretched by manipulation ... this is my preference as the arthroscopic release of inferior capsule carries a small risk of damaging the axillary nerve.
EXAMINER
What does the evidence say, which is better – MUA/capsular release?
What does the evidence say, which is better – MUA/capsular release?
CANDIDATE
The literature is divided between both treatment modalities. MU A is simple and capsular release is a bit more invasive. There is also hydro-dilatation which some centres perform. The ongoing UK FROST trial (RCT) comparing physio only vs MUA+physio vs MUA+capsular release should enable us to know which modality of treatment is better in the future.
The literature is divided between both treatment modalities. MU A is simple and capsular release is a bit more invasive. There is also hydro-dilatation which some centres perform. The ongoing UK FROST trial (RCT) comparing physio only vs MUA+physio vs MUA+capsular release should enable us to know which modality of treatment is better in the future.
EXAMINER
Thankyou. When the examiner sensed his ability a small extra challenge was given – do you want to examine anywhere else? And the candidate was able to demonstrate his/her knowledge – association with
Thankyou. When the examiner sensed his ability a small extra challenge was given – do you want to examine anywhere else? And the candidate was able to demonstrate his/her knowledge – association with
source p. 440
Dupuytren’s contracture – the candidate would have been given an extra point for these smart moves and also backed up with evidence of literature and ongoing trials.
source p. 441
Structured oral examination question 4
EXAMINER
This is a radiograph of a 63-year-old gentleman’s right shoulder (Figure 7.4a). Proceed.
This is a radiograph of a 63-year-old gentleman’s right shoulder (Figure 7.4a). Proceed.
CANDIDATE
This plain AP radiograph shows normal glenohumeral joint and acromioclavicular joint, well- maintained subacromial space but the under surface of the acromion is sclerotic suggesting the possibility of him suffering from subacromial impingement. Can I see an axillary view, please?
This plain AP radiograph shows normal glenohumeral joint and acromioclavicular joint, well- maintained subacromial space but the under surface of the acromion is sclerotic suggesting the possibility of him suffering from subacromial impingement. Can I see an axillary view, please?
EXAMINER
Yes (Figure 7.4b).
Yes (Figure 7.4b).
CANDIDATE
There are deposits of calcium in the supraspinatus tendon ... It is important to ask for multipleX -ray views of the shoulder to confirm the diagnosis of calcific tendonitis. The calcification may be missed with one view of the shoulder, particularly with subscapularis involvement, soAP radiographs in internal and external rotation aswell as scapularY and/or axillary views of the shoulder are recommended.
There are deposits of calcium in the supraspinatus tendon ... It is important to ask for multipleX -ray views of the shoulder to confirm the diagnosis of calcific tendonitis. The calcification may be missed with one view of the shoulder, particularly with subscapularis involvement, soAP radiographs in internal and external rotation aswell as scapularY and/or axillary views of the shoulder are recommended.
EXAMINER
What is your opinion about his pain in the shoulder?
What is your opinion about his pain in the shoulder?
CANDIDATE
Well, he could be struggling with calcific tendonitis.
Well, he could be struggling with calcific tendonitis.
EXAMINER
What do you want to do?
What do you want to do?
CANDIDATE
I would like to know the patient symptoms, examination findings, the treatments he has had so farand his expectations.
I would like to know the patient symptoms, examination findings, the treatments he has had so farand his expectations.
EXAMINER
He is a keen golfer and gradually over the last 2 years he has developed the pain on overhead activities. He has not had an y interventions sofar. He wants to continue playing golf without pain. He has got positive impingement signs.
He is a keen golfer and gradually over the last 2 years he has developed the pain on overhead activities. He has not had an y interventions sofar. He wants to continue playing golf without pain. He has got positive impingement signs.
CANDIDATE
Well, I would inject his subacromial space with steroid today to relieve the bursitis secondary to the calcific tendonitis, which is causing impingement symptoms, and review him in 8 weeks in clinic with repeat X-rays to assess the calcium deposits.
