اللهم يا معلّم موسى علّمني، ويا مفهم سليمان فهّمني، ويا مؤتي لقمان الحكمة وفصل الخطاب آتني الحكمة وفصل الخطاب اللهم اجعل ألستنا عامرة بذكرك، وقلوبنا بخشيتك، وأسرارنا بطاعتك، إنك على كل شيء قدير، حسبنا الله ونعم الوكيل

Updates through https://medatlax.com/Clinical/Level-11/Orthopedics/OSCE/OSCE-Ortho/OSCE-Ortho - will be highlighted yellow - If there is any adjustment or edits please let me know Dr.alkharji@proton.me

Will be 4 stations

History
⁠Joint exam
⁠Any skills we took (aspiration, cast, traction, etc.)
⁠Discussion from the lectures we took (Cauda equina, compartment, open fracture, septic arthritis, DDH, etc.)

Other exams and Other cases by end of file

collected from previous batches, Lina serhan, Ghuzlan, haya, Haneen Alsultan, Dania abuobaid, Alzahraa Ismaeel, Deema alsarawi, ~FA, Mujahid Almuhaydib, and Ola Al-Rayes

Examination of Spine
- Neurological Examination
  - Upper Limb Neurological Clinical Examination Station
  - Lower Limb Neurological Clinical Examination Station
- Peripheral Nerve Examination
- Examination of the Spine / back
  - Back ROM & Neurological
  - McMaster MSK Examination Series
  - Spine Examination – OSCE Guide

Cases

Compartment Syndrome
Open Fracture
Septic Arthritis
DDH
Cauda Equina
Other Cases

OSCE

History

DDH, Knee pain, Shoulder stiffness, Back pain, Sport Injury

Item	Details
Introduction	* Introduce self.
	* Explain purpose of history.
	* Explain what you want to do.
Patient’s Information/Demographics	* Patient (baby’s) name and age: (e.g., 3 months for DDH, 56-year-old lady for knee pain, 50-year-old man for shoulder stiffness, 53-year-old male for back pain, 23-year-old man for sport injury).
	* Chaperone and their relationship to the baby (for DDH).
	* Name, Age, Occupation (for adults).
Chief Complaint	* DDH: “The nurse mentioned there are some concerns about your baby’s left/right hip. Can you tell me more about what you’ve noticed or what the nurse observed?”
	* Knee pain: Pain in both knees for 3 years.
	* Shoulder stiffness: Shoulder stiffness for 2 months.
	* Back pain: Progressive Back pain for one year.
	* Sport injury: Right knee pain after football injury 3 months ago.
History of Present Illness - Onset	* When did you first notice anything unusual / when was it brought to attention?
	* Sudden or gradual? (for all).
	* Acute after an incident, or Chronic (for back pain, sport injury).
Site	* Where do you feel it?
	* Baby’s hip.
	* Where in the back (low, mid, upper for back pain).
	* Exact site (for sport injury).
	* Shoulder for stiffness.
Character	* Sharp, dull, throbbing?
	* (difficult with infant for DDH).
	* Dull, aching, sharp, hot (for back pain, sport injury).
Radiation	* Does the pain radiate elsewhere?
	* (For discomfort/pain for DDH).
	* Down to thigh, leg, toes (for back pain).
	* Down or Upwards, back (for sport injury).
Associations	* DDH: Clicking, popping, or clunking sounds from hip.
	* Knee pain: Hotness, swelling.
	* Shoulder stiffness: Pain / Swelling / Clicking.
	* Back pain: Constitutional symptoms, others.
	* Sport injury: Fever, Swelling.
Time Course	* Continuous, intermittent, worse at night/morning? (for DDH).
	* Progressing/improving, all day / at end of day, at activity (for back pain, sport injury, shoulder stiffness).
Exacerbating Factors	* What makes it better or worse (e.g., position, movement)? (for DDH).
	* Activity, bending, coughing/sneezing, lifting (for back pain).
	* Activity, stairs (for sport injury).
Relieving Factors	* What makes it better or worse (e.g., position, movement)? (for DDH).
	* Medications, rest, position (for back pain, sport injury).
Severity	* Getting worse, or staying the same? (for DDH).
	* DDH: Scale 0-10 pain is difficult for infants, focus on behavioral changes.
	* Others: Scale 1-10 (for back pain, sport injury).
SOCRATES (for discomfort/pain)	* Site, Onset, Character, Radiation, Alleviating/Aggravating Factors, Timing, Everyday Impact, Severity/Progression (for DDH).
Associated Symptoms (DDH Specific)	* Swelling, stiffness, deformity, instability?
	* Limping, use of walking aids (less relevant for infant).
	* Swaddling practices (legs straight and tight vs. free movement).
	* Clicking, Locking (hip).
	* Does she favor one leg, move one leg less?
	* Asymmetry in thigh/gluteal folds?
	* Crying/discomfort with movement?
	* Difficulty changing diapers/dressing?
DDH Risk Factors (“3 Fs” + others)	* Antenatal: Illnesses/complications during pregnancy, oligohydramnios.
	* Birth History: Delivery complications, breech presentation (especially frank), APGAR score, C-section vs. vaginal, multiple birth, NICU admission.
	* Post-natal: Ever in Pavlik Harness or hip spica cast?
	* Family History: DDH or other hip problems?
	* First born child?
	* Female baby?
	* Foot abnormalities at birth?
Developmental Milestones (DDH)	* Head control?
	* Rolling?
	* Reaching for toys?
	* Meeting age-appropriate milestones (smiling, tracking, cooing)?
Function / Normal Daily Activities	* Knee pain: Stiffness / Normal daily activities/ Walking / Sitting in prayer / cross-legged / Arabic toilet / Fitness Activity / Limping.
	* Shoulder stiffness: Reaching / Putting shirt on / using hand / Fitness Activity.
	* Back pain: Stiffness / Normal daily activities / prayer / bending / lifting.
	* Sport injury: Walking, standing, praying, Sitting, Going up/ down stairs, Sports.
Impairment to Sleep/Work	* Disturbing night’s sleep (for all).
	* Affecting work / sick leaves (for all).
Previous Problems (Specific Joint)	* Knee pain: Trauma: twisting/popping, Fractures / casting.
	* Shoulder stiffness: Infection/Trauma.
	* Back pain: Trauma, lifting heavy weight.
	* Sport injury: Trauma twisting / popping / Fractures / casting / Surgery / Stiffness / Deformity / Crepitus.
Other Problems in the Knee	* Instability - Giving way, Locking, Crepitation/Clicking sound (for knee pain).
Swelling	* DDH: Any visible swelling around the hip?
	* Knee pain, Shoulder stiffness: Exact site: front, medial, behind. Onset: Acute / Chronic. Character: Soft / Hard. Progression: Same / increasing / reducing. Exacerbating / Relieving factors.
	* Back pain: Site, onset, progression.
	* Sport injury: When (sudden or late), how long, continuous, less or more, on/off. Swelling in /behind knee.
Deformity	* DDH: Any visible deformity around the hip?
	* Knee pain, Back pain, Shoulder stiffness: Site / Direction. Onset: Time. Progression: Same / increasing / reducing.
Neurological (Back Pain Specific)	* Numbness/Tingling LL (where?).
	* Heaviness / weakness.
	* Sexual ability.
	* Sphincter control— urine/stool.
Giving Way (Sport Injury Specific)	* Sudden loss of stability in knee.
Locking (Sport Injury Specific)	* Painful / opens after a click.
Previous Management	* DDH: Has anything been done or tried for this hip problem (e.g., changes in swaddling, physiotherapy, repositioning)?
	* Knee pain, Shoulder stiffness: Investigations / current or past treatment.
	* Back pain: Investigations: X-rays, CT, MRI, others. Treatment: Medications, Physiotherapy, Surgery.
	* Sport injury: Investigation & treatment.
Past Medical History	* DDH: Any other medical problems or hospital admissions? Chronic illnesses? Blood transfusions? Seen other doctors for hip/related issues?
	* Adult conditions: Medical: HT / DM / Osteoporosis. Infections (Pulmonary, GIT, Urinary), Fever, Cough. TB. Tumors breast, uterus, lungs/ Recent weight gain or loss (for back pain).
Past Surgical History	* Knee pain: Knee or others.
	* Shoulder stiffness: Shoulder or others.
	* Back pain: At Back or others.
Drug History / Current Medications	* DDH: Currently on any medications (prescribed or over-the-counter)? What are they and why?
	* Shoulder stiffness: Specific: NSAIDs, steroids, General.
	* Back pain: Hormones/ Steroids.
Allergies	* DDH: Any known allergies (food, drugs, environmental)? Reaction?
	* Shoulder stiffness: Drug allergies?
Immunization History (DDH)	* Up-to-date with routine childhood immunizations? Last vaccination?
Other Joints Problems	* Joints affected / Problem (for all adult conditions).
Diet/Calcium intake/Vit. D/Sun Exposure	* (for knee pain, sport injury).
Family History	* Adult conditions: OA / Tumors / Osteoporosis / HT/DM (for knee pain, shoulder stiffness, sport injury).
	* Back pain: Infection, TB, Back diseases, Scoliosis, Tumors.
Systemic Inquiries (Review of Systems)	* DDH: General well-being: Headache, chest pain, palpitation, cough, joint pain, edema? (less relevant but general screening). Constitutional Symptoms: Fever, weight loss, night sweats, loss of appetite, loss of sensation/motor (less specific but for overall health).
	* Adult conditions: CVS. Respiratory. GIT. Urogenital. CNS & PNS. MSK. Metabolic system. psychiatric.
	* Sport injury: History related to major body systems.
Lifestyle / Social History / Living Conditions	* DDH: Feeding method, sleep pattern, recent travel, stress in household/support systems. Swaddling Practices.
	* Sport injury: Residence.
	* Back pain: Stairs, helper at home.
Smoking / Alcohol / Drug Abuse	* (for all adult conditions).
Attitude with patient & Showing concern	* Professional (for all).
Good question style / Confidence / no hesitation / no gaps	* (for all).
Summary (DDH)	* “Just to summarize, the nurse has noted a positive finding suggestive of DDH in your 3-month-old daughter’s [left/right] hip. From what you’ve told me, you haven’t noticed [mention positive/negative from above]. Is that correct?”
	* “Is there anything else that you think is important or that I should know about your baby?”
Mechanism of Injury (Sport Injury Specific)	* Twisting - varus/valgus stress.
	* Direct fall - direct blow (direction).
	* Swelling after injury - how soon? How large?

if recent truama take AMPLE

Examination summarized

General approach

Phase		Procedure & Key Points
1. Opening & Preparation		• Introduction & Consent: Greet the patient, introduce yourself, explain the procedure, and gain informed consent. Ensure privacy. • Exposure: Adequately expose the joint being examined and the joints above and below. • Positioning: Start with the patient standing for gait/posture, then move to sitting and supine as needed. Always compare with the unaffected side.
2. Look (Inspection)		• Gait & Posture: Observe the patient walking for any limp (e.g., antalgic, Trendelenburg) and check their overall posture. • Local Inspection: From all angles, look for: - Scars, Swelling, Skin changes, Symmetry. - Atrophy (muscle wasting). - Deformity (angulation, fixed flexion).
3. Feel (Palpation)		• Temperature: Use the back of your hand to assess skin temperature, comparing it to the contralateral side. • Tenderness: Gently palpate key structures, starting away from the painful area: - Bony landmarks (joint lines, epicondyles). - Soft tissues (muscles, tendons, ligaments). • Effusion: Check for joint fluid (e.g., patellar tap for the knee).
4. Move (Movement)		• Active Range of Motion: Ask the patient to move the joint through its full range. Note any pain or limitation. • Passive Range of Motion: Gently move the patient’s joint through the same range. Feel for crepitus and assess the end-feel. • Power: Test the strength of key muscle groups against resistance. • Joints Above & Below: Briefly assess movement in adjacent joints to rule out referred pain.
5. Special Tests		• Perform joint-specific provocative tests to confirm a diagnosis. Examples: - Knee: Lachman’s, McMurray’s. - Shoulder: Apprehension, Neer’s. - Hip: Thomas, Trendelenburg. - Spine: Straight Leg Raise.
6. Completion		• Neurovascular Status: Always assess distal circulation (pulses, capillary refill), sensation, and motor function. • Final Steps: Thank the patient, help them get comfortable, and state that you would complete your assessment with a history and relevant imaging.

Skill

Knee Aspiration

https://www.youtube.com/watch?v=sRVAzsZEBVY&pp=ygUUS25lZSBhc3BpcmF0aW9uIG9zY2U%3D https://www.youtube.com/watch?v=ikXvLLlpoas&pp=ygUUS25lZSBhc3BpcmF0aW9uIG9zY2U%3D

Item	Procedure
Indication Ask student	Diagnostic: arthritis, septic Therapeutic: reducing massive effusion
Contraindications Ask student	Cellulitis over injection site Broken skin over injection site / psoriasis…etc. Uncontrolled anticoagulation therapy / or sever coagulopathy Joint prosthesis / or just before planned knee arthroplasty
Introducing	Informing patient of the procedure - benefits Explaining the procedure Explain risks: Mild pain / Infection (1:10,000) / Bleeding Obtain consent / explain alternatives
Preparation / position Ask student	Patient in supine position Knee straight - slightly flexed (15-20°) on small support
Antiseptic technique	Using gloves Cleaning with antiseptic lotion or Betadine / alcohol Starting in center with circles enlarging to periphery Not coming back from periphery to center
Aspiration	Site: Lateral midpatellar or / Superiolateral patellar Needle entry: Perpendicular to femur, parallel to ground Needle size: 18G / 20G Aspiration / keep needle and change syringe if full Gently compressing suprapatellar region with the other hand Apply band aid Handling / disposal: No recapping - Disposal in sharp disposal box Alcohol swab disposal in trash - not in sharp disposal box
Post procedure instructions	Rest the knee, no heavy activity for 2-3 days Call immediately for any fever, chills, or redness of the knee Call if discomfort of the injection does not resolve within 72 hours
Overall	Attitude with patient

Injection of shoulder

https://www.youtube.com/watch?v=HvH__fP__RU&pp=ygUdc2hvdWxkZXIgam9pbnQgaW5qZWN0aW9uIG9zY2U%3D

https://www.youtube.com/watch?v=52dLCmM2bVw&pp=ygUoc2hvdWxkZXIgam9pbnQgYXNwaXJhdGlvbiBpbmplY3Rpb24gb3NjZQ%3D%3D

https://www.youtube.com/watch?v=f1iO3laXaxs&pp=ygUoc2hvdWxkZXIgam9pbnQgYXNwaXJhdGlvbiBpbmplY3Rpb24gb3NjZQ%3D%3D

https://www.youtube.com/watch?v=OAeOEc-X0kU

This patient has chronic shoulder pain (OA glenohumeral / subacromial pathology) has not responded to NSAIDs. You are required to inject the site with steroid and local anesthetic agent.

