DISLOCATION OF THE KNEE JOINT

SCENARIO

A-20-year male arrived at the emergency with pain and swelling of the left knee joint caused by struck the tree during riding of motorcycle one hour ago (fig. 9). He is conscious and without others region injury.

Fig. 9. Right knee in closed traction

How the candidate solves the scenario problem

This scenario is only a knee injury problem with pain and swelling caused by motorcycle accident. The possibilities may be extra or intra articular fractures, knee joint dislocation or/and soft tissues around the left knee injuries and these conditions should be discussed in greater depth between Examiner and Candidate

Learning Objectives Evaluation in Examination

The Examiners should be able to evaluate:

·         The Candidate ability to detect the viability disturbance of the distal part and then manage as soon as possible and collect the information or data for accurate diagnosis determination

·         Ability to predict acute and long-term problem of the abnormalities

·         Ability to plan the management and outcome

·         Ability to predict the complications of the abnormalities.

·         Ability to show a good attitude and professionalism in health care of the abnormalities

Part A:  The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination

Learning Objectives Evaluation in Examination

a.       The Candidate ability to detect the viability disturbance of the distal part and then manage as soon as possible and collect the information or data for accurate diagnosis determination

The first the Examiner question: What are the possibilities according to the scenario?

According to the scenario or patient complaint, the Candidate should be able to consider a conclusion that much information or data must be collected completely (table 34)

Table 34: List information of the scenario

Medical sciences	Information
Epidemiology	Male and young patient
Clinical features:	·         History taking: Pain, swelling and motorcycle  accident (incomplete information) ·         Physical examination: Swelling (incomplete information) ·         Investigation: No information ·         Diagnosis: should be discussed ·         Acute and long-term problem should be discussed
Anatomy and pathophysiology	The Examiners should be able to discuss
Management (emergency and definitive) and outcome	The Examiners should be able to discuss
complications	The Examiners should be able to discuss

The Examiners is able to evaluate the Candidate ability by asking some questions to collect the history taking and characteristics of the physical examination and investigations data based on probabilities of abnormality of the patient. The Examiners are able to discuss the incomplete or no information and others on table 22 above.

Anatomy of the Knee

The Candidate should able to explain anatomy structure of the knee. Stabilization of the knee depends on bones (femur condyles, proximal of tibia and patella) and soft tissues around the knee joint that includes capsule, ligaments (ACL, PCL, MCL and LCL) and muscles.  The Candidate should focus on the urgency of popliteal artery injury in knee dislocation. According to anatomy of popliteal artery gives off five genicular arteries such as: paired superior and paired inferior arteries and the middle genicular artery in popliteal fossa. The genicular arteries are also the collateral circulations supplying to the knee such as the lateral femoral circumflex and anterior tibial arteries. These arteries could be damaged by injury in 10% - 40% of knee dislocation and these genicular arteries cannot compensate for a rupture popliteal artery. The patella is stabilized by lateral and medial retinaculum of the patella and ligamentum prepatellar.

The Examiners also should be able to discuss the tibial nerve joins the popliteal artery in popliteal fossa of the knee and the peroneal nerve passes around the proximal fibula just distal to the fibular head related to injury.

·         Vascular Assessment

Vascular examination is an emergency evaluation for limb threatening. The location of popliteal artery has a potential damage cause of traction or direct trauma in knee dislocation. The presence of pulses does not rule out an artery injury especially if there is an intimal injury or collateral rupture. The overall incidence of popliteal artery injury is one in three (33%). Measurement of ankle-brachial index (ABI) with a Doppler ultrasound by measuring the systolic pressure in the affected leg dividing the systolic pressure in ipsilateral arm should be evaluated in physical examination. If ABI value of > 0.9 showed to be reliable marker of normal artery patency but ABI measurement may be less reliable in patients with peripheral vascular disease such as diabetes and hypertension or elderly patient. ABI of < 0.9 or 0.8 should be further evaluation with arteriography.