Well, I would inject his subacromial space with steroid today to relieve the bursitis secondary to the calcific tendonitis, which is causing impingement symptoms, and review him in 8 weeks in clinic with repeat X-rays to assess the calcium deposits.
EXAMINER
Incidentally there is also another X-ray of his right shoulder which was performed 2 years ago when he started to have the pain, which shows the same calcium deposits. Does it change your plan?
Incidentally there is also another X-ray of his right shoulder which was performed 2 years ago when he started to have the pain, which shows the same calcium deposits. Does it change your plan?
CANDIDATE
... Well, I would then book him now for arthroscopic excision of the calcium deposits.
... Well, I would then book him now for arthroscopic excision of the calcium deposits.
EXAMINER
Will you perform any other procedures during the surgery?
Will you perform any other procedures during the surgery?
CANDIDATE
I will consent him for arthroscopy and proceed ... so that I can assess the shoulder and perform the necessary at the time of the surgery.
I will consent him for arthroscopy and proceed ... so that I can assess the shoulder and perform the necessary at the time of the surgery.
source p. 442
Figure 7.4a Anteroposterior (AP) view of right shoulder.
Figure 7.4b Axillary view of right shoulder.
Did he not start well? Did this candidate proceed well – with diagnosis and management plan? Did he pickup the clues from the examiner and correct himself? What will be your scoring for this candidate?
Will you diagnose and manage this problem differently like the next candidate?
EXAMINER
This is a radiograph of a 63-year-old gentleman’s right shoulder. Proceed.
This is a radiograph of a 63-year-old gentleman’s right shoulder. Proceed.
CANDIDATE
This plain AP radiograph shows normal glenohumeral joint and acromioclavicular joint, well- maintained subacromial space but the under surface of the acromion is sclerotic suggesting the possibility of him suffering from subacromial impingement. Can I see an axillary view, please?
This plain AP radiograph shows normal glenohumeral joint and acromioclavicular joint, well- maintained subacromial space but the under surface of the acromion is sclerotic suggesting the possibility of him suffering from subacromial impingement. Can I see an axillary view, please?
EXAMINER
Yes.
Yes.
CANDIDATE
There are deposits of calcium in the supraspinatus tendon ...
There are deposits of calcium in the supraspinatus tendon ...
EXAMINER
What is your opinion about his pain in the shoulder?
What is your opinion about his pain in the shoulder?
CANDIDATE
Looking at the radiographs, and the duration of his problem ... (EXAMINER: 2 years) and his age I feel he has got degenerative calcification in his cuff and subacromial impingement.
Looking at the radiographs, and the duration of his problem ... (EXAMINER: 2 years) and his age I feel he has got degenerative calcification in his cuff and subacromial impingement.
EXAMINER
What do you want to do?
What do you want to do?
CANDIDATE
I would like to know the patient symptoms, examination findings, the treatments he has had so farand his expectations.
I would like to know the patient symptoms, examination findings, the treatments he has had so farand his expectations.
EXAMINER
He is a keen golfer and gradually over the last 2 years he has developed the pain on overhead activities. He has not had an y interventions sofar. He wants to continue playing golf without pain. He has got positive impingement signs.
He is a keen golfer and gradually over the last 2 years he has developed the pain on overhead activities. He has not had an y interventions sofar. He wants to continue playing golf without pain. He has got positive impingement signs.
CANDIDATE
I want to know if he has had any X-rays in the past and would like to assess the status of his cuff with an ultrasound scan/MRI scan.
I want to know if he has had any X-rays in the past and would like to assess the status of his cuff with an ultrasound scan/MRI scan.
EXAMINER
This is the X-ray taken 2 years ago – showing the same calcification. There cent ultrasound scan shows intact cuff.
This is the X-ray taken 2 years ago – showing the same calcification. There cent ultrasound scan shows intact cuff.
CANDIDATE
Well, I would inject the subacromial bursa today with steroid and review the patient in 8 weeks to see if the injection has helped his pain as a diagnostic t est for impingement.
Well, I would inject the subacromial bursa today with steroid and review the patient in 8 weeks to see if the injection has helped his pain as a diagnostic t est for impingement.