Item	Procedure
Indication of arthrocentesis of the shoulder	Diagnostic: arthritis, septic
	Therapeutic: reducing massive effusion
	Steroid Injection for : OA glenohumeral joint, AC joint, sub- acromial bursa
Contraindications	Cellulitis over injection site
	Skin lesion over injection site / psoriasis…..etc.
	Uncontrolled anticoagulation therapy / or sever coagulopathy
	Uncooperative patient
Introducing	Explaining the procedure
	Explain risks: Mild pain / Infection (1:10,000) / Bleeding
	Obtain consent / explain alternatives
Preparation Antiseptic technique	Seating patient properly
	Cleaning with antiseptic lotion or alcohol
	For Glenohumeral joint:
	o Feel the coracoid, go lateral to it from anterior Posterior glenohumeral injection
	For subacromial bursa/space
	o Feel acromioclavicual joint, go under it from lateral - Feel acromioclavicual joint, go under it from lateral Subacromial (not in checklist) Bicipital (not in checklist)
	If at proper site, the green light should turn on
Post injection	Apply band aid
	Remind patient to take NSAID as pain may increase initially
Needle	Handling / disposal: No recapping - Disposal in sharp disposal box
	Alcohol swab disposal in trash - not in sharp disposal box
Overall	Attitude with patient

Injection for Tennis elbow (Lateral Epicondylitis)

https://www.youtube.com/watch?v=8BYcYnN-H1s&pp=ygU3SW5qZWN0aW9uIGZvciBUZW5uaXMgZWxib3cgKExhdGVyYWwgRXBpY29uZHlsaXRpcykgb3NjZQ%3D%3D

This patient has lateral epicondylitis. You are required to give him an injection

Item	Procedure
Indication	Failure to respond to conservative treatment
	Ο Rest, NSAID orally and topically, Cold/hot packs, U/S Physiotherapy
Introducing	Informing patient of the procedure
	Explaining the procedure:
	Ο Mixture of steroid and local anesthetic
	Ο Pain may increase for 1-3 days – need to take oral NSAID
Preparation / position	Ο Seating patient properly Ο Elbow flexed on chair in front of patient Or: sitting with flexed elbow on table in front (from front)
Antiseptic technique	Using gloves
	Cleaning with antiseptic lotion or alcohol
	Ο Starting in center with circles enlarging to periphery
	Ο Not coming back from periphery to center
Site of injection	Lateral epicondyle: → Common extensur
	Ο Feel and identify area of maximum tenderness
	Ο Just distal to tip of lateral epicondyle
Injection	Needle perpendicular to skin
	Ο If at proper site, the green light should turn on
Post injection	Apply band aid
	Remind patient to take NSAID as pain may increase initially
Needle	Handling / disposal: No recapping - Disposal in sharp disposal box
	Alcohol swab disposal in trash - not in sharp disposal box
Overall	Attitude with patient

Injection for golfer elbow (medial epicondylitis)

https://www.youtube.com/watch?v=eVaguVc53DM&pp=ygUfSW5qZWN0aW9uIGZvciBnb2xmZXIgZWxib3cgb3NjZQ%3D%3D

This patient has medial epicondylitis that has not responded to conservative management. You are required to inject the site with steroid and local anesthetic agent.

Item	Procedure
Introducing	Informing patient of the procedure
	Explaining the procedure:
	$\circ$ Mixture of steroid and local anesthetic
	$\circ$ Pain may increase for 1-3 days - need to take oral NSAID
Preparation	Seating patient properly
	$\circ$ Elbow flexed on chair in front of patient
	$\circ$ Or: sitting with shoulder externally rotated and flexed elbow
Antiseptic technique	Using gloves
	Cleaning with antiseptic lotion or alcohol
	$\circ$ Starting in center with circles enlarging to periphery
	$\circ$ Not coming back from periphery to center
Site of injection	Medial epicondyle:
	$\circ$ Feel and identify area of maximum tenderness
	$\circ$ Just distal and slightly anterior to tip of medial epicondyle
	$\circ$ Must avoid the ulnar nerve behind the medial epicondyle
Injection	Needle perpendicular to skin
	If at proper site, the green light should turn on
	Major mistake if the red light is turned on (injury to ulnar nerve)
Post injection	Apply band aid
	Remind patient to take NSAID as pain may increase initially
Needle	Handling / disposal: No recapping - Disposal in sharp disposal box
	Alcohol swab disposal in trash - not in sharp disposal box
Overall	Attitude with patient
![[OSCE-Ortho-1762600385435.webp	295x221]]

Aspiration of knee, injection of elbow & shoulder

Joint Aspiration and Injection (and soft tissue)

Indications

Diagnostic Indications

Evaluate an acutely swollen and inflamed ‘hot’ joint
Rule out Infection (most important)
Analyze synovial fluid
- Characterize mono- or polyarthritis
  - Inflammatory
  - Degenerative
- Crystalline (Gout, pseudogout)

Therapeutic Indications

Drain large effusions / haemarthrosis
- Symptomatic relief
- Improves function

Contraindications

✓ Prosthetic joint
✓ Overlying cellulitis
✓ Active skin disease (e.g. psoriatic lesions at the site of injection)
Flare in the joint post-injection when performed previously
✓ Bleeding diathesis
- anticoagulation, hemophilia, thrombocytopenia
- not an absolute contraindication, but be careful
Two weeks before planned Arthroplasty

Complications

✓ Infection
- very rare if good sterile technique ( $< 1 : 10000$ )
✓ Bleeding / Haemarthrosis
✓ Vasovagal syncope
✓ Pain
Cartilage injury
- Poor technique

What to Do with Aspirate?

Visual Assessment

Check yourself
- Clear colorless: normal
- Clear yellow:
  - can read through: non-inflammatory
- Turbid: Inflammatory
- Pus
- Blood

Laboratory Analysis

Send for:
- ✓ Cell count with differential
  - in purple-top tube
- ✓ Gram stain / Culture and sensitivity
  - in sterile container or red-top tube
- ✓ Crystals
  - In red-top tube
- ✓ Glucose, Total Protein

Joint Injection

Medications

✓ Steroids
✓ Local anesthetics +/-
Other material:
- ✓ Hyaluronic acid ?
- Glucosamine ???
- Chondroitin ???

Indications

1. Inflammatory Arthritis

(e.g. rheumatoid arthritis, spondyloarthropathies)
Up to six months improvement from a single joint injection

2. Osteoarthritis (OA)

A weaker indication for steroid injection

Soft Tissue Injection

Treatment of Localized Inflammation

Bursitis
- Trochanteric, subacromial, prepatellar, olecranon
Flexor tenosynovitis (Trigger finger / thumb)
Tenosynovitis (DeQuervain’s)
Lateral epicondylitis (Tennis elbow)
Medial epicondylitis (Golfer’s elbow)
Plantar fasciitis
Adhesive capsulitis – Frozen shoulder
Carpal tunnel syndrome

Tennis Elbow (Lateral Epicondylitis)

Have you ever heard of tennis elbow or suffered from elbow pain? Continue reading to learn about this condition and a new study that may change the way we approach treating this problem.

Steroid injection for tennis elbow

INJECTION TARGET Therapeutic agent is injected between the bone and the common extensor tendon (about 1 cm anterior to the lateral epicondyle with the elbow in a flexed position)

Golfer’s Elbow (Medial Epicondylitis)

Pain occurs on the inside part of the elbow where the tendons of the forearm connect to the medial epicondyle. Pain may spread down the forearm to the wrist.

Types of Casts (techniques), traction (techniques), Splints, nails, implants, slings, and mobility aid

Traction

Type of Traction	Purpose	Usage	Advantages	Attachments	Disadvantages/Complications
Manual Traction	Obtain closed reduction of a fracture or dislocation by direct pulling force from a physician.	During manipulation for fracture or dislocation reduction.	Direct and immediate control for reduction.		Requires skilled practitioner; not sustained.
Skin Traction	Reduction, maintaining alignment, immobilizing joints, pain relief. Primarily for muscle spasm, shortening, and overcoming gravity.	Children (<2 years for Gallows traction, max 10-12 kg) and temporary management in adults (<3 weeks duration, <4.5 kg weight limit).	Easy to apply; no risk of bone infection or epiphyseal plate injury.	Types: Gallows Traction: Fixed Traction (Thomas Splint): Balanced Traction (Thomas Splint): Cervical Skin Traction:	Costly due to hospital stay; hazards of prolonged bed rest (thromboembolism, decubitus ulcers, pneumonia, UTI, depression); requires meticulous nursing care. Contraindicated with skin damage (DM, varicose ulcers), wounds, marked swelling, circulatory problems.
Skeletal Traction	Strong, sustained pulling force for fracture reduction and alignment, pain relief, and overcoming muscle spasms. Used when stronger force is needed or for longer duration.	Adults (when surgery is not possible/desirable), when >4.5 kg weight is needed, or traction needed for >3 weeks. Common pin sites: upper tibia, femoral condyle, calcaneum, skull.	Reduces and maintains limb length and alignment; maintains reduction; reduces pain and muscle spasm.		Infection; over-distraction; nerve damage (from heavy force or direct injury during insertion, e.g., common peroneal nerve); bone fragmentation/break; pin breakage.

Fixed Skin Traction on Thomas Splint

https://www.youtube.com/watch?v=nu9xgb1mOu8&pp=ygUpRml4ZWQgU2tpbiBUcmFjdGlvbiBvbiBUaG9tYXMgU3BsaW50IG9zY2U%3D

https://www.youtube.com/watch?v=wE21tHW7CPo

https://www.youtube.com/watch?v=7BEZTVqUBe0&pp=ygUpRml4ZWQgU2tpbiBUcmFjdGlvbiBvbiBUaG9tYXMgU3BsaW50IG9zY2U%3D

Procedure Category	Steps	Key Considerations …
Skin Traction Application	1. Two persons required.	Manual traction is performed by an assistant to realign the limb and reduce pain. The assistant continues pulling throughout the entire procedure.
	2. Apply skin traction with centralized end piece.	Ensures correct traction pull. Keep traction tape away from heel skin (5cm) to prevent skin breakdown and discomfort.
	3. Smoothly apply traction tape on skin.	Ensures even pressure and adhesion. The upper part of the traction tape should be below the fracture level.
	4. Apply bandage evenly with 50% overlap.	Bandage should not be too tight or too loose. Prevents pressure on the fracture site.
Thomas Splint Application	1. Prepare splint by adding bandage or foam pads between medial and lateral bars.	Provides comfort and prevents skin irritation.
	2. Apply Thomas splint correctly while assistant continues pulling.	Ensures proper alignment and immobilization. Position the angulated bar on the lateral side for correct orientation and effective traction.
	3. Push the ring as high as possible.	Allows for maximum leverage and traction.
	4. Pull rope and fix to the end of Thomas splint.	Applies the fixed traction.
	5. Apply a pillow under the splint (no pressure under the heel).	Prevents pressure sores on the heel.
	6. Check tightness of rope.	Ensures appropriate and effective traction force.

Application Procedure

Describe this method of treatment
- Skin traction
- On Thomas splint
- Fixed at the end of splint
What is this method used for?
- Immobilization of fracture femur
- For transportation to avoid complications
What are the limitations of skin traction?
- Skin lesions/wound
- Weight needed above 10 Lbs. (4-5 Kg.)
- Duration more than 3 weeks What are the possible complications of skin traction?

Skin problems: blisters, ulcers, allergies…
Prolonged immobilization of patient:
- Bed sores
- UTI, chest infection
- Depression
- Cost of prolonged hospitalizatio

Overview of Fixed Skin Traction

Description: Skin traction applied on a Thomas splint, with the traction fixed at the end of the splint. Purpose: Immobilization of a fractured femur, particularly for transportation, to avoid complications.

Limitations of Skin Traction

Presence of skin lesions or wounds.
Required weight above 10 lbs. (4-5 kg).
Duration exceeding 3 weeks.

Possible Complications of Skin Traction

Skin problems: blisters, ulcers, allergies.
Complications from prolonged immobilization:
- Bed sores
- Urinary Tract Infections (UTIs), chest infections
- Depression
- Cost of prolonged hospitalization

Additional Information:

Thomas Splint Indications: Immobilization of femur fractures for patient transportation; application of fixed traction.
Thomas Splint Parts: A. Ring, B. Lateral bar (angulated), C. Medial bar.
Thomas Splint Types: Complete ring (original design) and Half-ring (easier to apply).
Modern Traction Splint: Easily holds a lower limb with straps and simplifies fixed traction application.

Skeletal Traction: OSCE

https://www.youtube.com/watch?v=pbHRbdOsvH4

Category	Detail …	Image Reference
Definition	Inserting a metal (Steinman pin) into the bone and applying traction on it.
General Technique Overview	1. Sedation (if needed) 2. Antiseptic skin preparation and draping 3. Local anesthesia 4. Stab incision 5. Pin insertion with T-handle/drill 6. Second stab incision (exit site) 7. Sterile gauze application 8. Stirrup and traction application (10% of patient’s body weight)
Equipment Needed prior to starting	- Disinfectant - Sterile towels - Needles and Syringe - Local anesthetic (e.g., 5 ml of 2% lignocaine) - Scalpel with pointed blade - Sharp pointed Steinmann pin - T-handle - Stirrup
Entry Points	Proximal Tibial Site: - Insertion: Laterally at a point 2cm distal and 2cm posterior (lateral) to the Tibial tuberosity. - Exit: Medially. - Avoids: Injury to the common peroneal nerve. Distal Femoral Site: - Insertion: Medially at level of upper patella in-line with mid-femur. - Exit: Laterally. - Avoids: Popliteal vascular damage and intra-articular injury.	Proximal Tibial Site: Distal Femoral Site:

Splints & Braces

Splint/ Brace Type	Region	Indications	Application Notes …	Attachments
Figure-of-8 Brace	Upper Limb	Immobilization of clavicle fractures	Wear with shoulder pressing back in an arch position; can use ready-made brace or foam sling.	, ,
Arm Sling	Upper Limb	Shoulder support in shoulder and clavicle injuries; forearm support (in cast)	Shoulder adducted, elbow flexed 90°, wrist at neutral position; supports the elbow and overcomes gravity.	]
Arm Sling with Shoulder Immobilizer	Upper Limb	Shoulder support after major surgeries	Shoulder adducted, elbow flexed 90°, wrist at neutral position; sling supports shoulder by applying waist sling keeping shoulder adducted.
Forearm Sling	Upper Limb	Support in humerus fractures (allowing traction by gravity); forearm support (in cast)	Shoulder adducted; elbow not supported to allow gravity to pull down on humerus.	,
Back Supports	Spinal	Limiting motion of spine to enhance healing (after surgery or in stable fractures); reduces back pain and discomfort (in back sprains/muscle pain)	Types: soft or rigid with rods; thoraco-lumbar, lumbar, lumbo-sacral. Precaution: Long-term use causes muscle weakness.	, ,
Soft Cervical Collar	Spinal	Partial support of cervical spine and neck muscles; muscle spasm, post-operative, nerve root entrapment syndrome in cervical spine	Choose proper size (height/length); apply reasonably tightly under the chin. Precaution: Long-term use causes muscle weakness.
Rigid Cervical Collar	Spinal	Trauma emergency (suspecting neck injuries); head/facial/forehead injuries, neck pain, unconscious patients	Adjust to proper height; use traction to support neck while applying; apply around neck with chin piece fitting well; optional anterior opening for tracheostomy.	, , , , , ,
Knee Immobilizer	Lower Limb	Immediate after knee injuries (instability, patellar fractures, haemarthrosis); post knee surgery	Apply with wider end on upper thigh; ensure opening is on the patella; apply tightly from up downwards.	,
Hinged Knee Splint	Lower Limb	Used in collateral ligament injuries	Supports and stabilizes injured knee (prevents varus/valgus movements); allows flexion/extension (hinged metal supports on sides).	, , ,
Ankle Foot Orthosis (AFO)	Lower Limb	Foot support for foot drop	Wear shoe on top of brace.	,
Silicone Spacer/Splint	Lower Limb	Adolescent hallux valgus (cosmetic complaint); initial treatment choice in mild cases	N/A	,
Malleable Finger Splints	Hand and Wrist	Phalangeal fractures; sprained interphalangeal joints	Flexion of MCP joint and extension of interphalangeal joints.	, , ,
Mallet Finger Splint	Hand and Wrist	Mallet finger injury (rupture/avulsion of extensor tendon at distal phalanx)	Finger must be fully extended in the DIPJ.	, ,
Wrist Splint	Hand and Wrist	Wrist support after minor soft tissue injuries and sprains; wrist immobilization for carpal tunnel syndrome (pre/post surgery); temporary intermittent support after cast removal post fractures	Rigid/metal part with a bend at the volar aspect; wrist immobilized in slight dorsiflexion.	,
Thumb Splint	Hand and Wrist	Thumb support after minor soft tissue injuries and sprains; Tenosynovitis (immobilizing thumb to reduce pain and inflammation of tendons)	Rigid/metal part on the dorsum of the thumb.	,