·         History Taking

Suspected patient’s dislocation typically severe pain and instability and is also unable to continue activity daily living. Generally patient often hears a “pop” at the time of injury in history taking. The Candidate has an ability to collect the information about the energy of injury mechanism. High energy velocity caused by an extremely violent force such as motorcycle or car accident may contribute knee dislocation and damage to structures of the knee complex that including disruption of the capsule, ligaments, neurovascular, menisci and bones of the knee joint. But low energy trauma e.g. sport injury may also knee dislocation that can contribute neurovascular and soft tissues damage. According to motorcycle accident history in the scenario can lead to posterior dislocation caused by direct force on the tibia while the knee in flexion position.  

·         Physical examination

The Candidate has an ability to seek the physical examination abnormalities of the patient. The knee dislocation problem is a spontaneously reduces before admission to emergency unit that it can be easy to underestimate the vital neurovascular trauma. Because of that, the Candidate should be considered the viability of the distal of the lower limb. Patient’s shoes should be removed as soon as possible and the assessment of neurovascular such as posterior and anterior tibial pulse, capillary refill test, skin color and temperature, dermatomes and myotomes compare the normal site. Open injuries happened with incidence of between 19% - 35% and have greater surgical urgency and overall higher complications rate. The dimple sign usually overlying the medial femoral condyle represents buttonholing of the medial femoral condyle through the anteromedial joint capsule following a posterolateral rotatory injury mechanism. Unreduced knee dislocation patient will obvious visible palpable deformity. Pain on palpated or tenderness is diffuse and ROMs of the knee joint are limited.

·         Special tests

The Candidate should be able to demonstrate special test of the knee (table 35)

Table 35. Special tests of the knee joint

Examination	Method	Significance
McMurray	Ext/inter rotat. and varus/valgus stress-extension	Meniscal injury or chondro-malacia of the articular surface
Varus/valgus stress	30 degrees	MCL/LCL laxity (grade I-IV)
Varus/valgus stress	0 degrees	MCL/LCL and PCL/posterior capsul laxity
Apley’s	Prone-flexion compression	DJD, meniscal pathology
Lachman	Tibia forward at 30 degrees of flexion	ACL (more sensitive)
Stabilized Lachman	Examiner’s thigh under the patient’s knee	ACL (use the posterior Lachman test to gauge the PCL)
Finacetto	Same as Lachman test, with the tibiasubluxing beyond the posterior horn of the menisci	ACL (severe)
Anterior drawer	Tibia forward at 90 degrees of flexion	ACL
Internal rotation drawer	Foot internally rotated with drawer	Tighter, normal, looser, ALRI
External rotation drawer	Foot externally rotated with drawer	Loosee, normal, looser, AMRI
Pivot shift	Flexion with internal rotation and valgus	ALRI
Flexion-rotation drawer	Shift with axial load	ALRI
Slocum	Supine-side flexion and pivot	ALRI
Pivot jerk	Extension with internal rotation and valgus	ALRI
Posterior drawer	Tibia backward at 90 degrees of flexio	PCL
Tibial sag	Flexion at 90 degrees, observation	OCL
90-degree quadriceps active	Extension of flex knee	PCL
External rotation recurvatum	Picking up of great toes	PLRI
Reverse pivot shift	Extension with external rotation and valgus	PLRI
External rotation at 30 and 90 degrees	Increased external rotation associated with PLRI	PLRI
Posterolateral drawer	Posterior drawer, lateral > medial	PLRI

Modified from Brinker MR (2001). Review of Orthopaedic Trauma, WB Saunder Comp, Philadelphia: MCL: medial collateral lig.; LCL: lateral collateral lig.; PCL: posterior cruciatum lig.; DJD: degenerative joint disease; ACL: anterior cruciatum lig.; ALRI: anterolateral rotatory instability; AMRI: anteromedial rotatory instability; PLRI: posterolateral rotatory instability.

Lachman and pivot-shifter tests for assessing ACL where the posterior drawer and posterior sag tests should be carried out to PCL integrity (sensitivity is 100%). Varus and valgus stress tests should be performed to evaluate LCL and MCL rupture respectively.