EXAMINER
Suppose his old X-rays do not show any deposits and if it’s recent then will you do the same?
Suppose his old X-rays do not show any deposits and if it’s recent then will you do the same?
CANDIDATE
In which case, this could be recent onset and I would consider sending the patient for ultrasound-guided injection and barbot age if possible as the current evidence shows it’s a good option as non-oper at ive first-line management.
In which case, this could be recent onset and I would consider sending the patient for ultrasound-guided injection and barbot age if possible as the current evidence shows it’s a good option as non-oper at ive first-line management.
EXAMINER
OK, He comes back in 8 weeks saying the pain was well controlled for 3 weeks and now the pain is back. What will you do?
OK, He comes back in 8 weeks saying the pain was well controlled for 3 weeks and now the pain is back. What will you do?
CANDIDATE
This proves the pathology of subacromial impingement and I am going to talk to the patient about subacromial decompression.
This proves the pathology of subacromial impingement and I am going to talk to the patient about subacromial decompression.
EXAMINER
Will you perform excision of the calcium deposits?
Will you perform excision of the calcium deposits?
CANDIDATE
No, not necessarily. This degenerative calcification is a chronic one. It is not acute calcific tendonitis. I will perform subacromial decompression and assess his cuff for obvious calcific deposits; if so, I shall clear them during the procedure as longas I don’t need to make a big rent/tear in the cuff/tendon which can lead to further weakness and unnecessary repair.
No, not necessarily. This degenerative calcification is a chronic one. It is not acute calcific tendonitis. I will perform subacromial decompression and assess his cuff for obvious calcific deposits; if so, I shall clear them during the procedure as longas I don’t need to make a big rent/tear in the cuff/tendon which can lead to further weakness and unnecessary repair.
EXAMINER
Thankyou.
Thankyou.
source p. 444
This second candidate was much clearer about the pathology and management plan, which will be rewarded by a better score. He did not have to be prompted by the examiners regarding the calcium deposit which was there 2 years ago, suggesting the degenerative calcification. The previous candidate failed to understand these prompting clues.
source p. 445
Structured oral examination question 5#
EXAMINER
Good afternoon. Can you tell me the findings from this radiograph of the left shoulder of a 76-year-old left-handed fit gentleman (Figure 7.5a)?
Good afternoon. Can you tell me the findings from this radiograph of the left shoulder of a 76-year-old left-handed fit gentleman (Figure 7.5a)?
CANDIDATE
This anteroposterior view of the left shoulder shows no evidence of glenohumeral joint or acromioclavicular joint arthritis. The subacromial space is narrowed with sclerosis of the under surface of the acromion.
This anteroposterior view of the left shoulder shows no evidence of glenohumeral joint or acromioclavicular joint arthritis. The subacromial space is narrowed with sclerosis of the under surface of the acromion.
EXAMINER
Would you like any other investigations ... prior to commiting yourself with a diagnosis?
Would you like any other investigations ... prior to commiting yourself with a diagnosis?
CANDIDATE
I would like to have ultrasound of his shoulder ... and may I know his symptoms, please?
I would like to have ultrasound of his shoulder ... and may I know his symptoms, please?
EXAMINER
The ultrasound which was requested by his GP shows torn subscapularis and supraspinatus with massive retraction of the tendons. He has difficulties with overhead activities. Can you tell me what is wrong with this shoulder?
The ultrasound which was requested by his GP shows torn subscapularis and supraspinatus with massive retraction of the tendons. He has difficulties with overhead activities. Can you tell me what is wrong with this shoulder?
CANDIDATE
From the X-ray ... which shows evidence of impingement by narrowing of the subacromial space, from the ultrasound scan ... which shows evidence of torn subscapularis and supraspinatus tendons and clinically he has got difficulties in overhead activities ...
From the X-ray ... which shows evidence of impingement by narrowing of the subacromial space, from the ultrasound scan ... which shows evidence of torn subscapularis and supraspinatus tendons and clinically he has got difficulties in overhead activities ...
EXAMINER
Yes, it is a nice summary of the situation wasting time]
Yes, it is a nice summary of the situation wasting time]
CANDIDATE
I think he has severe subacromial impingement and secondary cuff tear.
