Case Examination:
A 16-year-old male came to orthopaedic consultation complaining
pain during weight bearing, valgus angulation right distal lower leg with shortening.
He had open right lower leg fracture and had been operated debridement and
internal K-wire fixation of the fibula with external fixation of the tibia 11 months
ago. Physical examination revealed valgus angulation and 11 x 7 cm cicatric on
antero-medial aspect of the right distal lower leg without sinus. AP and
lateral projections radiographs of the right lower leg showed a gap on tibia
and fibula and closed of medullary canal of the fragments fracture end with
K-wire fixation and bowing to medial. On the tibia showed external fixation
without callus formation and a bit medial angulation (Fig.6).
Fig.6 AP and lateral projections radiographs of right lower leg
Learning
Objectives Evaluation in Examination
The Examiners should
be able to assess the Candidate ability:
1. To
describe and interpret the radiographs of the patient completely
2. To
illustrate past illness at 11 months ago clearly
3. To collect
physical examination data completely
4. To plan
the management and complication of the patient
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 Examiner should be able to assess:
1. The
Candidate ability to describe the radiographs of the right lower leg.
The
first point, Candidate describes the radiographs AP and lateral views show:
medial bowing of the apex of gap with internal K-wire of the fibula and
external fixation modification using between upper and lower part of the tibia
fragments. There is the gap about 2 cm, no callus formation and valgus
angulation of the distal fragment plus sequester on the end of the proximal
fragment. Based on pain on the weight bearing and valgus angulation of the distal
part of the right lower leg; the Candidate is able to decide the most likely problem
is non-union of the right distal tibia and fibula with chronic osteomyelitis directly.
The
Candidate should be able to explain pathogenesis of non-union
and risk factors. Infection rate of open fracture related to the open fracture
grading or classification. Poorly controlled diabetic patient inhibit process
wound healing and infection fighting-capabilities. Radiographic, computed
tomography (CT scan) and others advanced investigations are able to detect
non-union by carefully describing.
2.
The Candidate ability to illustrate past illness history
at 11 months ago clearly
The Candidate should
be able to illustrate the history and physical examination of the open fracture
of the right distal lower leg 11 months ago and its management such as:
irrigation and debridement, reduction internal fixation of the fibula and
external fixation of the tibia in detail and completely until serial
debridement and antibiotic in follow up care services.
Open distal fractures
of the right lower leg are damage vascularization
region and high-energy trauma, therefore the Candidate should identify life
threatening, history and physical examination, neurovascular status, size of the soft tissue
defect, periosteal stripping, bone loss, contamination for obtaining open
fracture classification based on Gustilo-Anderson (table 25) and lack of
healing process. The history of irrigation with sterile saline solution,
antibiotic and antitetanus agents should be performed in the initial treatment
of the open fracture. No consensus regarding optimal volume sterile saline
solution in irrigation. But debridement procedure and systemic antibiotic
should be as soon as possible. Irrigation and debridement ideally occurs within
6-8 hours from the time injury, even a little data to support this
intervention. This intervention and systemic antibiotic delay are the risks
factors for infection. These data are important the prognosis of the patient.
Table 25: GUSTILO and ANDERSON open fracture
classification
|
grade
|
defect
|
|
I
|
Open
fracture, clean wound <1 cm in length, simple fracture pattern
|
|
II
|
Open
fracture, wound >1 cm in length without extensive soft tissue damage,
minimal fracture comminution and contamination
|
|
III
|
Open
fracture, extensive soft tissue damage, severe fracture comminution or
segmental pattern. This type also includes farm injuries and fracture open for
> 8 hours before treatment
|
|
III A
|
Type III
fracture with extensive soft tissue damage but adequate periosteal coverage
of the bone
|
|
III B
|
Type III
fracture with extensive soft tissue damage and periosteal stripping, requires
soft tissue damage procedure
|
|
III C
|
Type III
fracture with an arterial injury requiring repair
|
The ultimate goal of
management open fracture is a clean wound with viable tissue. Therefore
removing all foreign bodies, dead tissues by irrigation and debridement and
antibiotic broad spectrum as soon as possible to prevent infection, reduction
and fixation are important. Re-debridement procedure may be necessary after 1-2
days after treatment. Now, the patient
problems are osteomyelitis, non-union and valgus deformity of the right distal
lower leg.
3. The
Candidate ability to collect physical examination data.
The Candidate should
be able to determine the general condition patient is good conditions and
antalgic gait. The Candidate should be able to present local examination data:
·
Look: muscle atrophy, shortening, and cicatrix on
anterior aspect of the distal right lower leg, no sinus and discharge, valgus
deformity and modification external fixator set on the tibia.
·
Feel: Decrease power muscles of the right lower extremity
and no tenderness, and
·
Move: ROM of the right knee is full but ROM of the
right ankle is limited.
