Ortho Examination 1

Station 1

My serve isn’t what it used to be

Start the Timer and Begin

Intro

Candidate introduces self with full name and role

Identifies patient with 2 pieces of information - eg name and date of birth

Adheres to appropriate infection control measures

Gains consent for examination

Adequately exposes the patient's limb - the patient should have difficulty removing their right shoulder from their shirt

Look

Full marks

Inspects anteriorly - Nil

Inspects laterally - Nil

Inspects posteriorly - Nil

Inspects spine - Nil scoliosis

Comments on 3 of; scars, bruising, muscle wasting, skin changes, casts or slings (nil present)

Feel

Screens for temperature change - nil

Palpates the Sternoclavicular Joint (SCJ) - nil

Palpates along the Clavicle - nil

Palpates Acromioclavicular Joint (ACJ) - nil

Palpates Acromion - nil

Palpates Coracoid process - nil

Palpates Head of the Humerus - mild tenderness on palpation

Palpates along the spine of the scapula - nil

Move

Screening Movements

Candidate uses 1 screening movement - the patient should fail to abduct the right arm and it should hang by your side. Trying to move the shoulder should cause intense pain.

Active Movement

Flexion/Extension - difficulty raising right arm for flexion and extension

Abduction - this is extremely painful. There is failure to abduct the right shoulder more than 15 degrees

Internal Rotation - this should not be painful as this movement is facilitated by the subscapularis muscle

External Rotation - this should not be painful as it is facilitated by both Infraspinatus and Teres Minor

Candidate compares movements between the affected and unaffected sides

Passive Movement

Passive movement - full passive movement with no pain

Special Tests

Resisted External Rotation - Nil - test as such

Resisted Internal Rotation - Nil - test as such or as such

Resisted Supraspinatus test / Jobe's test - actor should demonstrate failure to abduct arm to the required height due to severe pain - test as such

Drop arm test - patient should be unable to keep the right arm abducted, and should have the arm slap back to their side when the candidate releases it - test as such

Offers to complete distal neurovascular exam

Please note there are many specific tests for rotator cuff tears, these vary based on location and teacher. The tests presented here are some of the most commonly used. If the candidate uses a different named test that isolates the appropriate rotator cuff muscles then give the marks.

Examiner Instruction

At this point please direct the candidate to move on to diagnosis and management.

The Examiner should accept Rotator cuff injury as diagnosis, but should push for specific isolated injury.

Diagnosis & Interpretation

Full marks

Candidate should explain positive examination findings which supports diagnosis;
> Failure of abduction
> Pain in abduction
> Pain in resisted abduction (Jobe’s/Empty Can test)

Candidate should briefly explain negative findings of examination, and therefore justifies this is unlikely to be an Infraspinatus/Teres Minor/Subscapularis injury:
> Normal external rotation
> Normal internal rotation

Main differential - Supraspinatus Tear (please inform the candidate of the correct diagnosis once they have given their differentials, regardless of whether their answer was correct or not).

Submit for Scoring

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Station Written by: Dr Ranj Bhakar

Peer Reviewed by: Dr Benjamin Armstrong

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Ortho Examination 1

Station 1

Candidate Instructions

Setting:

Name: Steven Snow

Tasks:

Simulated Patient Instructions

Briefing

Opening Statement

Appearance and Behaviour