Abstract
Practise viva technique in a timed manner and adapt your technique to illustrate your strengths.
The following are viva examples of common clinical scenarios. The suggested reading references are all available to access free online. They provide useful supplementary information to the topic of the viva.
Make a list of conditions causing pain, locking, stiffness, flail and unstable elbow. Painful elbow pathology could be best remembered by its anatomical position – anterior, medial, posterior and lateral.
Introduction
Practise viva technique in a timed manner and adapt your technique to illustrate your strengths.
The following are viva examples of common clinical scenarios. The suggested reading references are all available to access free online. They provide useful supplementary information to the topic of the viva.
Elbow
Make a list of conditions causing pain, locking, stiffness, flail and unstable elbow. Painful elbow pathology could be best remembered by its anatomical position – anterior, medial, posterior and lateral. Do not forget the nerves around the elbow while making your list.
Structured oral examination question 1
Tennis elbow
EXAMINER: 36-year-old right-hand dominant manual worker, referred by his GP with a painful right elbow. His elbow radiographs are essentially normal. What would you like to do?
CANDIDATE: Well, I need to assess the patient’s elbow … after I had asked the history of his pain.
EXAMINER: Pain is on the lateral side, started gradually 3 months ago … no history of injury, aggravated by using a hammer and was initially relieved by rest. Now it is constant. He has normal range of movements. The point of tenderness is just around the lateral epicondyle.
CANDIDATE: From history and examination I think he has got tennis elbow …
EXAMINER: What do you do to confirm the diagnosis?
CANDIDATE: I will test if the pain is reproduced by resisted wrist extension.
EXAMINER: Well, he has more pain on resisted finger extension than wrist extension. Does it make you think more specifically?
CANDIDATE: …
EXAMINER: Which tendons are involved in tennis elbow?
CANDIDATE: ECRB …
EXAMINER: Can EDC also be affected?
CANDIDATE: …
EXAMINER: Well, tell me the pathophysiology of tennis elbow.
CANDIDATE: It’s termed as angiofibroblastic hyperplasia, which is … hyperplasia of the angiofibroblasts …
EXAMINER: Do you know any other similar pathology around the elbow?
EXAMINER: Why do you say tendonitis? What is the difference between tendonitis and tendonosis?
CANDIDATE: …
EXAMINER: Going back to the provocation test, if he had tenderness over the lateral proximal forearm on resisted finger extension, what does it tell you?
CANDIDATE: Maybe the disease process is extensive into the common extensor muscle belly.
EXAMINER: We’ll move onto the next scenario.
This elucidates a simple scenario where the lack of a pause, to engage a structured taught process, leads to a jumbled poor answer that does not do justice to the candidate’s true level of knowledge. Is the candidate a classical example for tennis elbow misdiagnosis? Does the candidate deserve anything above a score of 4? Would you approach this subject differently? Think and analyze before looking into the performance of the next candidate.
EXAMINER: 36-year-old right-hand dominant manual worker, referred by his GP with a painful right elbow. His elbow radiographs are essentially normal. What would you like to do?
CANDIDATE: I want to know the history of his right elbow pain please.
EXAMINER: It is on the lateral side, started gradually 3 months ago … no history of injury, aggravated by using a hammer and was initially relieved by rest. Now it is constant.
CANDIDATE: I will proceed with his examination … posture of elbow, range of movements especially looking for a lack of full extension and rotation … proceed to examine the specific site of tenderness on the lateral aspect.
EXAMINER: He has normal range of movements. The point of tenderness is just around the lateral epicondyle.
CANDIDATE: I would like to know if he has tenderness anterior or posterior to the lateral epicondyle and also any tenderness just distal to the lateral epicondyle.
EXAMINER: What does it tell you?
CANDIDATE: Anterior and distal to lateral epicondyle – ECRB tendinosis.
Posterior and distal to lateral epicondyle – EDC tendinosis.