Implants & Nail types

Description	Specific Details …	Image Links
K-wire (Kirschner Wire)	Indications: Pediatric fractures, small bone fractures in adults. Advantages: Easy to apply/remove. Disadvantages: Not stable alone, risk of infection.	, , , , ,
Tension-band Wires	Indications: Patellar and olecranon fractures, possible in malleolar fractures. Application involves K-wires as a base.	, , , ,
Orthopedic Screws	Material: Stainless steel or Titanium. Thread design varies by bone type (Cortex vs. Cancellous screws). Available in various sizes and lengths.
Screw Types - Fully vs. Partially Threaded	Fully threaded: Provides purchase. Partially threaded: Provides lagging (compression).	,
Screw Types - Partially-threaded Screws	Function: Achieve compression across fracture site (lag screw). Fully threaded can compress if cortex is over-drilled.	,
Screw Types - Cannulated Screws	Feature: Hollow, inserted over a wire for accurate placement in minimally invasive techniques.	, , , ,
Screw Types - Locked-head Screws	Feature: Threaded heads to anchor to special plates. Advantage: Good for osteoporotic bone, preserves periosteal blood supply by not pressing on bone.	,
Plate and Screws	Indications: Metaphyseal fractures, forearm fractures, complex long bone fractures. Advantages: Anatomical reduction. Disadvantages: Limits early weight-bearing, exposes fracture site.
Plate Functions	Functions: Compression, Bridging, Protection, Buttress.
Plate Types - Dynamic Compression Plate (DCP)	Feature: Oval holes designed for dynamic pressure between fracture fragments. Use: Simple diaphyseal fractures.	, ,
Plate Types - Bridging Plate	Feature: Provides stable fixation, maintains length, alignment, and rotation. The fracture site is undisturbed.
Plate Types - Semi-tubular Plate	Design: Shaped like half a tube. Indications: Lateral malleolus/fibula, metacarpals/metatarsals.	, ,
Plate Types - Locked Compression Plate (LCP)	Feature: Combination hole (oval and serrated). Advantages: Resists screw loosening/pullout, good for osteoporotic bone, preserves periosteal blood supply. Indications: Osteoporotic bone fractures, bridging comminuted fractures.	, , ,
Plate Types - Buttress Plate (T-Plate/L-Plate)	Indications: Lateral or medial tibial plateau fractures, distal radius fractures.	, , ,
Plate Types - Anatomical Plates with Locked Screws	Indications: Metaphyseal fractures. Advantages: Anatomically contoured, excellent fixation in metaphyseal areas and osteoporotic bone.	, ,
Dynamic Hip Screw (DHS)	Indications: Fixation of intertrochanteric fractures.
Inter-locking Nail	Indications: Fractures of long bones. Advantages: Minimally invasive, preserves fracture hematoma, allows early weight-bearing on lower limb.	, , ,
Orthopedic Staples	Indications: Foot surgery, epiphysiodesis for lower limb deformity correction.	,

OSCE Procedure: Upper Limb Cast Application

https://www.youtube.com/watch?v=kmMgML5Hp0Y&t=260s

Phase	Step	Action
1. Preparation	Pre-procedure	1. Introduce yourself, confirm patient identity, and explain the procedure, including risks and benefits, to obtain informed consent. 2. Ask about allergies to casting materials.
	Gather Equipment	Assemble all necessary materials on a trolley: • Stockinette • Padding roll (e.g., Soffban®) • Casting material (Plaster of Paris or Synthetic) • Bowl of water • Bandage scissors, crepe/conforming bandage • Sling, optional felt for bony prominences.
	Prepare the Patient	1. Position the patient comfortably (usually seated). 2. Expose the limb adequately. 3. Have the limb held in the specific required position. Correct positioning is critical for functional outcome. • Above Elbow Cast: Elbow at ~90° flexion. • Colles’ Cast: Wrist in slight palmar flexion and ulnar deviation.
2. Application	1. Apply Stockinette	Apply a tubular stockinette over the limb, ensuring it is smooth and extends beyond the planned cast margins.
	2. Apply Padding	1. Apply the padding roll (wadding) over the stockinette using a 50/50 overlap technique. 2. Apply extra felt padding over bony prominences like the ulnar styloid.
	3. Prepare & Apply Casting Material	1. Submerge the plaster or synthetic roll in water until bubbling ceases. Gently squeeze out excess water. 2. Begin applying the roll, overlapping by 50% for even thickness. For wrist casts, roll from “within out” through the thumb grip. For synthetic casts, it helps to cut a small curve in the bandage to navigate the thumb web-space smoothly. 3. For a slab, measure and create a 5-8 layer slab, dip it, and apply it to the limb. Secure it with a pre-soaked and squeezed-out crepe bandage to prevent shrinkage and constriction.
	4. Mould the Cast	While the material is setting, use the palms of your hands (not fingers) to mould the cast to the limb’s contours. For wrist casts, mould well into the palm to support the transverse metacarpal arch.
3. Finishing & Post-Application	1. Trim the Cast	Before it fully hardens, trim the cast edges to allow full movement of uninvolved joints. • Below Elbow: Expose the palmar crease for full finger flexion and ensure the thumb is completely free. The cast should end two fingers below the elbow crease. • Above Elbow: The cast should extend from the axilla to the knuckles.
	2. Finish the Edges	Fold the excess stockinette back over the cast edges and secure it with a final strip of plaster or adhesive tape.
	3. Final Checks	1. Perform a full neurovascular assessment distal to the cast (check for the “5 Ps”: Pain, Pallor, Pulselessness, Paresthesia, Paralysis). 2. Rest the limb on a pillow or in a sling for elevation.
	4. Patient Education	Provide clear verbal and written instructions on: • Cast care (keep dry, do not insert objects). • Warning signs requiring immediate medical attention. • Exercises for fingers, shoulder, and other free joints. • Arrange a follow-up appointment.

Cast of upper limb

Materials

Plaster of Paris (Gypsum)
Synthetic Fiberglass

Order of appliance

Tubular Bandage
(Optional) Felt padding for specific areas
Padding Roll (Wadding)
(Dip casting material in) Water (for activation)
Plaster Roll OR Synthetic Cast Roll (applied and molded)

Exam

Examination of Shoulder

https://www.youtube.com/watch?v=vu1vuugtvIo&t=1s&pp=ygUcRXhhbWluYXRpb24gb2YgU2hvdWxkZXIgT1NDRdIHCQkDCgGHKiGM7w%3D%3D

Item	Procedure …	Related Attachments
Opening	• Greet the patient and Introduce yourself. • Ensure proper hygiene and Ensure adequate privacy. • Take permission and Expose the patient. • Note general position, swelling, etc.
Look	• Inspect in all sides for scars, discolouration, swelling, and deformities from the front, sides, top, and back. • Look for muscle wasting of supraspinatus and infraspinatus muscles • Compare both deltoids; comment if they seem symmetrical. • Check for winged scapula. General on patient: Position, Major deformity- swelling, Extra (cast, splint, traction, dressing). Anatomic local: Skin, Subcut. (LN, veins, nerves, tendons), Muscles (bulk, wasting, twitches), Bones (landmarks, swelling, angulation and deformity), Joints (position, swelling, redness). Inspection from multiple angles: Anterior, Posterior, Lateral, Above, Axilla. Atrophy check (with patient sitting): supraspinatus fossa, infraspinatus fossa, deltoid.
Feel	• Temperature: Compare both sides (proximal to distal) and comment if symmetrical. • Tenderness: Palpate for tenderness (always compare to the left shoulder) starting at: • Sterno-clavicular (SC) joint • Clavicle • Acromio-clavicular (AC) joint • Greater Tuberosity (GT) & Biceps tendon • Scapular spine • Palpate and compare rotator cuffs (supraspinatus, infraspinatus) and deltoids. General: Tenderness (Generalized/specific), Temperature (compare distal/proximal, Rt/Lt). Anatomic: Skin, Subcut., Muscle (tone, bulk, twitches, gaps, tenderness), Bone (tenderness, mass, crepitus, landmarks: Sternoclavicular, Acromioclavicular, Coracoid Process, Greater Tuberosity, scapular spine, and scapula), Joint (swelling, effusion, crepitation, synovial thickening, joint line tenderness). Specific areas: Acromio-clavicular Jt., Bicipital groove.
Move	• Ask the patient to stand up. • Active ROM: First Assess range of motion - screen for pain. Ask to perform: • Forward flexion / Extension • Abduction / Adduction • External / Internal rotation • Comment on the motion (e.g., “full active motion, no need for passive”). • Passive ROM: If active motion is limited, assess passively. • Examine joints above and below (e.g., C-spine, elbow). Movement Directions (normal range): Abduction (150°), Forward flexion (180°), Extension (45°), External Rotation (90°), Internal rotation (90°). Flexion / Extension: Look at range, smoothness, painful motion. Abduction / Adduction: Shoulder joint motion is associated with Scapulo-thoracic motion. The first 20°-30° of abduction should not require scapulo-thoracic motion. Note the arc of painful movement (Painful Arc: Supraspinatus, Rotator cuff, Acromio-clavicular). Internal / External Rotation: Apley’s Scratch Test.
Special Tests	Rotator Cuff Power (compare both sides): • Instability (Bankart): Apprehension Test (abduct and externally rotate arm, apply anterior pressure, watch patient’s face). • Supraspinatus (Empty Can Test): Flex shoulder to 30° with thumbs down; ask patient to resist. • Impingement tests: Neer’s Impingement Test, Hawkins’ Impingement Test. or neer’s rotator cuff + abduction resistance for supraspinatus • Infraspinatus: Ask patient to perform external rotation against resistance (elbows at 90°). • Subscapularis: Ask patient to perform internal rotation against resistance OR use the Lift-Off Test. • Teres Minor: Ask patient to perform external rotation against resistance in 90° of shoulder abduction. • Biceps Tendon: Speed’s Test (resisted shoulder flexion with elbow extended and supinated) OR Yergason Test. • Deltoid: Axillary nerve assessment: Motor (active abduction - then drop test- Deltoid), Sensory (upper lateral aspect of arm). Serratus Anterior - Scapular Winging; long thoracic nerve: push against wall - observe back • AC Joint: Cross Body Adduction Test. • Muscle power tests: Abductors/Adductors, Internal/External Rotators, Serratus Anterior (winging), Biceps Brachii.	Apprehension test: Neer’s Impingement Test: Yergason Test: External / Internal Rotators Strength Test: Supraspinatus Test: Serratus Anterior - Scapular Winging; long thoracic nerve: Biceps Tendon & Ruptured long head:
Overall	End your exam with full neurovascular examination, and systemic examination • Thank patient, cover, document. Maintain a professional and empathetic attitude with the patient.

Case: Adhesive Capsulitis (Frozen Shoulder)

Clinical Scenario

Patient: 55-year-old male, diabetic
Complaint: Pain and restriction of shoulder movement

Physical Examination Findings: 400

Assessment Questions

Q1: Describe the physical finding?

The patient is unable to raise his right hand above his head

Q2: What is your differential diagnosis?

Adhesive capsulitis (Frozen Shoulder) - Primary diagnosis
Acromioclavicular arthritis

Q3: What is the treatment for such a case?

Steroid injection
Physiotherapy
Arthroscopic release

Section 3: Shoulder Pathology & Examination

Questions 17-20: Shoulder Injuries and Tests

Clinical Scenario: 45 years old male fell from height and landed on his shoulder and presented to your clinic with painful shoulder.

Q17: What is the following test name and what does it test?

Apprehension test for anterior shoulder instability

Q18: What is the following test name and what does it test?