I think he has severe subacromial impingement and secondary cuff tear.
EXAMINER
What would you do for this gentleman?
What would you do for this gentleman?
CANDIDATE
Well, first I would perform a steroid injection in to his subacromial space.
Well, first I would perform a steroid injection in to his subacromial space.
EXAMINER
Can you tell me the landmarks and how you will perform the injection?
Can you tell me the landmarks and how you will perform the injection?
CANDIDATE
Yes, 2 cm inferior and medial to the posterolateral corner of the acromion, I will direct the needle towards the anterolateral corner of the acromion to be specific into the bursa.
Yes, 2 cm inferior and medial to the posterolateral corner of the acromion, I will direct the needle towards the anterolateral corner of the acromion to be specific into the bursa.
EXAMINER
Is it necessary to be specific in this patient ... he has got a massive cuff tear?
Is it necessary to be specific in this patient ... he has got a massive cuff tear?
CANDIDATE
??
??
EXAMINER
Well he comes back to clinic in 8 weeks with no difference to his symptoms. Do you have any management plans?
Well he comes back to clinic in 8 weeks with no difference to his symptoms. Do you have any management plans?
CANDIDATE
I will then perform an arthroscopic debridement of the cuff and bursa and a subacromial decompression.
I will then perform an arthroscopic debridement of the cuff and bursa and a subacromial decompression.
EXAMINER
Thankyou.
Thankyou.
source p. 446
Figure 7.5a Anteroposterior (AP) radiograph of left shoulder .
Do you recognize the candidate’s mistakes? What would you do differently? Did he treat the patient or the investigations? Did he interpret the investigations appropriately? Now the last candidate of the day arrives for the same scenario.
EXAMINER
Good afternoon. Can you tell me the findings from this radiograph of the left shoulder of a 76-year-old left-handed fit gentleman?
Good afternoon. Can you tell me the findings from this radiograph of the left shoulder of a 76-year-old left-handed fit gentleman?
CANDIDATE
This anteroposterior view of left shoulder shows proximal migration of humeral head with narrowing of the subacromial space and there is no evidence of glenohumeral joint or acromioclavicular joint arthritis.
This anteroposterior view of left shoulder shows proximal migration of humeral head with narrowing of the subacromial space and there is no evidence of glenohumeral joint or acromioclavicular joint arthritis.
EXAMINER
Would you like any other investigations ... prior to commiting yourself with a diagnosis?
Would you like any other investigations ... prior to commiting yourself with a diagnosis?
CANDIDATE
I would like to have an axillary view of his shoulder.
I would like to have an axillary view of his shoulder.
EXAMINER
Yes, we have axillary view. What are you looking for?
Yes, we have axillary view. What are you looking for?
CANDIDATE
I am looking for anteroposterior subluxation of the humeral head in the axillary view ... yes, there is anterior subluxation suggesting torn anteriorly placed subscapularis and from the AP view, the proximal migration of the humeral head suggesting supraspinatus tear ... this gentleman has got established cuff tear arthropathy.
I am looking for anteroposterior subluxation of the humeral head in the axillary view ... yes, there is anterior subluxation suggesting torn anteriorly placed subscapularis and from the AP view, the proximal migration of the humeral head suggesting supraspinatus tear ... this gentleman has got established cuff tear arthropathy.
EXAMINER
What would you do for him?
What would you do for him?
source p. 447
CANDIDATE
I need to know the patient symptoms, what has been done for the patient so farand what are his expectations?
I need to know the patient symptoms, what has been done for the patient so farand what are his expectations?
EXAMINER
He has got difficulties in overhead activities. He has had three injections by his GP, which have made no difference, and being ana rtis the would like to have reasonable ability to abduct his shoulder to reach for the top of the canvas during painting.
He has got difficulties in overhead activities. He has had three injections by his GP, which have made no difference, and being ana rtis the would like to have reasonable ability to abduct his shoulder to reach for the top of the canvas during painting.
CANDIDATE
Could you please tell me if he has any pain associated with his shoulder abduction?