·         Investigation

The Candidate should be able to tell the reason and description of the x-rays investigation. Radiographs will exclude the possibilities fractures around the knee joint. Antero-posterior (AP) and lateral views of the knee the proximal tibia is antero-medial of the distal femur, thickening of the soft tissues and no fracture lines. The lateral condyle of the right femur is in postero-lateral, condyles of the right tibia is in postero-medial and patella is in antero-medial (dislocation of the right patella and antero medial dislocation of the right knee joint (fig.10). The role CT angiography is popular its utility especially in suspected vascular injury cases. MRI is a valuable clinical tool in evaluating dislocatable knee because it can demonstrate the soft tissue injury in complex knee disruption and it was 85% - 100% correct except negative result for the lateral collateral ligament (LCL) and posterolateral capsule. MRI will allow the Candidate explain the preoperative evaluation and planning in knee surgery intervention. The accuracy MRI for detecting the extent or site of soft tissue pathology in knee dislocation is 85% - 100% and physical examination is only 53% - 82%. Radiography whether performed preoperatively or intraoperatively, remains source of controversy.

Fig. 10. AP and lateral views of the right knee

The proximal tibia is antero-medial of the distal femur

The Candidate should be able to perform the laboratory data for excluding infection or inflammation and others of the illness.

The Candidate should be able to determine the illness probabilities of the patient based on pain and swollen complaining such as: (1) trauma for instances fracture or dislocation of the right knee or (2) non - trauma such as: infection, inflammation, degenerative joint or malignancy of the right knee.

The Examiners are able to evaluate the Candidate ability to complete the key data for analyzing.  The Candidate is able to explain the discussion questions of the Examiner. It depends on his/her experienced of the Examiner for getting the objective, valid and reliable marks.

Ability to decide diagnosis

Summary: The patient’s complaining is severe pain, instability and is also unable to continue activity daily living of the right knee caused by an extremely violent force or high energy velocity of the motorcycle accident. Physical examination assessment of the neurovascular such as posterior and anterior tibial arteries pulse, capillary refill test, skin color and temperature, dermatomes and myotomes are still normal limit compare the other site. Palpation pain or tenderness is diffuse on the right knee and ROMs are limited actively and passively. Lachman and pivot-shift tests are positives where the posterior drawer and posterior sag tests are normal. Valgus stress tests is distracted compare other site. Antero-posterior and lateral views of the right knee radiographs the proximal tibia and patella are antero-medial of the distal femur, thickness of the soft tissues and no fracture lines. Based on information and data interpretation, integration and analysis the Candidate is able to conclude the antero-medial right knee dislocations diagnosis.

Term dislocation and fracture-dislocation can be confusion. The term of fracture-dislocation can be considered part of a continuum from tibial plateau fracture but its ligaments are not torn. The fracture-dislocation can also describe the tibial condyle fracture associated with ligament injury; but only pure ligaments injuries or includes avulsion of ligaments without fracture we call “knee dislocation”. Knee dislocation frequently reduces spontaneously after initial injury.

Acute knee dislocation is an uncommon or less than 0.02% of musculoskeletal injury with a high rate of associated trauma and potentially limb-threatening because an underestimate. A basic medical and clinical knowledge will allow accurate management with reducing of knee dislocation complications risk. There is no classification system to demonstrate the prognosis of knee dislocation. The anatomic classification system by Schenck and modified by Wascher et al is widely accepted (table 36).

Table 36. Schenk and Wascher et al classification system

Anatomic Classification of knee dislocation
KD I	Single cruciate + collateral torn	ACL + collateral intact
		PCL + collateral intact
KD II	ACL & PCL torn	Collateral intact
KD III Med	ACL & PCL & MCL torn	LCL + PLC intact
KD III Lat	ACL & PCL & LCL + PLC torn	MCL intact
KD IV	ACL/PCL/MCL/LCL + PLC torn
KD V	Fracture dislocation

The Examiners are able to assess the Candidate’s knowledge of basic medical and clinical sciences and skill of the knee dislocation in discussion such as:

(1) Dislocation anterior, posterior, medial or lateral and rotation of the right knee.