Empty can test for Supraspinatus power

Examination of the knee

Knee Exam

https://www.youtube.com/watch?v=17ZKya9yR2Y

https://www.youtube.com/watch?v=oyKH4EYfJDM

Item	Procedure	Purpose/ Indication …	Attachment Links	Positive Finding/Interpretation
Opening	Introduction, Privacy, Permission & Exposure	Initial patient interaction and setup
	Deformity and Extra	Initial visual assessment for gross abnormalities
Look	Compare both limbs, Skin, Muscle bulk, bony landmarks, hair distribution	Assess symmetry, signs of trauma, inflammation, muscle atrophy, structural changes	Visual examples - Skin, Muscle, Bone, Joint:	Swelling, scars, discoloration, hair changes, muscle wasting, bony protrusions, angulation, redness
	Back of knee	Assess for posterior aspect abnormalities, such as Baker’s cyst	Posterior aspect:	Swelling, tenderness, masses in the popliteal fossa
Feel	Tenderness (General, Localized): Quadriceps, Patella, Patellar tendon, Tibial tuberosity, Origin, and insertion of collateral ligaments, ACL, MCL	Identify areas of pain and inflammation in relevant structures	Tenderness - General: Tenderness - Localized: Medial Structures (Tibial Tuberosity, Joint Line, Medial Tibial Condyle, Patella, Medial Femoral Condyle, Joint Space, MCL): Lateral Structures (Quadriceps, Patella, Tibial Tuberosity, Head of Fibula, LCL, Lateral joint line):	Localized pain upon palpation
	Joint-line tenderness, medial and lateral	Assess for meniscal or collateral ligament pathology	Joint lines:	Pain upon palpation along the joint line
	Temperature: compare R & L, distal & proximal	Identify signs of active inflammation or infection	Temperature Comparison:	Increased warmth compared to contralateral side or unaffected areas
	Back of knee, baker’s cyst and tenderness	Further assess posterior knee for specific pathologies		Tenderness or swelling indicating a Baker’s cyst or other posterior pathology
	Anatomic Examination: Muscle (Quadriceps)	Assess muscle tone, bulk, and tenderness	Muscle (Quadriceps):	Abnormal tone, wasting, twitches, tenderness
	Anatomic Examination: Bone (Patella, Tibial Tuberosity, head of Fibula)	Assess bony landmarks for tenderness or deformity	Bone Landmarks:	Tenderness, mass, crepitus, abnormal landmarks
	Anatomic Examination: Joint assessment	Assess for swelling, effusion, crepitation, and synovial thickening	Joint Assessment:	Presence of swelling, effusion, crepitation, synovial thickening, joint line tenderness
Move	Active first: General screening for pain, then passive	Assess patient’s voluntary range of motion and pain patterns		Limited or painful active movement indicating muscle or joint involvement
	Flexion & Extension (Normal: Extension: 0° → Flexion: 140°)	Quantify the knee’s range of motion	Extension: Flexion:	Reduced or excessive range of motion; “lacks X degrees of extension”
	Locking (due to mechanical blockage)	Assess for mechanical obstruction within the joint	Locking:	Patient unable to fully extend or flex knee; suggests loose body or meniscal tear
	Hyper-extension	Identify excessive extension range	Hyper-extension:	Greater than normal extension of the knee joint
	Effusion: Milking OR Patellar Tap	Detect presence and severity of joint fluid	Large Effusion visible: Patellar Tap (Balloting):	Minimal effusion: Fluid demonstrable with “milking.” Mild effusion: Fluid pushed away, then reappears. Moderate effusion: Fluid not pushed away. Moderate/severe effusion: Positive patellar tap (balloting).
Special Tests	Collateral Ligaments: Varus and Valgus stress at 30 degree	Assess integrity of Medial (Valgus) and Lateral (Varus) Collateral Ligaments	Collateral Ligament Testing: Collateral Ligament Testing Views: Alternative Collateral Ligament Technique:	Increased laxity or pain during stress, indicating ligamentous injury
	Cruciate Ligaments: Overall indication	Assess integrity of Anterior and Posterior Cruciate Ligaments	Cruciate Ligaments Overview:
	ACL & PCL: Anterior/Posterior Drawer Test OR Lachman’s test OR Pivot Shift test	Assess integrity of Anterior and Posterior Cruciate Ligaments specifically	Anterior/Posterior Drawer Test: Lachman’s test:	Excessive anterior or posterior translation of the tibia, indicating ACL or PCL injury
	PCL: Drawer test OR posterior Sag test	Specifically assess Posterior Cruciate Ligament integrity	Sagging sign:	Posterior sagging of the tibia when the knee is flexed, indicating PCL tear
	Meniscus: McMurry’s test OR Medial & Lateral joint tenderness Apley grinding test	Assess for meniscal tears	McMurry’s test: Apley grinding test:	Click, thud, or pain during knee flexion, extension, and rotation during McMurray’s; pain during compression and rotation during Apley’s.
	Patellar test: Patellar Tracking Patellofemoral grind test Patellofemoral resistance test Patellar apprehension test	Assess patellar stability, patellofemoral pain, and chondromalacia	Patellar Tracking: Patellofemoral Grind Test: Patellofemoral Resistance Test: Patellar Apprehension Test: Summary of Patellar Tests:	Patellar Tracking: Abnormal movement of patella. Patellofemoral grind test: Pain during compression and quadriceps tightening. Patellofemoral resistance test: Pain with resisted patellar motion. Patellar apprehension test: Patient apprehension/discomfort when patella is pushed laterally.
Gait	Walking gait analysis (Normal, Antalgic, Lurch, Circumduction, High Step, Tip-toe)	Assess overall walking pattern and identify abnormalities Stance phase (60%) - Heel strike - Foot flat = mid-stance - Push off Swing phase (40%) (while foot is in air) - Acceleration - Mid-swing - Deceleration	Walking Gait Analysis: Normal Gait Cycle:	Deviations from normal gait cycle (e.g., painful weight-bearing, limping, compensatory movements). Normal: Normal stance and swing phases Antalgic: Painful to weight-bear – short stance phase Lurch: Shortening – painless limping – normal stance period Circumduction: Stiff hip – motion of pelvis compensates High Step: Foot drop – more hip & knee flexion needed to free toes from ground Tip-toe: Heel off the ground
Overall	Attitude with patient	Professional demeanor and interaction

Other Examinations

Examination of Spine

https://www.youtube.com/watch?v=5_txE56X2-8&pp=ygUZRXhhbWluYXRpb24gb2YgU3BpbmUgT1NDRQ%3D%3D

https://www.youtube.com/watch?v=pClOlpzo-Jc&pp=ygUZRXhhbWluYXRpb24gb2YgU3BpbmUgT1NDRQ%3D%3D

Spine Examination

Perform a general spinal examination.

Item	Procedure
Opening	• Introduction, Privacy, Permission & Exposure .Walk
Look	• General Position & Deformity • Skin, Muscles, and bony landmarks • Shoulder height from back • front, back, side: Standing OR Sitting .
Feel	• Tenderness, Temperature • Landmarks and muscles (central and paraspinal) • Sacro-iliac joints / Coccyx .
Move	• Forward flexion / Backward extension • R and L lateral flexion • R and L rotation .
Special Test (Ask to perform it & interpretation)	• Hoffmann’s sign: sitting ( Finger) • Spurling’s test: sitting (head)
	• Adam Foreword test: standing (Scoliosis, can be done with forward flexion)
	Sciatic - 45 degree pain - passive dorsiflex below it when no pain , test for tenderness • Straight Leg Raise test: supine • SLR Confirmatory test
	• Patrick / FABER test: supine
	Femoral Nerve • Femoral Stretch test: lateral or prone - Extend and flex the knee
Neurological (NOT IN CHECKLIST)	dermatome (fine, prick), myotome (power), reflexes, proprioception
General	• Attitude towards patient

https://www.youtube.com/watch?v=pJxMHa6SCgU&pp=ygUXU3BpbmUgTmV1cm9sb2dpY2FsIE9TQ0U%3D https://www.youtube.com/watch?v=pClOlpzo-Jc&pp=ygULU3BpbmUgIE9TQ0U%3D

Back ROM & Neurological

This patient has back pain radiating down to his right leg. examine the back

Item	Procedure	Technique …	Attachments
Look	General Examination
	On Patient	Standing, tilting forwards with hand on left side of lower back
	Local (Back, Shoulder, Flanks, Chest)	Position (best in standing), Views (Posterior, Lateral, Anterior), Normal curves and alignment
	Major Deformity and Swelling Assessment	Shoulder height, Deformity, Flanks, Space between arm and trunk, Masses
	Extra Items	Support (braces, walkers, etc.), Dressings
	Anatomic Local Examination
	Systematic Assessment	Skin (swelling, scars, color, hair, dryness), Subcutaneous (lymph nodes, veins, nerves, tendons), Muscles (bulk, wasting, twitches), Bones (landmarks, swelling, angulation, deformity), Joints (position, swelling, redness)
	Proper Exposure
	Comprehensive Look Assessment
Feel	Tenderness Assessment	Generalized (to start with), Specific (Spinous processes, Sacroiliac joints, Paravertebral muscles)
	Temperature Assessment	Compare distal/proximal, Compare right/left
	Anatomic Assessment	Skin (dryness, scars), Subcutaneous (nodules), Muscles (Paravertebral: spasm, bulk, tenderness), Bones (landmarks: spinous processes, iliac crest, coccyx - tenderness, mass), Joints (sacroiliac tenderness)
Move	General Motion Assessment	Change of shape/deformity during motion, Smoothness of motion, Extent (Range)
	Specific Movements
	Flexion and Extension
	R and L lateral flexion	Sideway Bending
	R and L rotation	Must be in Sitting position, help patient understand rotation movements
Special Tests	Structural Assessment Tests
	Adam’s Forward Test
	Sacro-iliac stress	Figure of four / or other tests (FABER Patrick Test)
	Neurological Tests
	Straight leg raise (Lasègue test)	In supine position, raise leg up with knee straight. Look and ask for pain. When pain starts, reduce leg raise, pain disappears. Now passively dorsi-flex ankle to reproduce pain.
	Femoral stretch	Femoral Stretch Test
	Neurological Lower Limb Examination
	Dermatomes	L1, L2, L3, L4, L5, S1
	Myotomes	Knee extension (L3,4), Knee Flexion (L5, S1), Ankle dorsiflexion (L4), EHL (L5), Ankle plantar flexion (S1), Eversion (S1), Great Toe Flexion (S1), hip L2-L3 flexor, hip extension (S1-S2)
	Reflexes	Knee jerk (L3,4), Ankle jerk (L5, S1) Babinski
	Functional Assessment
	Gait Assessment
	Standing and Sitting Assessment	Smoothness of action
	PR Examination	Per rectal examination when indicated
General	Attitude towards patient
Scoliosis Screening	Frontal Assessment	With child standing and facing you: Is one shoulder higher than the other? Is one arm farther away from the body? Are the hips level?	(Normal) (Abnormal) (Abnormal)
	Posterior Assessment	With child standing and facing away from you: Is one shoulder higher than the other? Is one shoulder blade higher than the other? Do the hips look uneven?	(Normal) (Abnormal)
	Forward Bending Assessment	With child bending away from you: Is one side of the rib cage higher than the other? Is the lower back uneven?
		With child bending toward you: Is one side of the rib cage higher than the other? Is the lower back uneven? Are the hips level?

McMaster MSK Examination Series

From: Raj Camona
Link: https://vimeo.com/36295624

Spine Examination – OSCE Guide

By: Lewis Potter
Link: http://geekymedics.com/spine-examination/

Examination of HIP

https://www.youtube.com/watch?v=Hkqr3mg6IWQ&pp=ygUUSGlwIEV4YW1pbmF0aW9uIE9TQ0U%3D

https://www.youtube.com/watch?v=R9IiCO9QjPY&pp=ygUUSGlwIEV4YW1pbmF0aW9uIE9TQ0U%3D

Item	Procedure	Additional Information …	Attachments
Look	General statement on the patient	General Assessment: Patient’s overall condition and comfort level. Local hip-thigh-lower limb assessment: Position and alignment, major deformities and swelling, external devices (casts, splints, traction, dressings). Anatomical Local Assessment: Skin (swelling, scars, color, hair distribution, dryness), Subcutaneous tissue (lymph nodes, veins, nerves, tendons), Muscles (bulk, wasting, fasciculations), Bones (landmarks, swelling, angulation, deformity), Joints (position, swelling, redness). Important: Always examine the posterior aspect.	Normal Positioning Left hip abnormal positioning Bilateral hip abnormal positioning Wheelchair positioning Local Hip-Thigh-Lower Limb Assessment (Position): Position assessment Postural Changes: Lumbar lordosis Major Deformities and Swelling: Major deformities Additional deformity examples More deformity examples External Devices (Immobilization): Cast example Additional cast examples More cast examples External Devices (Traction): Traction examples Additional traction examples More traction examples External Devices (Orthotics): Orthotics example 1 Orthotics example 2
	General on hip: Position/Swelling & deformity/ Attitude & extra
	- Anatomical: skin, subcutaneous
	- Muscles: Quadriceps, Gluteus Maximus
	- Bony landmarks: ASIS, Iliac crest, Lumbar lordosis
	Look at the back
Feel	Tenderness: Generalized/Specific points of tenderness	Palpation Assessment: - Tenderness: Diffuse vs. specific points. - Temperature: Compare distal/proximal and right/left sides. - Anatomical structures: Skin (dryness, hypo/hyperesthesia, scars), Subcutaneous (lymph nodes, nerves, vessels, tendons, nodules), Muscles (tone, bulk, fasciculations, gaps, tenderness), Bone (landmarks: ASIS, Greater Trochanter, Ischial Tuberosity; tenderness, masses, crepitus), Joint (swelling, effusion, crepitation, synovial thickening, joint line tenderness - hip joint too deep to elicit).
	- Bony landmarks: ASIS, Iliac crest, Lumbar lordosis
	- Temperature: Compare both sides, proximal and distal
	- Muscles: Quadriceps, Gluteus Maximus
Move	Active: General screening for pain	Movement Assessment Principles: - Active vs. Passive: Start with active movement to screen for pain. Passive assessment when needed for painless vs. painful ROM and muscle power. - Critical Technical Considerations: Differentiate true hip joint motion from pelvic motion. Stabilize the pelvis in neutral position. - Important note: Patients with fixed hip flexion may appear to have full range when supine by tilting the pelvis forward, which creates increased lumbar lordosis.
	Abduction / Adduction (compare with other side): ( ANY OF THESE) - Both together - Anchor one side at edge of table - Hold ASIS	Range of motion: Abduction: $4 5^{\circ}$ , Adduction: $1 5^{\circ}$ . Pelvic stabilization techniques: Perform motion on both hips simultaneously, anchor knee of opposite side over examination table edge, palpate ASIS to assess pelvic motion.	Range of Motion Assessment (Abduction/Adduction): Simultaneous abduction/adduction in flexion - Normal ranges: - Abduction: 45° - Adduction: 15° - Pelvic stabilization techniques: - Perform motion on both hips simultaneously - Anchor knee of opposite side over examination table edge - Palpate ASIS to assess pelvic motion Both hips simultaneously: - Stabilizes pelvis and compares both sides - Can be performed in flexion or extension Simultaneous abduction/adduction in extension Simultaneous assessment technique Edge of table stabilization Stabilizing the other hip at the edge of couch ASIS palpation technique Holding ASIS to assess beginning of pelvic motion
	- Flexion (compare with other side): - Extension (compare with other side):	Flexion: Initial position determined by Thomas Test. Procedure: Check for lumbar lordosis, flex opposite hip fully (lumbar lordosis disappears), check hip position, flex hip to assess range. Range of motion: Flexion from $3 0^{\circ}$ to $9 0^{\circ}$ . Extension: Normal range: $3 0^{\circ}$ . Positions for assessment: Lateral and prone. Important: In presence of fixed flexion deformity, extension is already in “minus” range and doesn’t require assessment.	Range of Motion Assessment (Flexion): Thomas Test positioning 1. Check for lumbar lordosis 2. Flex opposite hip fully 3. Lumbar lordosis disappears 4. Check hip position 5. Flex hip to assess range Flexion range measurement 30° to 90° - From 30° fixed flexion - To 90° flexion Flexion range measurement (alternative) Range of Motion Assessment (Extension): Extension - lateral position - Normal range: 30° - Positions for assessment: - Lateral position Extension - prone position
	Any of these two - External / Internal rotation: In extension, (both together) - External / Internal rotation: In flexion (compare with other side)	Must stabilize pelvis to prevent pelvic motion. Best technique: Perform on both hips simultaneously. Assessment positions: Supine with hips extended (observe patella orientation), Supine with hips flexed (use leg as pointer), Prone with hips extended.	Range of Motion Assessment (Internal/External Rotation): Supine with hips extended (observe patella orientation) Supine with hips flexed (use leg as pointer) Prone with hips extended
Special tests	- Thomas test	Purpose: Detect fixed flexion deformity of the hip. Positive Thomas test in neonates and young children is normal. Procedure: Assess lumbar lordosis before testing. Precaution: When knee has fixed flexion deformity, keep knee outside edge of couch.	Thomas Test (Precaution) Thomas Test (Solution)
	- Trendelenburg test	Purpose: Assess hip abductor strength and stability. Principle: Testing the hip the patient is standing on. Normal: Pelvis tilts down on weight-bearing hip (performed by hip abductors). Positive: Pelvis on non-weight-bearing hip tilts down AND trunk tilts to weight-bearing side. Causes of Positive Trendelenburg: Weak hip abductors, mechanically inefficient hip abductors, unstable pivot of motion, inhibited hip abductors (painful), reduced range of motion. Note: Almost any hip disease can cause a positive Trendelenburg test.	Trendelenburg Test setup Trendelenburg Test execution Normal vs Positive comparison Trendelenburg Test detailed Trendelenburg results
	- Leg length: True / Apparent	Galleazzi Test Purpose: Detect leg length discrepancy. Technique: Both heels must be at the same level. Apparent Length: Measurement: Midpoint to medial malleolus. Affected by: Pelvic tilt. Both lower limbs - Should be Parallel. True Length: Measurement: ASIS to medial malleolus. Not affected by Pelvic tilt. Position of both lower limbs - Should be identical.	Galleazzi Galleazzi Purpose: Detect leg length discrepancy Technique: Both heels must be at the same level ---- Apparent length measurement - Measurement: Midpoint to medial malleolus - Affected by: Pelvic tilt True length measurement - Measurement: ASIS to medial malleolus - Not affected by Pelvic tilt
	Neonatal Examination for Developmental Dysplasia of the Hip (DDH) - Ortolani Test / Barlow Test (NOT PART OF OSCE)	Ortolani Test Purpose: Reduces a dislocated hip. Expected finding: Feel a “clunk” (not a “click”). Barlow Test Purpose: Dislocates a reduced hip. Expected finding: Feel a “clunk” (not a “click”).	Ortolani Test technique Purpose: Reduces a dislocated hip - Expected finding: Feel a “clunk” (not a “click”) Barlow Test technique Purpose: Dislocates a reduced hip - Expected finding: Feel a “clunk” (not a “click”) Combined Ortolani/Barlow technique
Gait	- Walking	Normal Gait Cycle: Stance phase (60%): Heel strike, foot flat - mid-stance, push off. Swing phase (40%): Acceleration, mid-swing, deceleration. Abnormal Gait Patterns: Antalgic (painful to weight-bear - short stance phase), Lurch (shortening - painless limping - normal stance period), Circumduction (stiff hip - motion of pelvis compensates), High Step (foot drop - more hip & knee flexion needed to free toes from ground), Tip-toe (Heel off the ground - L4/L5).	Normal gait cycle
Overall	Attitude with patient	Summary of Orthopedic Examination System: Look, Feel, Move, Special tests. Sub-system helps ensure no steps are forgotten. Key considerations for hip examination: Important exposure considerations, stabilize pelvis in “Move” assessment, Special tests (Thomas, Trendelenburg, instability tests, length measurements), Gait assessment is essential.

