Orthopaedics and Traumatologic Examination : Part A

There are two versionsof the orthopaedic and traumatologic examination:

1.  A real case of exam.

After orthopaedics and traumatologic case selection by the examiners team; the Examiner asks the Candidate to collect the history taking and collect physical examination data of the orthopaedic and traumatologicpatient for analyzing and making the possibilities diagnosis.The Candidate should be able to select the important information and the reasoning of the investigations before presenting the summary

2.        Scenario or clinical signs or investigation findings exam.

The Examiner is able to select the scenario or clinical signs or radiographs of x-ray or laboratory of the patient and then the Candidate is able to ask some key of information in history taking,important data of the physical examinationand investigation findings. These information and key data are able to support the differential diagnosis or possibilities of the illness on the scenario orclinical signs or abnormalities of the investigation finding.

Because of that, good scenario problems are essential and have an important objectives competent examination goal. The problemsmust stimulate the Examiner to discuss independently and may vary and maybe design at different level of the illness condition for discussion. Patient’s problems should be able to have a specific format which starts by identifying and lists all of patient’s complaint (including medical and social)

The Examiners can discuss at any point of the interesting possibility and then extend basic medical and clinicalsciences questions freely for example: extend anatomy, physiopathology, history taking, diagnosis and management, and complications of the illness questions.

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

The Examiners should be able to evaluate:

                               I.            The Candidate ability of the history taking information collection:

1.       Patient identification, complaint, history of the illness and risk factors.The Candidate should be able to present the identity and complaint problem of patient as the reason why patient comes to consultation and he/she also narrates the history of the illness and risk factors. The symptom of the orthopaedics and traumatologic includes pain, activity limitation, swelling and stiffness (PASS). Other possibilities relevant symptoms are color changes, altered sensation, systematic illness, fatigue, sleep disturbance, depression and fear. The Candidate should be able to decide the type of symptom, its site and distribution, chronology, associated symptom, the response to health intervention, previous factors and its impact. The Candidate also should be able to identify about the pain, radiation, related to quality (inactivity, rest or at night), aggravatingand relieving factors, response to treatment and its impact. The causes of pain problem may be from bone, joint, and soft tissue/periarticular or referred or neurologic. There are five methods to measure the quality of pain includes: likert scale, visual analog scale, numerical rating scale, continuous chromatic analog scale and pain faces for children. The severity of pain relate to activity and analgesic drugs (Table 1).

Table 1. The severity of pain relate to activity and analgesic drugs

No pain	Degree of pain	Relating to activity	Relating to analgesics
	I	Pain on vigorous activity	Over counter drugs
	II	Pain walking outdoors	NSAIDs	·         Dosage ·         Efficacy ·         Side effect
	III	Pain walking indoors	Combination analgesics
	IV	Pain at night	No response to analgesics only Opiates alone
	V	Pain all the time

2.      Past medical illness, comorbidities and allergy history. The Candidate should be able to determine past medical history and comorbidities of the patient’s illness when, how and who makes the diagnosis, management and progress. He/she also tells the pregnancy history of the female patient if relevant with the present illness or organ function evaluation. The Candidate should be able to decide the history of allergy and severity of the abnormality, if relevant with the present illness.

3.      Family, social and cultureand occupation history. The Candidate should be able to describe the familyhistory of illness because there are some conditions which may have a familial predilection. History of social and culture are important to explore because it influences the process of disease; for example healing process of fracture may be influenced by smoking patient.Occupational history of patient can determine the management, for example a pianist should be treated with adequate reduction of the phalanx fracture and so on.

                                I.            The Candidate ability of the physical examination data collection:

1.      General condition/general appearance, ambulatory or non-ambulatory patient or crutch/cane or wheelchair use. The Candidate should be able to assess the gait for ambulatory patient and vital signs such as: temperature, blood pressure, respiration rate, pulse and body mass index (gait, arms, legs and spinal or GALS screening).

2.      Local examination data collection

·         Look: The Candidate should be able to tell the local abnormalities such as :symmetricity, deformity, open wound, skin defect, rashes, blister, burn, laceration or other sequelae. If fracture should identify: tenting and protrudingof the fragments fracture, muscle atrophy and so on.

·         Feel: The Candidate should be able to explain the data collection including, local tenderness, crepitation or step-off and swollen/lump or swollen at the lesion site. In case of tumor suspicion;he/she should be able to evaluate the size, surface, margin, consistency and mobility to the bone or the soft tissues around the lesion. The Candidate should be able to decide the levelof tenderness of thespine palpations, curvature, spine processes, step-off, and prominence. Costovertebral tenderness is an indication of organic back pain diagnosis caused by renal abnormalities. Tenderness on para-spinal muscle indicated(indicates)fracture, infection or tumor of the spine, and otherpossible diagnosis. Tenderness on sacroiliac joint or positive FABER maneuver is a sacroiliac signindication but intervertebral tenderness combined with seronegative spondylopathies (is suspicious) can be a suspicion ofa rheumatoid arthritis.

·         Move: The Candidate should be able to demonstrate the measurement of range of motion (ROM) of joints actively and passively. It could be full, fixed or limited result compared tothe normal side. The Candidate should also be able to ask the patient to perform forward flexion, extension, lateral binding and rotation of the spine movement examination. Limited spine motion without pain, it could be a degeneration process or ankylosing spondylitis. Movement of the cervical spine region should be carefully performedbecause it can causean iatrogenic injury.

·         Neurovascular evaluation: The Candidate should be able toassessthe sensation and vascularity (capillary refill test at the finger/toe pads) andthe Candidate explains the physiology and pathology reflex and upper and lower extremity,sensationof the radial, ulnar, median, femoral, tibial and peroneus nervesin carefully. The Candidate should also be able to evaluate the peripheral nerves (Table 2).