(2) Anterior and posterior tibial translation may injure ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament).

(3) Excessive valgus forces may disrupt MCL (medial collateral ligament) and excessive varus forces could rupture LCL (lateral collateral ligament) and medial or lateral meniscus may be injured by axial loading forces respectively.

The amount of ligamentous damage should be discussed. It could be both cruciate and one collateral ligament ruptures in knee dislocation but some patients who have one cruciate intact. The Examiners are also able to evaluate the Candidate knowledge of the anatomy and clinical sciences of the neurovascular injuries of the knee

Part B: The objectives examination evaluation of the patient’s problem, management and complications 

Learning Objectives Evaluation in Examination

a.     Ability to predict acute and long-term problem of the illness

The Candidate has an ability to explain that knee dislocation is the most common caused by high energy trauma on the knee joint and an orthopaedic emergency management. Knee dislocation may damage soft tissues of the stabilization of the joint such as ACL, PCL, MCL, LCL, neurovascular and meniscus. Palpation of the foot is warm and the pulse of the dorsal and pedal circulatory are still palpable. The lack of swelling and effusion in knee dislocation is relatively insignificant because of capsular damage and synovial fluid extravasation and lead to undetected the circulatory damage despite popliteal artery damage. The popliteal artery injured in approximately 20 – 40 % to all knee dislocation especially anteriorly or posteriorly. Thirty three percent of the peroneal nerve can be injured cause of its location passes around the fibular neck especially anterior, posterolateral and medial dislocation. In acute problem of knee dislocation is unstable of the joint and neurovascular disturbances. Long-term problem are necrotic of the distal of the knee or unable activity daily living and knee dislocation patient become dependent. Morbidity obese patients may have a higher incidence of knee dislocation caused by physiological stress on the knee compared with non-obese patients

b.    Ability to plan the management and outcome

“The knee dislocation is an emergency to reduce as soon as possible”

(Red Flags).

The Candidate is able to predict the outcome or prognosis after intervention or without treatment and complications of the knee dislocation in the discussion with the Examiners. The Candidate is able to explain the discussion questions of the Examiner. It depends on his/her experiences of the Examiner for getting the objective and transparent, valid and reliable marks.

The result of management depends on the age of patient, ability to participate in a rehabilitation program and desired future functional activities.

The topic discussion between the Examiners and the Candidate could be the goals of initial management of knee dislocation such as:

·         Recognizing and treat limb-threatening injuries and

·         Subsequently maximize long-term joint function particularly related to motion

·         Stability and strength.

·         Goal of definitive treatment includes

o   The anatomic repair or reconstruction of the knee ligaments and menisci to facilitate a stable joint,

o   Pain free, and

o   Functional knee with the avoidance of complications.

1)      Conservative Closed Reduction

The Candidate ability to explain the initial therapy of immobilization for either a spontaneously reduced or an unreduced dislocation by splinting in extension or more comfortable position and immediate transport to the nearest emergency unit of the hospital. In the emergency unit, the Candidate should be

able to reduce in closed intervention and reassess the vascular status immediately with algorithm for management in knee dislocation (illustration 5).

 

Illustration 5 Algoritm of knee dislocation management

Modified from Brinker MR (2001). Review of Orthopaedic Trauma, WB Saunder Comp, Philadelphia

Closed management of knee dislocation is a satisfactory result when immobilization of the joint for 4-6 weeks compared open reduction in non-randomized clinical study. Reconstruction surgery by arthroscopy is the best choice recently. But prolong knee immobilization must be evaluated about osteopenia, muscle atrophy, arthrofibrosis and complications.