examiner focused on movement and special tests
Compare between both hips during movement assessment
Perform both active and passive movements
Assess Range of Motion (ROM) and pain

Station 3: Hip Examination

Hip Examination

Case B: Pelvic Trauma

4.1) Open Book Fracture Management

1. Diagnosis? Answer: Open book fracture

2. Initial management? Answer: ATLS protocol, pelvic binder application

3. Mention 3 complications: Answer:

Bleeding
Pelvic instability
Neurological injuries

4. Difference between stable and unstable management:

Stable open book fractures can typically be managed non-operatively, with the use of a pelvic binder or external fixation to stabilize the anterior pelvic ring until the injury heals.

Unstable open book fractures require surgical intervention to achieve anatomic reduction and stabilization of both the anterior and posterior pelvic rings.

Neurological Examination

Upper Limb Neurological Clinical Examination Station

https://www.youtube.com/watch?v=4uAAjYzi7SY&pp=ygUcVXBwZXIgbGltYiBuZXVyb2xvZ2ljYWwgT1NDRQ%3D%3D

Section	Item …	Procedure
Look	Skin	Dryness/scars/wounds/ulcers. (Can’t do abduction of the thumb so it will be in adduction position. Specific for each.)
	Median	Thenar Muscles wasting and adducted thumb (ape hand), Pointing Index.

	Ulnar	Hypothenar muscle wasting, Ulnar Claw hand – in low lesions (in high lesions ulnar ½ of FDP is paralyzed, no claw hand) (ulnar paradox).

	Radial	Wrist drop.
Feel	Ulnar	Ulnar one and a half fingers (volar aspect medial half of forearm).
Sensation	Median	Sensation lateral three and half digits on palmar surface & distal phal. on dorsum (volar aspect lateral half).

	Radial Nerve	dorsal aspect. over lateral part of the dorsum of the hand (more prominent at anatomical snuffbox)

	Ulnar Nerve
Median N (Lesion above elbow)	Loss of wrist flexors	(Flexor-carpi-radialis).
	OK sign not possible	Loss of flexion of thumb and index finger (Flexor Pollicis longus and Flexor Digitorum Profundus for index finger).

	Loss of forearm pronation	(both Pronators): pronate against resistance.
	Loss of thumb opposition	(Opponens Pollicis).
Carpal Tunnel	Tinel’s sign	(It came with numbness in Median N Sensation).

	Phalen’s sign

Ulnar N	Adductor Pollicis	Froment’s sign.
	Palmar & Dorsal Interossi	Abduction/Adduction of fingers (against resistance).
	Paralysis of 3rd & 4th Lumbricals	The lumbrals are deep muscles of the hand that flex the metacarpophalangeal joints and extend the interphalangeal joints. (In lesion extension of MCP and flexion of IP).
	Abductor digiti minimi	Abduction of little finger against resistance.
Radial N	Loss of elbow extension	(Triceps) – in high lesions.
	Loss of wrist extension
	Loss of thumb extension	(Extensor Pollicis longus and brevis).
	Loss of extension of fingers MP joints	(Extensor Digitorum). (If I can extend my wrist, but I can’t extend my PI. So, the problem is in the Posterior Interosseous Nerve).
Axillary N (NOT IN CHECKLIST)	Arm Drop Test (Deltoid Test)	Patient stands with arm at side. Examiner passively abducts arm to approximately 90°. Patient asked to actively maintain position. Examiner releases support. Positive Test Result: Arm drops from abducted position. Inability to maintain shoulder abduction. Indicates: Deltoid weakness/paralysis.

Overall	Attitude with patient	(throughout the examination).

Lower Limb Neurological Clinical Examination Station

https://www.youtube.com/watch?v=-7ERNH_o5Ss&pp=ygUcTG93ZXIgbGltYiBuZXVyb2xvZ2ljYWwgT1NDRQ%3D%3D

https://www.youtube.com/watch?v=LH-HuLSGNC8&pp=ygUcQmFjayBST00gJiBOZXVyb2xvZ2ljYWwgT1NDRQ%3D%3D

• Perform a neurological exam of the lower limb.

Item	Procedure
Opening	• Introduction, Privacy, Permission & Exposure
Dermatomes	• L1, L2, L3
	• L4, L5, S1
Myotomes	HIP - L3 • Knee extension (L3, L4)
	• Knee Flexion (S1, S2)
	• Ankle dorsiflexion (L4)
	• Great Toe Extension (L5)
	• Ankle plantar flexion (S1)
	• Great Toe Flexion (S2)
Reflexes	• Knee jerk (L3, L4) - gaurd hand
	• Ankle jerk (L5, S1)
General	• Attitude towards patient

hof clonus babinsk .. rev- UML signs…

Name this test and what it’s indicating for?

Hoffman’s sign
It indicates an upper motor neuron lesion.

Peripheral Nerve Examination

Cases

Orthopedic Emergencies Summary

Condition	Definition & Risk Factors	Assessment Plan (History, Clinical Features, Investigations)	Management Plan	Differential Diagnosis	Complications & Contraindications
Compartment Syndrome	Increased pressure within a closed fascial compartment, leading to reduced tissue perfusion, hypoxia, and irreversible muscle and nerve damage. Causes: Fractures (especially tibia/forearm), severe soft tissue trauma, arterial injury, burns, tight casts/dressings, post-ischemic reperfusion swelling, IV fluid extravasation, and bleeding disorders (e.g., hemophilia). High-Risk Notes: Pain may be absent in altered consciousness, children (monitor analgesia response), polytrauma, sedated/epidural cases, or concomitant nerve damage. Open fractures do not always decompress pressure. Gross/Clinical: -tense, shiny leg swelling with blisters in compartment syndrome. Imaging: - Intraoperative fasciotomy	History/Symptoms: Pain out of proportion to the injury (e.g., a “bursting” sensation), which is not relieved by analgesia. Clinical Features (The 5 P’s): - Pain with passive stretch (early, key sign; e.g., ankle dorsiflexion for leg, wrist for forearm). - Paresthesia (early). - Palpable tense swelling (shiny skin, blisters: clear=mild, serosanguinous=severe, bloody=worst; dusky/pallor skin). - Pallor, Paralysis, Pulselessness (late, ominous signs; pulses often palpable until late). Investigations: Primarily a clinical diagnosis (high suspicion key). Compartment pressure measurement can confirm: absolute pressure >30 mmHg or Delta Pressure (Diastolic BP - Compartment P) ≤ 25 mmHg.	Initial: ABCs, supplemental oxygen. Remove all circumferential dressings, casts (bivalve to skin), and splints. Elevate the limb to heart level (not above; higher reduces inflow). Correct any hypotension. Surgical: Urgent Fasciotomy if no response within 1h or confirmed pressure (prophylactic in high-risk like major osteotomy). Release all compartments/skin with long incisions; debride necrotic muscle via 4C’s (early: pink/red, soft, contracts/bleeds on pinch; late: dark, firm, no response); preserve neurovascular. Wound open (bulky dressing/splint, VAC, or boot-lace gradual closure); repeated inspections x48h; coverage in 3-5 days (skin graft usual; flap if nerves/vessels/bone exposed).	Cellulitis, Deep Vein Thrombosis (DVT), Arterial occlusion, Severe soft tissue injury without compartment syndrome; equivocal cases in polytrauma.	Complications: Volkmann’s ischemic contracture (permanent deformity, weakness, sensory loss, chronic pain). Contraindications (Fasciotomy): Confirmed >48h (irreversible damage, high infection risk from dead tissue); crush injuries with already necrotic muscle.
Open Fracture	A fracture with a breach in the overlying skin and soft tissues, creating communication with the external environment. All open fractures are considered contaminated (even small punctures; aka compound fracture). Causes: Can result from high-energy trauma (RTAs, falls, firearms; signs: degloving, crush syndrome, bone loss, segmental) or low-energy trauma. Contamination risk higher with farm/soil injuries, bites, delayed presentation (>12h), fecal/oral/soil/water exposure. Mechanism: Low/high velocity missiles (cavitation >300 m/s); in-out (cleaner) vs. out-in (dirtier). Gross/Clinical:	History: Mechanism of injury (energy, time, place, type/impact method), consciousness, wound size/bleeding amount, other injuries (often missed), tetanus status. Assessment: ATLS protocol (ABCDE) first (treat patient, not fracture; exclude shock/brain injury, monitor vitals; viscera exam: ribs=lungs/liver/spleen, pelvis=bladder/urethra). Examine wound (look/feel/move carefully post-splint), check distal neurovascular status, compartment syndrome. Photograph/remove gross contamination; cover with saline dressing. *Classification (Gustilo-Anderson): - Type I: <1 cm wound, clean, minimal soft tissue. - Type II: >1 cm wound, moderate soft tissue (no stripping). - Type IIIA: Extensive soft tissue damage, but adequate bone coverage. - Type IIIB: Extensive soft tissue loss with periosteal stripping; bone exposed, requires flap coverage. - Type IIIC: Any open fracture with an arterial injury* requiring repair.	Initial (ER): ATLS first. Cover wound with sterile saline-soaked dressing, splint limb, IV fluids (request blood if needed); traction if no distal pulse/deformity. Prophylaxis: Tetanus prophylaxis/serum and broad-spectrum IV antibiotics immediately (culture tissue/blood); clean major contamination. Surgical: Urgent debridement/irrigation within 6-12h (“Dilution is the solution to pollution”; pulse-irrigate 3-6-9L saline; excise non-viable tissue/foreign material, trim skin edges, remove dead muscle/detached bone, preserve N/V). Stabilization: external fixator (preferred severe; replace with cast post-infection); internal if clean/minimal. Wound closure delayed (primary if small/clean; secondary if contaminated/large). Early soft tissue cover.	The diagnosis is typically obvious. Key: Classify severity; identify associated injuries like compartment syndrome, vascular damage, or high-energy signs (e.g., crush). Differentials for contamination: Primary (field debris) vs. secondary (post-fixation if poor debridement).	Complications: Infection (cellulitis, osteomyelitis, chronic with sequestra/drainage, gas gangrene), tetanus; higher with delay/exposure/bites. - embolisms fat, thrombi others.. Case Insight: Unconscious patient (e.g., open tibia post-RTA): ABCDE/cervical collar, distal pulses/traction, admit for debridement; ankle fall: Splint post-ABC, assess neurovascular.
Septic Arthritis	An infection within a joint space, leading to purulent effusion and rapid destruction of articular cartilage (damage within 8 hours). Risk Factors: All ages; pediatric (<2y, hip; prematurity/C-section); adult (>80y, knee; diabetes, RA, cirrhosis, HIV, crystal arthropathy, endocarditis/bacteremia, IV drug use; psudomonas, recent surgery). Route: Hematogenous (most common), direct inoculation/trauma/surgery, contiguous from osteomyelitis/soft tissue (esp. intracapsular metaphysis: hip/shoulder/elbow/ankle/umbilicus). S. aureus most frequent (>50%). ⇒ - Swollen and erythematous knee joint with visible effusion in septic arthritis. Imaging: - X-ray demonstrating early joint space changes in pediatric hip septic arthritis.	History: Acute onset of single hot, swollen, painful joint, fever/malaise; vaccination history (children). Age-specific: Neonates (irritability, feeding refusal, pseudo-paralysis, no fever); children (ill appearance, high fever, no weight-bearing); adults (superficial: knee/ankle/wrist). Clinical Features: Joint in resting position; extreme pain on movement (active/passive); inflammation (red, hot, swollen, effusion/fluctuation). Investigations: - Labs: High WBC (neutrophils), ESR/CRP (CRP early); Blood cultures positive ~50%. - Joint Aspiration: (guide via US); fluid: WBC >50,000/μL, >50% PMNs, positive Gram/culture (>50%); glucose/protein low, no crystals; alpha-defensin. Table: Normal (<200 WBC, clear); Noninflammatory (<2k WBC, yellow); Inflammatory (2-50k WBC, cloudy); Septic (>50k WBC, pus/yellow, culture+). - Imaging: Early X-ray normal/widened space/subluxation (infants: lateral femur); later narrowing/bone involvement; US for effusion; MRI for effusion/bone (emergent challenge). Kocher criteria (children hip): Fever >38.5°C, non-weight bearing, WBC >12k, ESR >40 mm/h (0=0.2%, 1=3%, 2=40%, 3=93%, 4=99% septic); CRP >2 mg/dL predictor.	This is an orthopedic emergency. Medical: Admit, NPO, IV fluids, splint joint. Joint aspiration first, then empiric IV antibiotics (age/risk-based: flucloxacillin Gram+; 3rd-gen cephalosporin neonates; Lyme if endemic; don’t delay surgery; IV 3 weeks + oral 2-3 weeks; monitor WBC/ESR/CRP; organism-specific post-culture). Surgical: Emergency irrigation/debridement (arthrotomy/washout); if pus/turbid, open drainage.	Transient Synovitis (children 4-8y, M:F 2:1, self-limited 2-7 days w/NSAIDs like ibuprofen; risk: trauma/viral; resolves <1 week; table: fever <38.5, weight-bearing yes, WBC <12k, ESR <40), Gout/Pseudogout (crystals+), Other differentials Reactive arthritis, Hemarthrosis (trauma/hemophilia), Lyme disease, Cellulitis, Acute osteomyelitis (nearby metaphysis), Rheumatic fever.	Complications: Rapid cartilage destruction, osteoarthrosis (partial), joint dislocation (tense effusion), epiphyseal destruction (neonates: pseudoarthrosis), ankylosis (massive; adhesions/fibrosis). Case Insight: 14y boy hip post-fall (fever, limited motion, WBC 13k, ESR 23; early X-ray normal, late destruction if delayed).
Cauda Equina Syndrome	Compression of the bundle of nerve roots at the lower end of the spinal cord (the cauda equina; thecal sac). Causes: Most commonly large central lumbar disc herniation. Other: spinal stenosis, tumor, epidural abscess/hematoma, trauma. - Sagittal MRI of lumbar spine showing central disc herniation compressing nerve roots.	History/Symptoms (Red Flags): - Back pain (most common), bilateral sciatica/leg pain (2nd). - Saddle anesthesia (numbness in perineum, buttocks, genitals; highly specific). - Bladder/Bowel Dysfunction: Urinary retention (early) → overflow incontinence (late); unilateral/bilateral leg sensory/motor changes. Clinical Exam: Reduced anal tone, perineal sensory loss, lower limb weakness. Investigations: Urgent MRI to confirm diagnosis/cause (essential for early detection).	This is a neurosurgical emergency. Surgical: Immediate decompression to prevent permanent deficits; perform within 24h (absolutely <48h) of symptom onset.	Conus Medullaris Syndrome, Severe bilateral radiculopathy, Peripheral neuropathy.	Complications: Permanent leg paralysis, urinary/fecal incontinence, sensory/motor deficits.
Joint Dislocation	A complete disruption and loss of contact between the articular surfaces of a joint. Neurovascular status must be checked/documented before/after reduction (3 E’s for shoulder: epilepsy, electric shock, ETOH). Causes: Vary by joint. Shoulder most common (sports; anterior 98%, shallow glenoid/wide ROM; static: ligaments/labrum/capsule; dynamic: muscles). Hip/Knee high-energy (RTA; hip stable via labrum/ligaments). Small joints/AC/Patellar sports/falls (AC: cyclists, no vascular emergency unless open). - Shoulder (Anterior): - Flattened shoulder contour with subcoracoid humeral head bulge in anterior dislocation. - Hip (Posterior): - Leg shortened, adducted, internally rotated; X-ray confirms femoral head displacement posterior to acetabulum. - Knee: - Gross tibiofemoral misalignment with potential popliteal artery compromise from high-energy trauma. - Small Joints (Fingers): - Dorsal dislocation of proximal interphalangeal joint showing angular deformity from hyperextension.	Shoulder: Ant: Arm adducted, loss of deltoid contour, bulge below clavicle (flattened lateral); axillary nerve check. Post: Locked internal rotation, flat front/prominent coracoid (missed >50%, light bulb/empty glenoid signs); rule out greater tuberosity/neck/lesser tuberosity/glenoid fractures. X-ray (AP/axillary/scapular; CT if doubt). Hip: Post (90%): Short, adducted, internally rotated/flexed; sciatic nerve check; rule out femur/acetabulum/patella fractures/intraarticular fragments (RTA dashboard). Ant (rare): Abducted, externally rotated/flexed; palpable groin head. X-ray + post-reduction CT. Knee: Gross deformity; popliteal artery (pulses/ABI; angiography even if intact/suspicion), peroneal nerve. X-ray (avulsions: tibial spine cruciate, fibular styloid collateral) + CTA. Small Joints/Patellar/AC: Obvious deformity (patellar: adolescent females, genu valgum/↑Q angle, high patella, spontaneous via quad); X-ray (standard knee for patellar).	General: Prompt closed reduction under analgesia/sedation; immobilize post-reduction (sling for AC/shoulder; splint/buddy taping for small). Specifics: - Shoulder/Hip/Small/AC/Patellar: Closed reduction (traction/counter for small; self for patellar); surgery if recurrent/unstable/displaced (AC stages 1-3 conservative first). - Knee: Immediate reduction, external fixation; urgent vascular repair; delayed ligament reconstruction (acute if needed). - ANKLE: immediate management (realignment, X-ray, back slab) and complications (AVN risk).	Fracture, Fracture-dislocation, Subluxation; shoulder: 3 E’s mechanisms; patellar: recurrent risk (laxity/valgum).	Shoulder: Axillary nerve injury, recurrent instability, greater tuberosity fracture. Hip: Sciatic nerve palsy, AVN, acetabular fracture. Knee: Popliteal artery injury/limb loss. Patellar/AC/Small: Recurrent dislocation, ligament laxity.

