What would you do in terms of investigations, consultations and management at the time and during the first week?

A 79 year old non insulin dependent diabetic (Type II) lady fell at home and on arrival at the Accident and Emergency Department 12 hours later was dehydrated and mildly confused. Her right hip had been replaced 13 years previously and she lived independently prior to the fall. Her relatives reported that her short term memory was deteriorating and that she had experienced several unexplained falls recently.

On examination she was in pain with an irregularly irregular pulse of 100 beats per minute, blood pressure of 95/60 and a temperature of 37.50. There was erythema over her sacrum, right medial malleolus and heels. Her urine was cloudy and pungent. The femoral fracture depicted in the radiograph was her only significant musculoskeletal injury.

Discuss:

  1. the patient’s initial assessment and management. (20)
  2. the treatment options and their advantages and disadvantages for this patient. (40)

It is agreed that revision arthroplasty is felt to be appropriate.

Discuss your:

  1. planning for surgery (15)
  2. surgical technique (15)
  3. rehabilitation plan (10)

Question 4. (30 minutes)

A male child develops a complete closure of the proximal tibial growth plate as a result of whole bone osteomyelitis at the age of six years. At the age of eight years his true leg length discrepancy is 1.5cms.

Outline:

  1. Your initial assessment of this patient. (10)
  2. Your prediction of future leg length discrepancy (LLD). (10)
  3. The treatment options highlighting advantages and disadvantages of each. (30)
    1. Nominate your treatment preference and why.

Question 5. (30 minutes)

A 40 year old male has an uncomplicated partial discectomy for a fight sided L5/S1 disc prolapse. The surgery was undertaken in the knee chest position with a padded bar to support the buttocks. Positioning was undertaken while you were scrubbing up.

When you visit the patient in recovery one hour later he complains that he cannot move his left arm.

Examination confirms complete loss of active shoulder abduction and external rotation, elbow flexion and extension, and wrist extension. Finger flexion and extension and intrinsic function remain intact. Sensation to light touch and pin prick is diminished in a patchy fashion over the posterio lateral aspects of the left arm, forearm, and radial two digits.

Further examination also reveals a complete foot drop on the left side with numbness over the dorsum of the foot.

  1. What do you think the above clinical findings represent. What is/are the likely cause/s? (15)
  2. How would you respond to the patients immediate concerns at that time? (5)
  3. What would you do in terms of investigations, consultations and management at the time and during the first week? (15)
  4. As you have been just appointed to your first consultant position, what coping mechanisms would you employ for yourself? (5)
  5. How would you approach your discussions with the patient and his family the day after surgery when the clinical picture is unchanged and what prognosis would you give them? (10)

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A 79 year old non insulin dependent diabetic (Type II) lady fell at home and on arrival at the Accident and Emergency Department 12 hours later was dehydrated and mildly confused. Her right hip had been replaced 13 years previously and she lived independently prior to the fall. Her relatives reported that her short term memory was deteriorating and that she had experienced several unexplained falls recently.

On examination she was in pain with an irregularly irregular pulse of 100 beats per minute, blood pressure of 95/60 and a temperature of 37.50. There was erythema over her sacrum, right medial malleolus and heels. Her urine was cloudy and pungent. The femoral fracture depicted in the radiograph was her only significant musculoskeletal injury.

Discuss:

  1. the patient’s initial assessment and management. (20)
  2. the treatment options and their advantages and disadvantages for this patient. (40)

It is agreed that revision arthroplasty is felt to be appropriate.

Discuss your:

  1. planning for surgery (15)
  2. surgical technique (15)
  3. rehabilitation plan (10)

Question 4. (30 minutes)

A male child develops a complete closure of the proximal tibial growth plate as a result of whole bone osteomyelitis at the age of six years. At the age of eight years his true leg length discrepancy is 1.5cms.

Outline:

  1. Your initial assessment of this patient. (10)
  2. Your prediction of future leg length discrepancy (LLD). (10)
  3. The treatment options highlighting advantages and disadvantages of each. (30)
    1. Nominate your treatment preference and why.

Question 5. (30 minutes)

A 40 year old male has an uncomplicated partial discectomy for a fight sided L5/S1 disc prolapse. The surgery was undertaken in the knee chest position with a padded bar to support the buttocks. Positioning was undertaken while you were scrubbing up.

When you visit the patient in recovery one hour later he complains that he cannot move his left arm.

Examination confirms complete loss of active shoulder abduction and external rotation, elbow flexion and extension, and wrist extension. Finger flexion and extension and intrinsic function remain intact. Sensation to light touch and pin prick is diminished in a patchy fashion over the posterio lateral aspects of the left arm, forearm, and radial two digits.

Further examination also reveals a complete foot drop on the left side with numbness over the dorsum of the foot.

  1. What do you think the above clinical findings represent. What is/are the likely cause/s? (15)
  2. How would you respond to the patients immediate concerns at that time? (5)
  3. What would you do in terms of investigations, consultations and management at the time and during the first week? (15)
  4. As you have been just appointed to your first consultant position, what coping mechanisms would you employ for yourself? (5)
  5. How would you approach your discussions with the patient and his family the day after surgery when the clinical picture is unchanged and what prognosis would you give them? (10)
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