2)      Surgery Management

The rational of the knee dislocation surgery is primary derived from retrospective studies comparing conservative and surgical procedure. Most of orthopaedics and traumatologic surgeons prefer to delay surgery procedure for ≥ 10 – 15 days for decreasing swelling, improving quadriceps muscle function and the damage of the capsule healing. The result of less 3 weeks delay surgery is a better clinical stability and increased functional outcome when compared with delayed surgery is more 3 weeks. Capsular healing allows an arthroscopic technique to be used for cruciate reconstruction with a decreased risk of iatrogenic compartment syndrome. ACL and PCL reconstruction ideally by arthroscopic but MCL and LCL should be repaired in open surgery. The conservative of immobilization management during 3 – 10 weeks is only for a stable post-reduction. According to EBM is no longer than 6 weeks due to stiffness and dysfunction complication of the knee.

Absolute indications for surgery would include:

(1) Irreducible dislocation in closed reduction management,

(2) Dysvascular limbs, and

(3) Open injuries.

Associated fractures and/or avulsion-type trauma is better with early repair within 2 – 3 weeks. The joint spanning external fixator set application is an open dislocation, history of vascular repair and impossible to maintain after splinting of the joint reduction adequately. The advantage of this procedure is the ability to evaluate the skin, compartments syndrome and vascular status of the affected site with serial assessment.

The Candidate should be able to decide the surgical timing caused its affected by some factors include vascular status, open or closed injury, reduction stability, skin conditions, multiple system injuries, other orthopaedic injuries and meniscus and articular surface trauma. Therefore, Levy et al (2009) recommend the treatment of multiligament injured should be assessed:

(1) Evaluation of the vascular condition can be assessed by physical examination and ABI measurement with the selective use of arteriography,

(2) The acute surgery planning for all ligament structures damage should be done,

(3) Pre-operative and post-operative joint-spanning external fixator can be used selectively

(4) Reconstruction ACL and PCL structures should be planned by arthroscopic,

(5) But MCL and LCL repairing should be done by open reconstruction surgery,

(6) Primary open reconstruction of the MCL or PMC (postero-medial corner) structure should be done, either stage or with concomitant ACL/PCL repairing, and

(7) Can be used allograft or autograft tissue for all ligamentous reconstructions.

The common allograft selections are able from Achilles and tibial anterior tendon. Allograft is able to use in reconstruction surgical procedure because graft site morbidity is eliminated and the number of incision, tourniquet time, and postoperative pain and stiffness are decreased. Surgical reconstruction intervention has been proved to be more beneficial for young and active or athletic patient. The surgical procedure depends on which the rupture of ligaments and the severity of the ligaments damage. Grade III ligamentous trauma should be repaired or reconstructed in open technique.

3)      Rehabilitation

The Examiners may discuss the rehabilitation aim of knee dislocation. The Candidate should be able to explain the restoring of the level activity but conservative treatment distributes the limitation of the starting exercises immediately. Rehabilitation includes straight-leg raises, electric muscle stimulation, and short arcs motion. Ice and leg elevation should be done but vigorous quadriceps or hamstring strengthening exercises must be avoided to prevent further injury exacerbation.

Discussion of postsurgical rehabilitation is also important in examination. Postsurgical rehabilitation depends on the ligament injured and repaired. Full extension is primary goal during the first week of postoperative. Long-leg brace using for limitation of extension is usually in 40⁰ position and 70⁰ of flexion in applying of the continuous passive-motion machine to prevent an undesirable strain on the repaired ligaments. Straight-leg raises are also begun at this time but the brace should be blocked in full extension. If the patient has adequate control of leg, ambulation with crutch is allowed during the first 6 weeks. Strengthening exercises include hamstring sets and short-arc quadriceps exercises should be used unlocking brace.

The Candidate should be able to explain the unlocking brace using in full ROM activities and progressive weight bearing with crutches at 7 – 10 weeks and also to continue the quadriceps strengthening exercises with manual resistive exercises. Strength training more progressive with advance exercises will continue during 25 – 36 weeks and then proprioceptive exercises or balance exercises should be implemented. Running activities can be started around 6 months postoperatively but downhill running should be avoided. The final stage of rehabilitation consists of significant amount of sport-specific exercises

c.     Ability to predict the complications

The Examiners and the Candidate will discuss about the very serious complications in knee dislocation. The prognosis of knee dislocation depends on the velocity of trauma and neurovascular injury, treatment method, and patient’s demand of wishing to return to full activity or the rehabilitation desirably. The Candidate estimates the associated bones and soft tissues damage in high velocity knee dislocation but low energy knee dislocation has a relatively good prognosis because 77% knee dislocation due to low-velocity returned to some type of sport and 19% returned to their previous level of the competition.