Compartment Syndrome

Section 5: Trauma & Fracture Management

Questions 8-12: Lower Limb Trauma

Clinical Scenario: 22 years old medical student involved in RTA who sustained this leg injury.

Q8: Before assessing his leg, what protocol should you use? ATLS

Q9: What is your diagnosis according to x-ray? middle third tibia diaphysis comminuted segmental fracture and lower third fibula fracture

Q10: Describe the injury in the photo knowing that the victim foot is cold and pulseless? gustilo anderson open fracture 3c

Q11: What is your initial management in ER? realignment check pulse again, lavage, IV ATB empirical, prepare for urgent surgery once stable

Q12: What is your temporary and definitive management, which other surgeons should be working with you and for what?

Begin with ATLS to identify and manage any life threatening injuries
Debridement of the open fracture to remove foreign materials
Lavage using 3-9 of normal saline cleanse the wounds
Realignment to restore the normal alignment of the bone
IV broad spectrum Antibiotics and tetanus vaccine
Cover the bone with sheets apply pelvic binder to protect the bone
External fixation as a temporary management to protect soft tissues
Second debridement after 2 days to remove any necrotic tissues
Reassess and monitor for infections
Consult vascular surgeon to correct the vascular injury
Definitive management by Open Reduction and Internal Fixation by Intramedullary Nail

Station 2: Acute Case Discussion

Topic: Open Fracture Management

_page_34_Picture_4.webp|227x171

A patient came to the ER following a MVA and had a closed tibial fracture.

• First Take AMPLE history

Allergies
Medications
Past medical history
Last oral intake
Events leading to injury/illness

Q: What are you seeing? Open fracture in lower half of tibia.

Q: What will you do in examination? (ATLS is intact) Examine the pt “Look, Feel, Move”

Neurovascular assessment
Soft tissue examination
Size of wound measurement
Rule out other injuries
Rule out compartment syndrome

apply a passive e stretch to the anterior leg compartment for example (Perform passive plantar ﬂexion), and assess

if there’s any pain (But that’s not the scope of the discussion, hat matters is that you have to say that compartment syndrome has to be ruled out).

Q: How will you manage it in Emergency room?

IV antibiotics
Tetanus prophylaxis
Apply direct pressure to control bleeding
NSAIDs for pain control
Remove gross debris from the wound
Place sterile dressing on the wound
Realign the limb and apply splint
Prepare for surgery
The examiner will tell you that the wound measures around 5 cm, and there is no periosteal stripping. What type of open fracture?
- Gustilo type 2

The examiner will say: The patient had severe pain with passive stretch and tense compartments when you felt his leg

What is the Dx? Compartment syndrome
How many compartments in the leg? 4 (ant., lateral and two post.)
How can you measure the compartment pressure? Manometer
What is the treatment of this patient? Fasciotomy

Open Fracture

Open Fracture Management

Clinical Scenario

Patient: 30-year-old man
Mechanism: Car accident
Presentation: Unconscious, large anterior left leg wound, severe deformity, exposed bone
Task: Describe emergency management actions

Emergency Management Protocol

Immediate Actions (ABCDE):

Save life, save limb, save function
Cervical spine protection
Wound management:
- Cover with sterile dressing
- Splint leg
- Take photograph before dressing
Secondary survey:
- Check distal pulses
- If no pulse, correct major deformity by traction
IV fluids: Request blood if needed
Anti-tetanus prophylaxis
Antibiotics: Broad-spectrum coverage

Further Assessment:

Accident details: Type, mechanism, location, time since injury
Pre-hospital management
Patient factors: Age, comorbidities, medications, consciousness status
Tetanus vaccination status

Gustilo Classification:

Essential for surgical planning and prognosis

Surgical Management Principles

Debridement Protocol:

Principle: “Dilution is the solution to pollution”
Thorough irrigation and debridement
Remove all contaminated and non-viable tissue

300

Fixation Options:

External fixation (initial management)
Internal fixation (when indicated)

Complications:

Despite proper management, chronic osteomyelitis may develop
Risk of sequestrum formation and persistent drainage

Embolism

Management for the fractures till the permanent fixation – external fixation
After 4 days this is his picture: What’s the name of the condition shown in the picture? “Fat Embolism Syndrome”
What’s your management “after the previous condition”? Respiratory support

Case C: Lower Limb Trauma

4.2) Open Fracture Management Protocol

1. Diagnosis? Answer: Open fracture in distal tibia

2. Emergency Management?

IV antibiotics
Tetanus vaccine
Apply pressure to control bleeding
Give NSAIDs for pain
Debridement and apply sterile dressing
Realign by splint
Admit and prepare for surgery (ORIF)
Wound closure

3. Mention 3 complications:

Infections
Compartment syndrome
Vascular injury

4. Specialist referrals:

Vascular surgeon
Plastic surgeon

Ankle Fracture-Dislocation

Immediate management after ABC protocol:
1. Realignment
2. Send to x-ray
3. Temporary back slab
Complication of dislocated talus: High risk of AVN

Arthrodesis

Septic Arthritis

Case: Septic Arthritis in Infant (10 months)

Clinical Presentation

History: Fever for 2 days, poor feeding, cries with diaper changes
Examination: Ill appearance, temperature 39.4°C, normal chest and abdomen, moves all limbs except left lower limb
Key Finding: Left hip held in flexion, painful on passive movement

Assessment Questions

Q1: Write TWO differential diagnoses?

Septic arthritis
Osteomyelitis

Q2: Write FOUR blood investigations?

WBC count
CBC with differential
CRP
ESR

Q3: Write TWO abnormalities on x-ray?

Widening of joint space (left hip)
Left hip increased opacity

Q4: Write TWO imaging studies you would request?

MRI
CT scan

Q5: Management plan after admission and supportive measures?

Aspirate joint and send for culture
Drain if pus found
Antibiotic Therapy:
- IV flucloxacillin + 3rd generation cephalosporin for 7-10 days
- Followed by 3-6 weeks oral antibiotics
- Change antibiotic according to sensitivity
Surgical drainage (arthrotomy) - MUST be included in answer

Questions 13-16: Pediatric Hip Pathology

Clinical Scenario: A 1-year-old boy. He was brought to the emergency department by his mother, complaining of irritability associated with constitutional symptoms for 10 hours. He had a history of otitis media 2 weeks ago. The laboratory investigation showed WBC 18000, CRP 130, and ESR 60.

Q13: List three symptoms considered constitutional symptoms.

Answer:

High grade fever
Loss of appetite
Fatigue

Q14: What is the next step to confirm the diagnosis? 200x200 Clinical Presentation

Patient: 2-year-old child
Symptoms: Fever, vomiting, left hip pain, limited range of motion
X-ray Findings: Localized osteopenic lesion in upper metaphysis of left femur, reaching epiphyseal plate

Differential Diagnosis

Osteomyelitis
Septic Arthritis
Further investigation needed

Recommended Investigations

Laboratory: CBC with differential, CRP, ESR
Imaging: Ultrasound, MRI

Answer: Arthrocentesis (Sending for Culture, WBC Count, Glucose, & Protein)

Q15: What is the most likely diagnosis? Septic Arthritis

Q16: What is the gold standard treatment for his condition? Answer: Sending to OR for debridement and irrigation (arthrotomy washout) then giving a proper antibiotic after receiving the result of arthrocentesis

Station 2: Septic Arthritis Case Discussion

Clinical Scenario: A 50-year-old female presented to the ER with history of left knee swelling for 6 hours and positive constitutional symptoms. No history of trauma. On examination, she is febrile 38.5°C. Locally: redness, hotness, severe swelling and restricted range of motion. Q: 18-months old baby, febrile and unable to move his limb, no history of trauma. X-ray provided

Questions:

Q1: What is your differential diagnosis?

Septic arthritis
Osteomyelitis
Transient synovitis

B) What are the x-ray findings on child

Left hip dislocation
Wide joint space
Left hip increased opacity.

Q2: How would you treat?

Admission and IV antibiotic
Emergent arthrotomy and washout

Q3: What investigation would you order?

CBC, wbc
ESR, CRP
Blood culture
Joint aspiration (cell count, glucose, protein, culture, color, crystals) -

Q4. Write TWO images that would you request?

Q5. After admission and giving supportive measures: Analgesic, antipyretic, IV fluid, What is your management plan for this patient.

IV flucloxacillin and 3rd generation cephalosporin for 7-10 days + 3-6 weeks oral antibiotic. 1. Aspirate and send to culture, drain if pus found.
Change antibiotic according to sensitivity.

Septic Arthritis Cases

Case: Septic Arthritis of the Hip

Clinical Presentation

Patient: 14-year-old boy
History: Right hip pain following a fall with abrasions few days prior
Symptoms: Fever, limited right hip motion
Laboratory Findings:
- WBC: 13,000 (not significantly elevated)
- ESR: 23mm/hour (not significantly elevated)
Initial X-ray: No significant findings

Diagnostic Imaging

Initial X-ray Findings: 400

Pediatric Elbow Infection

Age: 6-year-old
Presentation: Localized tenderness, hotness, swelling, edema, reduced elbow ROM
Differential Diagnosis:
1. Cellulitis
2. Osteomyelitis
3. Septic arthritis
4. both septic & osteomyelitis
5. Ewing’s sarcoma

nvestigations

• WBC: leukocytosis, neutrophils
• C-reactive protein: raises very early
• ESR: raises several days later
• Blood culture
• Aspiration from sub-periosteal collection or joint
• Gram stain
• Culture /

• Check yourself

• Clear colorless: normal
• Clear yellow:
• can read through:
• non-inflammatory
• Turbid: Inflammatory
• Pus
• Blood

DDH

full case can be found in history beginning of the document

Case: Developmental Dysplasia of the Hip (DDH)

Clinical Assessment

Inspection Findings:

Describe abnormalities on hip inspection
Assess for limited abduction

Imaging: Required for diagnosis (ultrasound in infants, X-ray in older children)

Of course. Here are some clinical scenario questions and answers based on your note on DDH.