4. The
Candidate ability to decide accurate diagnosis
Base on
the information of the history taking and data of physical examination and
radiographics above, the Candidate should be able to conclude accurate
diagnosis is non-union, osteomyelitis and valgus deformity. There are 4 type of
non-union include:
a) Atrophic
or avascular non-union cause by lack of biologic capacity to heal or there is
no evidence of cellular activity at the level of the fracture. The end
fractures fragments are typically narrow, rounded and osteoporotic and
frequently avascular.
b) Hypertrophic
non-union with the biological activity but it’s a lack capacity healing because
of an inadequate fixation. The end of fracture fragments are hypertrophic
callus formation.
c) Oligotrophic
non-union
This patient is
infected non-union. Untreated atrophic and hypertrophic non-union can become
pseudoarthrosis. The synovial-lined capsule envelops the bone ends of fracture
fragments with synovial fluid content.
Table
26: List of part A evaluation
|
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 &cor-rect)
|
20
Incomplet presentation or correct response of stimulation question)
|
0
(incor-rect
or no res-ponse)
|
Marks
|
|
The candidate ability to
collect the data of the history taking, physical examination and
investigation for non-union
and chronic osteomyelitis diagnosis determination in discussion.
|
|
|
|
|
|
TOTAL
MARKS of Part A
|
| |||
MARKS:
§ Marks 30: Candidate
presents the history taking, physical examination and investigation and analyze
key data for non-union and chronic osteomyelitis 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 and investigation needed or a mistake analyzing
data for non-union and chronic osteomyelitis 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
and analyzing of the key data for non-union and
chronic osteomyelitis diagnosis determination.
Part B: The
objectives examination evaluation of the patient’s problem, management and
complications
Learning Objectives Evaluation in Examination
a.
The
Candidate ability to decide acute and long-term problem
Non-union of the tibia and fibula become a pseudoarthrosis
in a long-term problem. The Candidate should be able to explain pathogenesis of non-union and risk factors. The incidence of non-union
will be increased in open fracture grade III caused of infection and unstable K
wire fixation in the right fibula and external fixation modification set on the
right tibia. The other caused is poorly controlled diabetic patient because of
the inhibition process wound healing and infection fighting-capabilities. Osteomyelitis
rate will be increased after open fracture grade III and inadequate antibiotics
treatment and concerning valgus deformity could be inadequate K wire and external
fixation modification set of the fracture fragments or early weight bearing
mobilization of the patient.
The Candidate should remember acute pain and lower leg
angulation are the first problem to this patient caused by non-union and
chronic osteomyelitis of the right tibia and fibula, and limping may be involved and affect daily
activity of living. Chronic osteomyelitis long-term problem may be become
active, sepsis and death. The other long-term problems are decreased patient
activity that can lead to lack lower quality of life of this patient.
b.
The
Candidate ability to plan the management and complication of the patient
The Candidate should be able to inform the technique of
surgery in detail, clearly and completely to this patient. There are three abnormalities
in this case:
1)
The Candidate should be able to
understand the pathology of chronic osteomyelitis that characterized by
presence of bacterial biofilm and bacterial resistance to host defenses and
antibiotic and often requires surgical debridement intervention with long-term
systemic antibiotic using. The Candidate should order laboratory examination
especially ESR and CRP which are elevated in more than 90% of osteomyelitis
cases as regards to WBC count is only positive approximately 40% of cases.
Chronic osteomyelitis patient should be performed debridement, sequesterectomy,
surgical drainage and antibiotic therapy.
2)
Angulation of the right lower leg
contributes to abnormal weight bearing axis and may lead to early weight
bearing joints degeneration. Therefore, the Candidate should be able to explain
the problem’s solution is an achieving normal alignment/axis of the tibia and
the same length with the left side of the lower extremity. Now, the question
“Is that attainable?”
3)
Preparation the step of surgery
includes:
·
Location of the incision an surgical
approach removal of implants of the tibia and fibula
·
Debridement and sequesterectomy and
·
How to achieve the normal anatomy
length and axis of the right lower leg, and
·
Preparing of implants type using.
Before debridement the Candidate removes K-wire and external
fixation and then reduces and fixed the fibula by plate and screws.
All fibrous tissues in the fibula and tibia gap should be
removed or debridement and decortication and then surgical drainage and sequesterectomy.
If during debridement the candidate didn’t find pus the internal implant
fixation can be used. The Candidate must reduce fibula fragments firstly and
fixed by narrow plate 6 holes so the anatomical length of the tibia can be
achieved. After fixing of the tibia by plate and screws, the graft of the illiac
crest put in the gap (fig.7).
Fig.7: After surgery intervention
1.
The
Candidate ability to predict the complications
The Candidate should be able to predict complications that have
been treated with antibiotics and surgical intervention.
Patient can lead to functional deficit of the extremity or early
degeneration of the weight bearing joint. These complications depend on the
amount of tissue debrided or non-vital structures have been removed after
stabilization. The complications after surgery are infection, sepsis and Candidate
should also to plan health promotion and disease prevention
to this patient in detail clearly and completely.