EXAMINER: It is anterior and distal to lateral epicondyle. Tell me the provocation test for ECRB tendinosis.
CANDIDATE: Pain on elbow extension/forearm pronation/fingers flexion/wrist in extension against resistance.
CANDIDATE: EDC tendinosis should have pain on elbow extension/forearm pronation/wrist neutral/fingers extension/long finger extension against resistance.
EXAMINER: Does the EDC provocation test tell you anything else?
CANDIDATE: Yes. If EDC provocation test produces pain over EDC origin, it suggests EDC tendinosis. Pain over radial tunnel – radial tunnel syndrome.
EXAMINER: What do you understand by tennis elbow?
CANDIDATE: It is the tendinosis and not tendonitis of ECRB/EDC tendons.
EXAMINER: Tell me the histological appearance of tendinosis.
CANDIDATE: Histologically, there are no acute inflammatory cells. There is granulation-like tissue consisting of immature fibroblasts and disorganized non-functional vascular elements called angiofibroblastic hyperplasia. It is theorized to result from an aborted healing response to repetitive micro-trauma. There is a lack of extracellular cross-linkage between fibres and fibrils are fragmented with varying length and diameter. Pain arises possibly from tissue ischaemia. Essentially the repetitive tensile overload, which exceeds tissue stress tolerance, causes tissue damage. If the tissue damage occurs at a rate which exceeds the tissue’s ability to heal, it causes tissue degeneration.
EXAMINER: Do you know any other tendinosis around the elbow other than golfer’s elbow?
EXAMINER: Do you know any associated conditions?
CANDIDATE: Cuff pathology, Achilles tendinopathy and CTS.
EXAMINER: Lastly, if you have a refractory tennis elbow what would concern you?
CANDIDATE: I would be worried about the possibility of other diagnoses such as radial tunnel syndrome, radio-capitellar arthritis, posterolateral rotatory instability and radio-capitellar plica.
If you were the examiner, how much would you score for this candidate?
Suggested reading
Key learning points
Tennis elbow is a degenerative tendinopathic process affecting mainly ECRB within the common extensor origin.
It is frequently seen in middle-aged individuals (35–50 years) who have excessive and repetitive use of these muscles whereby the rate of tendon damage exceeds the rate of repair.
Be aware of typical presenting features (local tenderness, poor grip) and be able to describe tennis elbow provocation tests: Maudley’s test (resisted third digit extension), Cozen’s test, Mills and the ‘chair’ lift test (lifting the back of a chair with a three-finger pinch (thumb, index and main fingers) and the elbow fully extended).
Differential diagnosis includes: referred pain, PIN entrapment, lateral column elbow degenerate disease.
Treatment is essentially non-operative with activity modification in the vast majority of individuals (75–95%): activity modification, physiotherapy, counterforce bracing/wrist splints, ultrasonography, NSAIDs and local cortisone injections.
Quantity (2–3 cm3).
Location anterolaterally below the extensor tendon, not intratendinous or subdermal.
Frequency: no more than three (6–12 weeks apart).
BEWARE: subcutaneous fat atrophy.
Rarely, in recalcitrant cases, surgery is offered.
Have an awareness of novel therapies: PRP injections, botulinum toxin, high-voltage electrical stimulation and extracorporeal shockwave therapy.
Structured oral examination question 2
Osteochondritis dissecans
EXAMINER: Look at these radiographs of the right elbow of a 33-year-old patient and tell me the findings (Figure 8.1).
CANDIDATE: This plain radiograph of a right elbow shows one loose body in the anterior aspect of the joint.
EXAMINER: What would you like to know if you are allowed to ask only one question?
CANDIDATE: I want to know his presenting symptoms.
EXAMINER: He gets intermittent painful locking symptoms. What is the diagnosis here?
CANDIDATE: Well he has a loose body in the elbow …
EXAMINER: Tell me the conditions which produce loose bodies in a joint.