A 6-day-old female infant, born in a breech position, is presented for her newborn check. During the examination, you flex her hips and knees to 90 degrees. As you gently abduct the left hip, you feel a distinct “clunk” as the femoral head seems to relocate into the acetabulum.

Question: What is this clinical sign called, and what risk factors for DDH are present in this infant? What is the recommended initial management?

Answer:

Sign: This is a positive Ortolani test, which signifies the reduction of a dislocated hip.
Risk Factors: The infant has three major risk factors: being a baby girl (4-6x), breech presentation (5-10x), and a positive physical finding.
Initial Management: For a neonate under 2 weeks, the initial approach is to avoid adduction swaddling and consider using double diapers. The infant should be seen again at 2 weeks of age. If the hip remains unstable, a Pavlik harness is the treatment of choice.

A 7-month-old infant is brought for evaluation. The parents noticed asymmetrical thigh folds and that the left leg appears shorter than the right when they change his diapers. On examination, there is a clear limitation of abduction on the left hip. An X-ray is ordered.

Question: What is the sign related to leg length discrepancy called? According to the note, what radiographic findings would confirm a dislocation, and what is the standard treatment for this age?

Answer:

Sign: The apparent shortening of the femur is confirmed with the Galeazzi test.
Radiographic Findings: On an AP X-ray, the femoral head would appear above the horizontal line drawn through the tri-radiate cartilage and lateral to the perpendicular line from the edge of the acetabulum. Shenton’s line would also be broken.
Treatment: For an infant between 6-12 months, the standard treatment is a closed reduction under general anesthesia, followed by a hip spica cast.

_page_40_Picture_2.jpeg|231x275 _page_40_Picture_3.jpeg|317x293

Acetabular angle (acetabular index): Normal: ≤ 25° Dislocated: > 35°

Shenton’s line:

A 2.5-year-old child presents with a noticeable limp since she started walking. Her parents describe it as a “waddling” motion. An orthopedic surgeon confirms a diagnosis of bilateral DDH.

Question: What is the gait pattern described called when it is bilateral? What is the recommended surgical management for a child of this age?

Answer:

Gait: A bilateral Trendelenburg sign results in a waddling gait.
Surgical Management: For a child over 2 years of age, the treatment is more complex and involves surgery: open reduction, acetabuloplasty (pelvic osteotomy), and femoral shortening.

_page_41_Picture_2.jpeg|315x253 12-24m⇒ 24m

Cauda Equina

Etiology: Severe compression of nerve roots in the thecal sac of lumbar spine, most commonly due to acute lumbar disc herniation
Critical: Early diagnosis is essential

Clinical Features:

Back pain (most common)
Unilateral or bilateral leg pain (2nd most common)
Saddle anesthesia (highly specific)
Bladder dysfunction: Urinary retention → overflow incontinence
Unilateral or bilateral sensory changes in legs
Unilateral or bilateral motor weakness in legs

Diagnosis:

Urgent MRI to confirm cause

Treatment:

Prompt surgical decompression
Should be performed within 24 hours, absolutely within 48 hours

Section 2: Lower Limb Neuroanatomy

Questions 4-7: Peripheral Cutaneous Nerve Supply

Interpret each nerve: 1- Saphenous nerve 2- Deep peroneal nerve 3- Superficial peroneal nerve 4- Medial planter nerve

Interpret each nerve:

Axillary neve
Radial nerve
Median nerve
Ulnar nerve
Musculocutaneous nerve

Other Cases

Sport Casse

Q19: What is the pathology in the shown image? 45 years old male fell from highet and landed on his shoulder and presented to your clinic with painful shoulder, What is the the pathology in the shown image? _page_14_Picture_9.webp|285x252

Supraspinatus tear

Q20: The yellow arrow indicates what pathology? _page_15_Picture_2.webp|263x235

Hill-Sach lesion

Case: Rotator Cuff Tear

Clinical Presentation (2022)

Patient: Chronic shoulder pain with limited abduction
Imaging: MRI provided
Assessment Required:
- Identify 2 signs on inspection (ale - making of supraspinatus)
- Describe painful arc test to identify subacromial impingement syndrome
- Identify imaging technique (MRI)
- Diagnosis: Rotator cuff tear with impingement syndrome

Imaging Findings: 400|276x295 400|314x299

Clinical Presentation

History: Previous shoulder dislocation
Assessment: Describe inspection findings, painful arc, imaging studies

clinical features

age 40-60 years
pain
shoulder looks normal or wasted
tenderness
painful abduction arch 60 to 120 degree
neer’s test (+ve)
Hawkin’s test (+ve)

300

Xray

calcification
degenerated ac jt

MRI

brusitis / thickening of tendon

Case Study	Patient Presentation	Mechanism of Injury	Key Symptoms/Examination Findings	Imaging Findings	Treatment Plan (Conservative & Surgical)
Acute ACL Injury	23 y.o. male, right knee pain after sports injury	Twisting injury	Heard a “pop”, cannot bear weight, swelling/bruising. Positive Lachman, Anterior drawer, Pivot shift tests.	ACL tear	Conservative: Physical therapy. Surgical: ACL reconstruction (if failed PT, high activity, desires pivoting sports).
Medial Meniscus Tear	31 y.o. male, left knee pain for 4 weeks	Twisting injury after stepping in a hole	Painful with walking, limited flexion, history of “locking” and “clicking”. Joint line tenderness on medial aspect. Positive McMurray’s test.	Meniscus tear	Conservative: Physical therapy. Surgical: Diagnostic arthroscopy, Meniscal repair vs. Meniscectomy (if conservative fails).
Posterior Shoulder Dislocation	29 y.o. male with seizure disorder, left shoulder pain for 2 weeks	Preceded by seizure	Shoulder locked in internal rotation, limited external rotation. Asymmetry of shoulders.	Posterior shoulder dislocation	Early (<2 weeks): Closed reduction, immobilization, physical therapy. Late (>2 weeks): Surgical intervention. Important: Seizure control.
Recurrent Shoulder Instability	35 y.o. male, left shoulder pain and instability	Recurrent dislocation history	Multiple previous reductions/PT failure. Good and pain-free ROM. Positive Apprehension test.	Hill-Sachs lesion, Bankart lesion	Surgical: Bankart repair, consider capsular shift, post-op rehab.
Rotator Cuff Tear	55 y.o. female, right shoulder pain	No history of trauma (insidious onset)	Night pain, cannot raise hand above head, worsening over time. Atrophy of shoulder muscles, tenderness at greater tuberosity. Limited abduction, weak abduction/ER. Positive Neer’s & Hawkin’s tests.	Rotator cuff tear	Surgical: Arthroscopic rotator cuff repair (since PT failed, complete tear).

Orthopedics cases

Section 1: Hip Pathology & Management

Question 1-3: Hip Osteoarthritis Case

Clinical Scenario: A 65-year-old male presented to your clinic complaining of left hip pain and stiffness for 5 years, progressive with time and affecting his activities of daily living. Conservative treatment failed to improve his pain & range of motion. On examination, there was pain and a limited range of motion, and Thomas’s test was positive.

page_1_Picture_2.webp|299x206 300

Q1: List 3 findings in the x-ray. Answer:

Narrowing of joint space
Osteophyte formation
Subchondral cyst and sclerosis
Varus deformity (knee image)

Q2: What is the diagnosis & its grade? Answer: Osteoarthritis – Grade 3-4?

Q3: What is the gold standard treatment for this patient at this stage? Total hip Arthroplasty for hip image

generally treatment Start with conservative treatment: patient education, weight loss and physical therapy. Pharmacological ( Paracetamol, NSAIDs). If conservative failed, surgery as above

Case: Posterior Hip Dislocation

Clinical Scenario

Patient: 28-year-old car driver involved in motor vehicle accident
Presentation: Conscious and oriented, left hip pain, unwilling to move hip due to pain

Physical Examination Findings: 400

Assessment Questions

Q1: Describe what the clinical picture shows?

Short limb, internally rotated and adducted hip, flexed knee

Q2: Write three differential diagnoses?

Posterior hip dislocation
Femur fracture (neck, midshaft, distal)
Pelvis fracture

Radiographic Findings: 400

Q3: What is the diagnosis? Posterior hip dislocation

Q4: Describe the management plan?

Start with ATLS protocol (ABC)
Control bleeding, immobilize limb, provide analgesia
Most important: Reduction under anesthesia and sedation
Imaging after reduction, CT to ensure no bony fragments disturb joint movement

Q5: Mention two possible complications?

Avascular necrosis (AVN)
Sciatic nerve injury

Infections & Tumours

Infections & tumor

Case	Initial Workup	Diagnosis	Key Characteristics	Treatment Options
1: Pediatric Elbow Infection 6 years old Localized tenderness, hotness & local redness, swelling & edema, reduced ROM of elbow	CBC, CRP, ESR, Blood culture, Aspiration (Gram stain, C&S), Imaging Studies (X-ray, Bone Scan, MRI)	Osteomyelitis, Cellulitis, Septic arthritis (DDx), Ewing sarcoma (DDx)	Early onset, inflammatory signs, pain, fever, leukocytosis, elevated CRP/ESR. Aspiration fluid analysis (clear colorless, clear yellow, turbid, pus, blood). X-ray signs (10-14 days), MRI perfect for early detection.	Supportive treatment, Splint immobilization, Antibiotic therapy (I.V. flucloxacillin, modify based on C&S, consult microbiologist), Surgical intervention (debridement, drainage)
2: Distal Femur Mass 16 years old Painless swelling at distal right femur, no inflammatory signs, no systemic symptoms	X-ray imaging of distal femur	Osteochondroma (Exostosis)	Bony exostosis with hyaline cartilaginous cap. Usually asymptomatic, common complaint: hard palpable mass. Symptoms from location, size, or pressure effects. Complications: growth disturbance, rare malignant transformation (1% in solitary).	Observation for asymptomatic lesions, Surgical excision for symptomatic/complicated cases, Regular monitoring.
3: Pathological Fracture 11 years old Pain in right arm after fall, no significant medical history, incidental discovery of bone lesion on X-ray	X-ray	Simple Bone Cyst	Solitary (unicameral) lesion. Affects children (5-15 years), metaphyseal location, not in adults. Commonly discovered by pathological fracture. Differentiated from Aneurysmal Bone Cyst (expansile) and Giant Cell Tumor (sub-articular, after physeal fusion).	Observation (cyst might heal spontaneously), Multiple bone marrow injections, Fracture fixation (flexible IM nailing), Surgical curettage and bone grafting.
4: Aggressive Bone Tumor 18 years old Painful mass at right femur, limited knee joint motion, history of trauma (8 weeks prior)	Radiographic findings, Staging Investigations (CT chest, MRI entire bone, Bone scan)	Osteosarcoma	Radiographic features: Radiolucency, sclerosis, poorly defined margins, extension into soft tissue. Periosteal reaction: Sunburst appearance, Codman’s triangle. History of trauma with initial misdiagnosis as contusion. Mandatory staging.	Metastasis workup (well-planned incision for biopsy), Neoadjuvant chemotherapy, Surgical management (wide resection, custom prosthesis), Adjuvant chemotherapy.

Station 5: Tumor Assessment

Bone Tumor Radiological Assessment:

Clinical Scenario: A 30-year-old male complaining of left knee pain for the last 3 months. Physical examination: patient is limping, local exam unremarkable.

Radiological Findings: _page_43_Picture_5.webp|150x263

Questions:

a) Mention four x-ray descriptions:

Eccentric lesion
Radiolucent
Soap bubble appearance
Abuts against the joint
Thin cortex
Narrow zone of transition
No periosteal reaction

b) Does the lesion look benign or malignant? Benign

300

Mention three X-ray findings:

Periosteal reaction involving the mid-tibia
Sunburst sign
Wide zone of transition

Is it benign or malignant?

Malignant

How can you reach a definitive diagnosis?

Diagnosis is made with a biopsy

Osteomyelitis Cases

Subacute/Chronic Osteomyelitis

Clinical Presentation

Common Age: 7-year-old boy
Symptoms: Pain in right thigh and knee for 3 weeks, swollen tender thigh
X-ray Findings: Metaphyseal rarefaction, periosteal formation, cavitation, sequestrum formation in distal femur

Diagnostic Criteria

X-ray Findings:

Osteopenic tibial metaphyseal rarefaction
Periosteal reaction (new bone formation)
Later changes: Increasing ragged appearance (mottling), sclerosis, rarefaction, cavitation, sequestrum, involucrum

Most Common Causative Organism: Staphylococcus aureus

Clinical Features

Severe pain, malaise, fever
Reluctant to move (“pseudoparalysis”)
History of previous source of infection
Localized pinpoint tenderness, hotness, local redness, swelling

Timeline Progression: 400 Initial X-ray → After 2 weeks

Advanced Imaging

MRI Findings: 400

Ultrasound Findings:

Sub-periosteal pus collection

Differential Diagnosis

Cellulitis
Acute septic arthritis
Acute rheumatism

Treatment Protocol

Supportive Treatment: Pain control, hydration
Immobilization: Splint
Antibiotics:
- I.V. antibiotics for 6 weeks
- Oral antibiotics for 3-6 weeks (if CRP returns to normal)
Surgical Drainage: If fever and tenderness persist >36 hours after starting antibiotics

Complications

Septicemia
Metastatic infection
Septic arthritis
Chronic osteomyelitis

Subacute Osteomyelitis (Brodie’s Abscess)

Clinical Features

X-ray Findings: Well-defined cavity in metaphysis
Presentation: Long history of pain, swelling, local tenderness
Treatment: Antibiotics for 6 months, surgical evacuation of abscess

Imaging Findings: 400

Chronic Osteomyelitis

Clinical Features

X-ray Findings: Rarefaction surrounded by sclerosis, cavities, sequestra
Presentation: Recurrent bouts of pain, redness, tenderness, fever, sinuses
Treatment: Antibiotics, sinogram, sequestrectomy, surgical debridement
Complications: Recurrence, pathological fracture, growth disturbance

Imaging Findings: |233x360 |253x332

Bone Tumors

Benign Tumors

Osteochondroma (Exostosis)

Clinical Features:

Age: 16-year-old boy
Presentation: Painless swelling at distal right femur
No inflammatory signs, no systemic symptoms

Nerve? Common peroneal nerve (doreseflexion)

X-ray Findings: 400|266x340

Characteristics:

Bony exostosis projecting from external surface of bone
Hyaline cartilaginous cap
Usually asymptomatic
Symptoms from location, size, pressure on adjacent structures

Complications:

Growth disturbance (in multiple lesions)
Malignant transformation (rare in solitary lesions: 1%)

Simple Bone Cyst

Clinical Features:

Age: 11-year-old boy
History: Right arm pain after fall
No medical illness

Characteristics:

Solitary unicameral cyst
Children (not seen in adults)
Metaphyseal location
Often discovered by pathological fracture

Treatment Options:

Observation (may heal spontaneously)
Multiple bone marrow injections
Fracture fixation (flexible nail)
Surgical curettage and bone grafting

Differential Diagnosis of Cyst-like Lesions:

Lesion Type	Location	Expansion Pattern	Age Group
Simple Bone Cyst	Fills medullary cavity	Does not expand bone	Children
Aneurysmal Bone Cyst	Metaphyseal side of physis	Expansile	Variable
Giant Cell Tumor	After physeal fusion	Extends to sub-articular	Young adults
![[cases-1762476028972.webp	300	700x204]]