·         Stiffness

The candidate should be able to focus on stiffness of the knee joint after more than 6 weeks immobilization when less than 4 weeks of immobilization may produce with good ROM knee joint but unacceptable laxity or late instability. Because of that, the benefit of early ROM of the knee joint and delayed cruciate repair intervention is the prevention of knee stiffness. Arthrofibrosis after surgery or conservative procedures is the most common complication that requires manipulation or arthroscopic adhesions lysis.

·         Vascular trauma

The candidate should also be able to focus on the serious complication of vascular trauma result from the high velocity trauma. The popliteal artery has a potential to injury. It is estimated in 10% - 40% of knee dislocation and especially the most common are anterior or posterior mechanism because of fibrous tethering both proximal at adductor hiatus muscle and distally at the soleus arch muscle. Vasospasm never is used as an explanation for dysvascularity but many vascular injuries are non-flow-limiting intimal tear that rarely progress to this lesion. Arterial damage is repaired in timely (during 6-8 hours after trauma), the prognosis is good.  Vascular injury is left untreated for more than 8 hours may contribute 86% the amputation compared with 11% chance if treated within 8 hours.

·       Nerve injury

The Candidate should able to explain the incidence nerve injury associated knee dislocation is 10% - 35%. Peroneal nerve injury is poor prognosis because the full activity is never recovery. Therefore, a comprehensive rehabilitation program must accommodate the emergent implementation in knee dislocation patient.

·         Compartment syndrome

The Candidate should able to understand acute compartment syndrome complication with painful passive muscle stretch, swelling or hyperesthesia as possible signs is often happened. If pressures are above 35 mm Hg; fasciotomy is indicated. Fasciotomy intervention changes if systemic pressure is low or if revascularization is performed. Therefore, the primary care should be able to monitor carefully. Post treatment complications may involve persistent instability and loss of knee join motion.

·         Early degeneration process

The Candidate should able to explain the early degeneration process of the knee joint dislocation cause of severe chondral contusion associated with the injury. Osteoarthritis of knee dislocation usually occurs in a population younger than 40 years of age, a group is not indicated for knee replacement.

·         Prognosis

Overall most publications conclude the majority knee dislocation patient can expect a return to their activities of daily living with varying degrees of functional loss based on variable of the severity of injury, success of repairing and presence of associated neurovascular complications and open injury.

Part C:  The objectives examination evaluation of a good Candidate’s attitude and professionalism.  

Learning Objectives Evaluation in Examination

1.      The Candidate ability to show a good attitude in the illness health care services in dislocation of the knee joint discussion. What is Candidate plan the beneficence management orientation and avoid malaficence in the health care intervention on the discussion?

2.      The Candidate ability of good professionalism in dislocation of the knee joint  health care services

·         The Examiners should evaluate the professionalism of the Candidate. He/she should enhance the quality of medical care delivered based on biopsychosociol-cultural knowledge for patient in the knee dislocation discussion.

·         The Examiners should evaluate the Candidate decision making of the priority knee dislocation management among some options based on the evidence of medicine (EBM) in the discussion. What is the candidate knee dislocation management decision in health care and the reasoning of explanation mechanism, advantages and disadvantages clearly and knowledgeable to the patient?

·         The Candidate is able to explain the discussion questions of the Examiner. It depends on his/her experiences of the Examiner for getting the objective, valid and reliable marks.