Could you please tell me if he has any pain associated with his shoulder abduction?
EXAMINER
No ... not at all.
No ... not at all.
CANDIDATE
I would start with non-operativ e management in terms of a deltoid muscle rehabilitation programme to compensate for the cuff deficiency. As he is not in pain and there is no established arthritis, this would be my initial management. If he fails with this treatment regime and is still struggling functionally , I would then offer a reverse-polarity shoulder replacement if he is otherwise healthy and fit for surgery. I will also get a CT scan of the shoulder joint to assess the glenoid bone stock and version as preoperative planning. I would inform the patient the procedure is performed purely for functional out come as he is not in pain and go through the benefits and risks and complications associated with such surgery.
I would start with non-operativ e management in terms of a deltoid muscle rehabilitation programme to compensate for the cuff deficiency. As he is not in pain and there is no established arthritis, this would be my initial management. If he fails with this treatment regime and is still struggling functionally , I would then offer a reverse-polarity shoulder replacement if he is otherwise healthy and fit for surgery. I will also get a CT scan of the shoulder joint to assess the glenoid bone stock and version as preoperative planning. I would inform the patient the procedure is performed purely for functional out come as he is not in pain and go through the benefits and risks and complications associated with such surgery.
EXAMINER
He is very fit. Why do you prefer reverse shoulder to a total shoulder replacement?
He is very fit. Why do you prefer reverse shoulder to a total shoulder replacement?
CANDIDATE
The reverse shoulder (Figure 7.5b), although non-anatomical, brings the centre of rotation of the glenohumeral joint medially and thereby increases the moment arm of the deltoid, allowing good abduction of the shoulder .
The reverse shoulder (Figure 7.5b), although non-anatomical, brings the centre of rotation of the glenohumeral joint medially and thereby increases the moment arm of the deltoid, allowing good abduction of the shoulder .
EXAMINER
Would you not try to repair the cuff prior to this major surgery?
Would you not try to repair the cuff prior to this major surgery?
CANDIDATE
No. The radiographs show established cuff arthropathy and in this situation it is not possible to reverse the pathology with cuff repair. Also, it would be a difficult cuff repair with a high chance of failure.
No. The radiographs show established cuff arthropathy and in this situation it is not possible to reverse the pathology with cuff repair. Also, it would be a difficult cuff repair with a high chance of failure.
EXAMINER
Can you name some complications of the reverse polarity replacement?
Can you name some complications of the reverse polarity replacement?
CANDIDATE
Short term: infection dislocation, haematoma formation (duet o dead space), nerve injury (axillary, musculocutaneous) and periprosthetic fracture. Long term: scapular notching, acromion fracture, aseptic loosening , deltoid fatigue and failure.
Short term: infection dislocation, haematoma formation (duet o dead space), nerve injury (axillary, musculocutaneous) and periprosthetic fracture. Long term: scapular notching, acromion fracture, aseptic loosening , deltoid fatigue and failure.
EXAMINER
Well, we will move on to the next scenario. Whom do you think played the game well in this scenario? Analyze the candidate’s ability to show their knowledge to the examiner. Learn how not to waste time and not to lower the expectations of the examiner. When the examiner’s expectations godown, the questions may become simpler and the score drops. Show the knowledge appropriately to please the examiner. Make the game interesting for the examiners and you will walkaway with a good score. Treat each scenario as a separate exam to reach a good overall score. Remember: the examiners do not know your previous performance, either good or bad. Therefore, forget the previous performance and move on.
Well, we will move on to the next scenario. Whom do you think played the game well in this scenario? Analyze the candidate’s ability to show their knowledge to the examiner. Learn how not to waste time and not to lower the expectations of the examiner. When the examiner’s expectations godown, the questions may become simpler and the score drops. Show the knowledge appropriately to please the examiner. Make the game interesting for the examiners and you will walkaway with a good score. Treat each scenario as a separate exam to reach a good overall score. Remember: the examiners do not know your previous performance, either good or bad. Therefore, forget the previous performance and move on.
Figure 7.5b Reverse shoulder replacement.