Table 2. Evaluation of peripheral nerves

Nerve	Muscle	Sensory
Upper extremity
Axillary	Deltoid-shoulder abduction	Lateral aspect arm
Musculoscutaneous	Biceps-elbow flexion	Lateral proximal forearm
Median	Flexor pollicislongus-thumb flexion	Tip of thumb, volar aspect
Ulnar	First dorsal interosseous-abduction	Tip of little finger, volar aspect
Radial	Extensor pollicislongus-thumb extension	Dorsum thumb web space
Lower extremity
Obturator	Adductor-hip adduction	Medial aspect, midtight
Femoral	Quadriceps-knee extension	Proximal to medial malleolus
Peroneal Nerve
Deep branch	Extensor halluces longus-great toe extension	Dorsum first web space
Superficial branch	Peroneousbrevis-foot eversion	Dorsum lateral foot
Tibial	Flexor halluces longus-great toe flexion	Plantar aspect foot

·         Muscle power grading (scale: 0-5). The Candidate should be able to determine the muscle of the extremities such as:

0.      No visible of palpable muscle/tendon contraction

1.      Any flicker of motion or visible and/or palpable muscle/tendon contraction

2.      Full range of movement out of plane of gravity

3.      Full range of motion against gravity only

4.      Full range of motion against some resistence, but weaker than expected

5.      Normal strength

1.      The special clinical test ability, for example apprehension test of the shoulder for detection of recurrent dislocation, Drawer test of the knee for anterior/posterior cruciate ligaments integrity or othermaneuver evaluations.

                                     III.            The Candidate ability to explain the reason investigation ordering and determining relevant investigation with interpreting the results and then analyze, investigate, interpret the key data collection and assess the risk factors for accurate diagnosis or formulating a limited differential diagnosis. The Candidate should be able to describe radiographic (x-rays, CT scan, MRI, ultrasound, and Nuclear medicine scan) and laboratory data (complete blood count, basic metabolic panel, blood type and screening, and the basic coagulation tests, prothrombin time and partial thromboplastin, synovial fluid analyses and urine pregnancy for woman of child bearing age) to support the diagnosis and management plan. A good Candidate in clinical experience knows how to ask the same question in several ways and use appropriate different terminology to patient.

                                        IV.            Achieve the accurate diagnosis maybe using the analyzing or interpretation the key data relate to the systematic knowledge of each possible patient illness that includes prevalence, patient presentation, risk factors and or others clues. There are several possibilities or differential diagnosis based on acute or chronic complaint or trauma and non-trauma of the musculoskeletal system (illustration 1 &2). 

The Candidate can easily establish adiagnosis in acute trauma patient but concomitant signs such as weakness or paralysis; paresthesias or pulselessness is a fracture complications. Furthermore, complaint of pain at the right knee in a patient suffering from Crohn’s disease and under chronic use of corticosteroid may not have knee abnormality at all. The pain maybe referred from avascular necrosis of the ipsilateral head of the femur. Other example, a left knee pain and fever maybe a sign septic joint infection and so on.

Table 3.List of part Aevaluation

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	10 Complete & correct presenta-tionstatement	6 Incom-pletepresenta-tion or Correct response to stimula-tion question	0 Inco-rrect response or no response	Marks
a.       Ability to gather information of the history taking includes: ·      Identity and patient’s complaint, history of the illness and risk factors,  ·      Past medical history or comorbidities (when, how and who makes the diagnosis), allergy, severity of the abnormalities, ·      The information of the family, social, culture and occupation history, and  pregnancy history (if relevant to the present illness), management and progress or organ function evaluation
b.      Ability to collect the physical examination such as: ·         The data of the  general condition, ambulatory or gait evaluation(crutch/cane/wheel-chair using), andbodymass index, ·         Local examination (look, feel, move and ·         Muscle power & neurovascular, the special  clinical test or maneuver evaluation and the investigations
c.    Investigation reasoning Interpret, analyzing key data for some possibilities  or accurate diagnosis determination determination
Total marks part A

 MARKS OF PART A:

§  Mark 10: Candidate presents: (a)the history taking or (b) physical examination or(c) investigation andanalyze key data for some possibilities or accurate diagnosis determination in discussion completely and correctly

§  Mark 6: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting (a) history taking or(b) physical examination and (c) investigationneeded or a mistake analyzing datafor some possibilities or accurate diagnosis determination in discussion correctly.

§  Mark 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of (a) history taking, (b) physical examination,(c) investigation andanalyzing of the key datafor some possibilities or accurate diagnosis determination in discussion

§  Maximal marksof part A is 30

OTHER ALTERNATIVE EVALUATION LIST

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

Learning Objectives Evaluation in Examination

The Examiner should be able to assess

The Candidate ability to recognize the system musculoskeletal abnormalityjoint scenario

Discussion between the Examiner and the Candidate is how the Candidate make the most likely diagnosis of the system musculoskeletal abnormalitybased on the key data in the scenario (history taking, physical examination and investigation finding) to support diagnosis and how he/she integrates and of analyze all data  and last is problem issues of the system musculoskeletal abnormalitypatient (table 4). The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marks.

Table 4: List of the evaluation marks of part A

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 & correctpresentation	20 Incomplete 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 some possibilities or accurate diagnosis determination in discussion

MARKS:

§  Marks 30: Candidate presents the history taking, physical examination andinvestigation andanalyze key data for some possibilities or accurate diagnosis determination 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, investigationneeded and analyzing datafor some possibilities or accurate diagnosis determination 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 andanalyzing of the key datafor some possibilities or accurate diagnosis determination.