Table 37. List of evaluation the knee dislocation examination

PART A: The objectives examination evaluation of the history taking physical examination and investigation data collection for some possibilities or accurate diagnosis determination	30 (complete & correct)	20 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to complete the history taking information, physical examination and investigation data related to the knee dislocation diagnosis in discussion
PART B: The objectives examination evaluation of the patient’s problem, management and complications	20 (complete & correct)	15 (incomplete presentation or correct response of stimulation question	0 (incorrect or no response)	Marks
1.      Ability to predict acute and long-term problem of the knee dislocation in discussion
2.      Ability to plan the knee dislocation management and outcome of the knee joint dislocation in discussion
3.      , Ability to predict the complication of the knee joint dislocation in discussion.
PART C: The objectives examination evaluation of a good Candidate’s attitude and professionalism	10 (complete & correct)	6 (incomplete presentation or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to show a good attitude and professionalism in knee dislocation health care in discussion
Total marks (A = B + C)

MARKS:

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for knee joint dislocation diagnosis determination:

• Marks 30: Candidate presents the history taking, physical examination and investigation and analyze key data of knee joint dislocation completely and correctly
• Marks 20: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting history taking or physical examination and investigation needed or a mistake analyzing data of the knee joint dislocation correctly.
• Marks 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of history taking, physical examination, investigation and analyzing of the key data of the knee joint dislocation

Part B: The objectives examination evaluation of the patient’s problem, management and complications   :

• Marks 20: Candidate presents the acute and long-term problem or management planning, or complications prediction of the knee joint dislocation completely and correctly.
• Marks 15: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of the acute and long-term problem determination or management planning, or complications prediction of the knee joint dislocation correctly.
• Marks 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of the acute and long-term problem determination, management planning, and complications prediction
• Maximal marks of part B  is 60

Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism:

• Marks 10: Candidate ability to show a good attitude and basic medical and clinical knowledge to decide management based on evidence (professionalism) in health care services of the knee joint dislocation
• Marks 6: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good basic medical and clinical knowledge and management decision based on evidence in health care services of the knee joint dislocation.  
• Marks 0: Impolite attitude and Candidate is also a bad basic medical and clinical knowledge without evidence management decision in health care services of the knee joint dislocation  

Table 38. Other evaluation list of the knee joint dislocation

CONTENTS OF EVALUATION	Marks
Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	30 (complete & correct)	20 complete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to collect the key data of the history taking, physical examination and investigation data collection for knee joint dislocation diagnosis determination in discussion
Part B: The objectives examination evaluation of the patient’s problem, management and complications	60 (complete & correct)	45 (incomplete presentation or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to determine acute and long-term problem, select the best option of the management  and to decide the complication of knee joint dislocation in discussion
Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism.	10 (complete & correct)	6 (incomplete presentation or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to show a good attitude and professionalism in health care of the knee joint dislocation discussion
Total Marks (Part A + B + C)

MARKS of Part A:

• Marks 30: Candidate presents the history taking, physical examination and investigation and analyze key data for knee joint dislocation completely and correctly
• Marks 20: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting history taking or physical examination and investigation needed or a mistake analyzing data for knee joint dislocation correctly.
• Marks 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of history taking, physical examination, investigation and analyzing of the key data of the knee joint dislocation

MARKS of Part B:

:

• Marks 60: Candidate presents the acute and long-term problem, management planning, and complications prediction of knee joint dislocation completely and correctly.
• Marks 45: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of the acute and long-term problem determination, management planning, and complications prediction of knee joint dislocation correctly.
• Marks 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of the acute and long-term problem determination, management planning, and complications prediction of the knee joint dislocation

MARKS of Part C:

·         Marks 10: Candidate ability to show a good attitude and basic medical and clinical knowledge to decide management based on evidence (professionalism) in health care services of knee joint dislocation

• Marks 6: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good basic medical and clinical knowledge and management decision based on evidence in health care services of knee joint dislocation.  
• Marks 0: Impolite attitude and Candidate is also a bad basic medical and clinical knowledge without evidence management decision in health care services of the knee joint dislocation

Conclusion = Part A + Part B + Part C

·         Marks: 85-90 is superior ·         Marks: 79-84 is excellent ·         Marks: 69-78 is pass; and ·         Marks: 60-68 is fail

·         Marks: 85-90 is superior ·         Marks: 76-86 is excellent ·         Marks: 65-75 is pass; and ·         Marks: ≤ 65 is fail

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