Malignant Tumors

Osteosarcoma

Clinical Features:

Age: 18-year-old female
Presentation: Painful mass in right femur
Limited knee joint motion
History: Trauma 8 weeks ago (initially diagnosed as contusion)
Red Flag: Night pain

X-ray Findings:

Radiolucency and sclerosis
Poorly defined margins
Extension into soft tissue
Periosteal reaction:
- Sunburst (sun-ray) appearance
- Codman’s triangle

Staging Investigations:

CT Chest: Mandatory for pulmonary metastasis evaluation
MRI: Entire involved bone, determines soft tissue/marrow involvement
Bone Scan: Discover skip lesions (always hot)

Treatment Protocol:

Search for metastasis
Well-planned incision
Chemotherapy
Surgical wide resection with custom-made prosthesis

Knee pain & Degenerative disease

Degenerative Joint Disease

Osteoarthritis of the Knee

Clinical Presentation

Age: 54-year-old lady
Duration: Bilateral knee pain for 3 years
History: No clear trauma history

History Taking Framework (SOCRATES)

Pain: Site, onset, character, radiation, associated symptoms, time course, exacerbating/relieving factors, severity
Activity-related pain: Increases with movement
Sleep disturbance: Pain affects sleep
Functional impact: Stiffness, limited ROM, difficulty with stairs, chair rising
Medical history: Menopause, diet (osteoporosis risk), chronic diseases

Physical Examination Protocol

General Assessment:

Weight, height, BMI
Pain level, comfort, overall appearance

Local Examination (Look, Feel, Move):

Deformity: Usually genu varus
Muscle wasting: Thigh muscle atrophy
Swelling/Effusion: Joint line swelling, Baker’s cyst (popliteal cyst)
Tenderness: Joint line tenderness, warmth
Range of Motion: Limited movement
Special tests: Gait assessment, neurovascular examination

Investigation Protocol

Radiographic Studies:

AP & lateral weight-bearing views
Sunrise view (patellofemoral assessment)
PA view in 30° flexion

X-ray Findings:

Joint space narrowing (medially)
Osteophyte formation
Subchondral sclerosis
Subchondral cysts
Loose bodies
Deformity

Additional Investigations:

CT scan (for surgical planning)
MRI (for soft tissue assessment)
Laboratory studies (to rule out other differentials)
Arthrocentesis (joint aspiration):
- Clear fluid, WBC <2000/mm³, normal viscosity

Management Protocol

Conservative Management:

Weight reduction
Walking aids
Physiotherapy
Pain management (NSAIDs, analgesics)

Surgical Management:

Timing based on severity and functional limitation
Options range from arthroscopy to total knee replacement

Section	Topic	Details
Case 1: Lady with Chronic Knee Pain	Patient Presentation	54-year-old lady, pain in both knees for 3 years, no clear trauma history.
	Comprehensive History	Pain assessment (characteristics, severity, impact), Medical background (occupation, meds, comorbidities, menopause, diet).
	Clinical Examination	General assessment (pain level, comfort, weight, general appearance), Local Examination (position, attitude, extra-articular findings, systematic exam: Look, Feel, Move).
	Diagnostic Investigations	Laboratory Studies (CBC, inflammatory markers, metabolic panel, RF if indicated), Imaging Studies (AP standing, lateral, skyline views of both knees).
	Management Strategy	Conservative (weight reduction, walking aid, PT), Medical (NSAIDs, analgesics, disease-modifying agents, intra-articular injections), Surgical (timing, arthroscopy, osteotomy, TKA).
Case 2: Young Patient with Acute Knee Injury	Patient Presentation	25-year-old patient, right knee pain, history of acute sports injury.
	Injury Mechanism	Acute Phase (immediate pain, violent rotation with flexion, immediate swelling/hemarthrosis, delayed swelling/effusion), Subacute/Chronic Phase (giving way episodes, repeated attacks of swelling/pain, functional limitation).
	Clinical Examination Findings	Physical Signs (swelling pattern, quadriceps wasting, functional instability), Special Ligament Tests (Anterior drawer, Lachman’s, Pivot shift).
	Diagnostic Imaging	Hip osteoarthritis comparison images (for context, not direct knee injury imaging).
	Treatment Approach	Non-Surgical (PT for quad strengthening, proprioception, ROM, activity modification, bracing), Surgical Indications (active individuals with instability, recurrent instability, failed conservative, early arthritic changes).
	Post-Operative Rehabilitation	Phase 1 (protected/early controlled motion), Phase 2 (strengthening, proprioception), Phase 3 (return to specific activities), Phase 4 (return to sports).

Station 1: Knee Ligament History Taking

Clinical Scenario: A 21-year-old male presented to the clinic with history of right knee instability for three months.

ACL Injury History Framework:

Demographic Data:

Name, Age, Gender, Occupation, current living location
Chief complaint: Instability, knee pain
Onset: Since when? Was it preceded by any event? & How did it occur?

Key Questions for Knee Ligament Injuries:

SOGRATES pain assessment
Have you heard popping sound?
Were you able to complete the game?
Did you notice any knee swelling at the time of event?
Giving away sensation (“can’t trust your knee”)?
Mechanical symptoms (“Locking & clicking”)?
First aid provided?
Limited range of movement or stiffness?

Associated Symptoms:

Deformity, Pain, Swelling, Stiffness, Instability
Altered sensation, Weakness, Loss of functions
Limping & constitutional symptoms

Past Medical History:

Similar episodes, Chronic diseases
History of surgery, trauma, blood transfusion
Hospital admissions, medications, known allergies
Use of orthotics

Functional Assessment:

Difficulty rising from chair, climbing stairs, praying?
Walking distance capacity
Level of activity: Type of sport & intensity

Differential Diagnosis Table:

Condition	Mechanism of Injury (MOI)	History and Symptoms (Hx/ssx)	Special Tests	Diagnosis (Dx.)	Treatment (Tx.)
ACL	Non-contact pivoting injury (+/- lateral meniscal tear)	Deep knee pain, Pop during event, immediate Swelling, pt leaves filed, in chronic phase= Giving away	1. Ant drawer test 90flexion 2. Lachman’s test most sensitive 30flexion 3. Pivot shift test (extension-flexion w/ internal rotation)	X-ray (NL or Segond fracture) + MRI (sagittal view) shows high signal sign	1. Low demand pt: Non-OP: physiotherapy = Hamstring strengthening 2. Young pt or Active “athletic” =ACL reconstruction arthroscopy
PCL	Direct blow to prox tibia w/flexed knee “Dashboard injury” or Hyperextension	Post knee pain or asymptomatic (isolated PCL)	1. Post. drawer test 90flexion 2. Post. Sag sign	X-ray (+/- avulsion fractures) + MRI (sagittal view) shows high signal sign	1. Isolated PCL = Non-OP: physiotherapy = Quadriceps strengthening 2. Combined ligament injury or Bony avulsion =PCL reconstruction arthroscopy +/- bony avulsion repair
Meniscus	Foot’s planted & sudden change in direction “twisting knee” occurs e.g., basketball, football	Localized pain, Swelling & mechanical symptoms (locking & clicking)	1. Joint line tenderness 2. McMurray’s test (pain or pop = +ve test) IR = testing Lateral meniscus ER = testing medial meniscus	X-ray NL, MRI (sagittal view) shows “double PCL” sign = Bucket handle tear	1. Degenerative tear = Non-OP 2. Non-vascularized white zone, complex, degenerative= Partial meniscectomy 3. Vasularized region “red zone” = Meniscal repair (NB. Repair ACL first if concomitant ACL tear)

Emergency Case

Case D: Femoral Shaft Fracture

_page_37_Picture_1.webp|375x309

Clinical Scenario: Adult patient victim of MVA, brought to ER by red crescent, isolated injury shown in radiograph.

Questions:

What is the diagnosis?
- Answer: Proximal 1/3 femur fracture
Describe the position of proximal fragment?
- Answer: Laterally
What is the muscle responsible for adduction (varus angulation) of distal fragment?
- Answer: Adductor magnus, adductor longus, adductor brevis
What is the first line of management in emergency room?
- Answer: Apply ATLS, Realign the limb, Apply neurovascular assessment, Immobilization

Spine case

Case: Spondylolisthesis

Clinical Presentation

Patient: 45-year-old lady
Complaint: Disturbing low back pain radiating to buttock
Aggravating Factors: Increased by physical activity
Clinical Findings: No neurological deficit, flat buttock, step sign on back examination

Q1: What is the most probable diagnosis? Spondylolisthesis (spondylolytic type)

Q2: What imaging do you need to confirm your diagnosis? X-ray (oblique views & lateral)

Radiographic Findings: 400|218x304

Q3: X-ray was done, mention 2 abnormalities showing in the image?

Anterior vertebral displacement
Affection (disruption) of the pars interarticularis

Q5: What is your management plan?

Conservative Treatment: NSAIDs, local heat packs, physiotherapy (patient not older with no severe symptoms)
Surgical Treatment: Spine fusion (if severe symptoms and older patient)

Station 4: Data Interpretation

Case A: Spinal Trauma

_page_36_Picture_2.webp|259x286

A ) What is the most likely diagnosis?

L2 Burst fracture

B ) Is it stable or unstable?

unstable

C ) What is your management in the emergency room?

Primary and secondary ATLS surveys
Neurovascular examination
strict log‑rolling and collar
Admission
Book for surgery

Note: you should mention neurovascular examination separately, not as part of primary and secondary surveys.

Name this test and what it’s indicating for?

Spurling test
Cervical radiculopathy

Case: Lumbar Disc Herniation

Clinical Presentation

Patient: 48-year-old man
Complaint: Low back pain radiating to right leg
Clinical Findings: Limited forward flexion of spine, positive SLR test

X-ray Interpretation:

AP + Lat view of the spine
Disc prolapse in L4-5, going to the right (as mentioned in scenario)
Osteophytes present
Narrow intervertebral spaces
Slight loss of lordosis
Maintained alignment
No sclerosis

MRI Interpretation:

Narrow disc space between L4-5
Disc bulging (herniation) to the right
L5 Root will be affected
Query L4 Root affection

MRI Findings: 400

Management Plan

Conservative Treatment: Analgesics, pain control, physiotherapy, weight control, stretching
Surgical Treatment: Discectomy (for persistent pain)

21st Case: A 45-year-old man came with back pain radiated to his left leg.

Abnormalities in X-ray (AP and lateral views):

Loss of lumbar lordosis
Deformity in vertebral bodies
Narrow cartilage space between L2-L3 and L4-L5
Reduced bone density

Most appropriate next investigation:

300 300

Pathological

Osteoporosis Pathological Fracture

Clinical Scenario

Patient: 44-year-old female
Presentation: Right leg pain, no trauma history
Medical History: Malabsorption or GI problems
Presumptive Diagnosis: Metabolic or endocrine disorder causing pathological fracture

Recommended Investigations:

DEXA scans
ESR, serum calcium and phosphate
Urinary calcium and phosphate
Vitamin D level
PTH level
Serum ALP
CRP
Osteoclastic activity markers
Bone turnover rate measures
Renal profile, LFT

Osteomalacia Pathological Fracture

Clinical Scenario

Patient: 38-year-old vegetarian lady
Presentation: Pain for one year
X-ray: Pathological fracture

Diagnostic Workup:

Serum Calcium: Slightly low/normal
Serum Phosphate: Slightly low/normal
Vitamin D Level: Low
Urinary Calcium: Very low
Alkaline Phosphatase: High (increased bone turnover)
PTH Level: Increased (secondary to maintain serum calcium)

Clinical Picture:

Osteopenia
Thin cortex
Deformity
Severe cases: Tetany, convulsions

Common Orthopedic Emergencies

Condition	Key Features	Immediate Management
Open Fracture	Skin break, exposed bone	ABC, cover wound, splint, antibiotics
Posterior Hip Dislocation	Short limb, internal rotation	ABC, reduction under anesthesia
Septic Arthritis	Fever, joint pain, refused movement	Aspiration, IV antibiotics, drainage
Compartment Syndrome	Pain out of proportion, pallor	Fasciotomy

Differential Diagnosis by Joint

Joint	Common Conditions	Key Distinguishing Features
Shoulder	Frozen shoulder, impingement, dislocation	Pain pattern, ROM limitation, instability
Knee	ACL tear, meniscal tear, OA	Mechanism of injury, special tests, age
Hip	Septic arthritis, DDH, AVN	Age, fever, pain pattern, imaging
Spine	Disc herniation, spondylolisthesis	Radiation pattern, neurological signs

Red Flags in Orthopedic Practice

Red Flag	Significance	Immediate Action
Night pain	Possible tumor/malignancy	Urgent imaging
Fever + joint pain	Septic arthritis	Emergency aspiration
Neurological deficit	Nerve compression/spinal cord	Urgent surgical referral
Inability to bear weight	Significant pathology	Immediate imaging

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OSCE

History

DDH, Knee pain, Shoulder stiffness, Back pain, Sport Injury

Examination summarized

Skill

Knee Aspiration

Injection of shoulder

Injection for Tennis elbow (Lateral Epicondylitis)

Injection for golfer elbow (medial epicondylitis)

Aspiration of knee, injection of elbow & shoulder

Joint Aspiration and Injection (and soft tissue)

Indications

Diagnostic Indications

Therapeutic Indications

Contraindications

Complications

What to Do with Aspirate?

Visual Assessment

Laboratory Analysis

Joint Injection

Medications

Indications

1. Inflammatory Arthritis

2. Osteoarthritis (OA)

Soft Tissue Injection

Treatment of Localized Inflammation

Tennis Elbow (Lateral Epicondylitis)

Golfer’s Elbow (Medial Epicondylitis)

Types of Casts (techniques), traction (techniques), Splints, nails, implants, slings, and mobility aid

Traction

Fixed Skin Traction on Thomas Splint

Application Procedure

Overview of Fixed Skin Traction

Limitations of Skin Traction

Possible Complications of Skin Traction

Skeletal Traction: OSCE

Splints & Braces

Implants & Nail types

OSCE Procedure: Upper Limb Cast Application

Cast of upper limb

Materials

Exam

Examination of Shoulder

Case: Adhesive Capsulitis (Frozen Shoulder)

Clinical Scenario

Assessment Questions

Section 3: Shoulder Pathology & Examination

Questions 17-20: Shoulder Injuries and Tests

Examination of the knee

Knee Exam

Other Examinations

Examination of Spine

Spine Examination

Back ROM & Neurological

McMaster MSK Examination Series

Spine Examination – OSCE Guide

Examination of HIP

Station 3: Hip Examination

Hip Examination

Case B: Pelvic Trauma

4.1) Open Book Fracture Management

Neurological Examination

Upper Limb Neurological Clinical Examination Station

Upper Limb Neurological Clinical Examination Station

Lower Limb Neurological Clinical Examination Station

Peripheral Nerve Examination

Cases

Orthopedic Emergencies Summary

Compartment Syndrome

Section 5: Trauma & Fracture Management

Questions 8-12: Lower Limb Trauma

Station 2: Acute Case Discussion

Topic: Open Fracture Management

Open Fracture

Open Fracture Management

Clinical Scenario