CANDIDATE: Could be post-traumatic, secondary to osteoarthritis, osteochondritis dissecans (OCD) or synovial chondromatosis.
EXAMINER: Now again … What would you like to know if you are allowed one more question?
CANDIDATE: Did he have any injury in the past?
EXAMINER: No, never … What is your diagnosis here, keeping in mind that there is only one loose body in the elbow?
CANDIDATE: It could be either secondary to osteoarthritis or OCD and I could rule out a post-traumatic cause as he had no injury.
EXAMINER: Can you look at the radiographs again and be more specific? [Showing the X-ray again to the candidate.]
CANDIDATE: I can see only one loose body. There is no calcification in the muscle or capsule.
EXAMINER: What does it tell you?
CANDIDATE: It helps me to rule out myositis ossification and synovial sarcoma.
EXAMINER: I want you to concentrate on the intra-articular pathology and try to narrow down your diagnosis between OCD and osteoarthritis.
CANDIDATE: I would like to know the history of his symptoms and have more investigations to be more specific.
EXAMINER: Well, he had unexplained painful elbow which lasted for about 18 months when he was 17 years of age … What do you think is going on with this elbow?
CANDIDATE: It sounds like it may not be osteoarthritis … it could be OCD.
EXAMINER: If you had been consulting him at the time of initial presentation 16 years ago, what would be your concern?
CANDIDATE: I would …
[Bell]
Figure 8.1 Anteroposterior (AP) radiograph of elbow.
Was this a good viva? Did he lack the knowledge of this subject of loose bodies? The candidate appeared to be hesitant and did not display his knowledge in a methodical manner.
EXAMINER: Look at these radiographs of the right elbow of a 33-year-old patient and tell me the findings.
CANDIDATE: These plain radiographs of a right elbow show a well-maintained joint space with evidence of a solitary loose body in the anterior aspect of the joint, most clearly visible in the lateral view.
EXAMINER: What would you like to know if you are allowed to ask only one question?
CANDIDATE: Has this patient had problems with this elbow as a teenager? In particular, whether it impaired his performance in competitive sport that involved repetitive overhead activities such as racquet and throwing sports or frequent axial loading of the elbow as seen in gymnastics or weightlifting.
EXAMINER: Yes, this patient had unexplained painful elbow that lasted for about 18 months when he was 17 years of age … What do you think is going on with this elbow?
CANDIDATE: Well, I suspect he had osteochondritis dissecans when he was 17, which explains the unexplained pain he had for 18 months and the OCD segment must have separated to form the loose body.
It is anticipated that the prognosis for a full recovery is poor with presentation in older teenagers.
EXAMINER: If you had consulted him at the time of initial presentation of OCD, what would you have done and why?
CANDIDATE: I would have advised him of the importance of activity modification and warned him that he is likely to have ongoing elbow symptoms of lack to full extension with intermittent pain and locking. I would have advised him to return if he had functional restrictions due to his elbow.
It would have been useful to perform an MRI scan to assess lesion size and condition of articular cartilage. In addition, to define and locate the presence of loose bodies. I appreciate that access to MR imaging would have been limited 17 years ago.
EXAMINER: MRI was not widely available then. Are there any other investigations that may have been useful?
CANDIDATE: An elbow arthrogram with contrast would have been an option. However, I suspect that, at the time, there was also limited availability of arthroscopic elbow surgery. Therefore, the value of this invasive investigation would be limited except in a specialist centre. Furthermore, the age at which he presented was not in the favourable range … that is after the closure of the physis … therefore, I would have followed him clinically more closely with serial plain radiographs and obtained a subspecialist opinion.
EXAMINER: This patient unfortunately had only one X-ray at the start of the presentation and as it did not show any obvious pathology, he was discharged from follow-up. What would you like to do now?
CANDIDATE: I would like to know his presenting symptoms. Has he had any treatment so far and what are his expectations?
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