Table 27: List of
part B evaluation
|
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 determine the problem
issue (acute and long-term problem patient) of non-union and chronic
osteomyelitis diagnosis in discussion:
|
|
|
|
|
|
2.
Ability to plan the management of non-union and chronic osteomyelitis
diagnosis in discussion
|
|
|
|
|
|
3. Ability to predict the complications of non-union and
chronic osteomyelitis diagnosis in discussion
|
|
|
|
|
|
TOTAL
MARKS of Part B
|
| |||
MARKS:
- Marks 20:
Candidate presents the acute and long-term problem or management
planning, or complications prediction of non-union and chronic
osteomyelitis patient 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
non-union and chronic osteomyelitis patient correctly.
- Mark/s 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 non-union and chronic osteomyelitis
patient
OTHER ALTERNATIVE EVALUATION LIST (Table 28)
Part B. The objectives examination evaluation
of the accurate diagnosis determination or possibilities of the abnormalities,
patient’s problem, management and complications
Learning
Objectives Evaluation in Examination
The Examiner should be
able to assess
1. The
Candidate capability to decide the acute and long-term problem of non-union and chronic
osteomyelitis. The Candidate should be able to explain the problem of non-union and chronic
osteomyelitis patient. The Examiner questions are varying depends on the Examiner
experience for achieving objective, valid and reliable marking.
2. The
Candidate ability to plan the management decision of non-union and chronic
osteomyelitis based on evidence (treatment algorithm)
The Candidate should be able to understand that the based on treatment
depends on accurate diagnosis, treatment options according to evidence of
medicine, patient need and facilities. The Examiner questions are varying
depends on the Examiner experience for achieving objective, valid and reliable
marking.
3. The
Candidate ability to predict the common complication of non-union and chronic
osteomyelitis, promotion and prevention issues
The Candidate should be able to explain complication of non-union and chronic
osteomyelitis, management complications, promotion and prevention of non-union and chronic
osteomyelitis patient. The Examiner stimulates a few questions for achieving
objective, valid and reliable marking.
Table 28:
List of the evaluation marks of part B
|
CONTENTS OF
EVALUATION
|
Marks
| |||
|
Part B:
The objectives
examination evaluation of the patient’s problem, management and complications
|
60
Complete
& correct presentation
|
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 non-union and chronic
osteomyelitis in discussion
|
|
|
|
|
MARKS:
- Marks 60: Candidate
presents the acute and long-term problem, the management and complications
prediction planning of non-union and chronic osteomyelitis 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, management planning and complications prediction determination of non-union and
chronic osteomyelitis 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 non-union and chronic osteomyelitis.
Part C:
The objectives examination evaluation of a good
Candidate’s attitude and professionalism.
Learning Objectives Evaluation in Examination
The Examiner should be able to assess:
1.
What is Candidate plan for the beneficial management
orientation and to avoid maleficence in health care intervention on the
discussion part B?
2. The Candidate ability of good
professionalism in chronic osteomyelitis with non-union health care services
b.
Professionalism Candidate should enhance the quality of
medical care delivered based to biopsychosociol-cultural knowledge for patient
in the discussion part B.
c.
What is the candidate management decision in health care and
the reasoning of explanation mechanism, advantages and disadvantageous clearly
and knowledgeable to the patient?
d.
Professionalism Candidate always makes decision of which
management is the best management based on EBM in the discussion part B? What
is the Candidate’s decision of management in health care? Does the Candidate
explain the reasoning, the advantage and disadvantage to the patient clearly
and knowledgeable enough?
Table 29: List of
part C evaluation
|
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 management
of non-union and chronic osteomyelitis patient in health care discussion
|
|
|
|
|
|
TOTAL MARKS of Part C
|
| |||
MARKS:
- 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 non-union and chronic osteomyelitis patient.
- 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 non-union and chronic
osteomyelitis patient.
- Marks 0: Impolite attitude and Candidate is also
a bad basic medical and clinical knowledge without
evidence management decision in health care services of non-union and chronic osteomyelitis
patient.
Conclusion total marks
= part A + part B + part C
Table 30. Other evaluation list of non-union and
chronic osteomyelitis
|
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 non-union and chronic osteomyelitis 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 non-union and chronic osteomyelitis 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
non-union and chronic osteomyelitis 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 non-union and chronic osteomyelitis 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 non-union
and chronic osteomyelitis 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 non-union and chronic
osteomyelitis
MARKS of Part B:
:
- Marks 60:
Candidate presents the acute and long-term problem, management planning,
and complications prediction of non-union and
chronic osteomyelitis 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 non-union and chronic
osteomyelitis 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 non-union and chronic
osteomyelitis
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
non-union and chronic osteomyelitis
- 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 non-union and chronic
osteomyelitis.
- Marks 0: Impolite attitude and Candidate is
also a bad basic medical
and clinical knowledge without evidence management decision in health care services non-union and chronic
osteomyelitis
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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and Beaty JH.edits (2013). Campbell’s
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CM, Wheelwright EF, Christie J and McQueen MM (1990). External fiaxation for
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801-804
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