Summary of Common Conditions Seen in OSCEs
Hints and Tips for the Exam
Most students practise the knee examination thoroughly, especially the ‘special tests’, while preparing for finals. As important as these are, remember to stick to the ‘look – feel – move – special-test – function’ routine in order to look slick and avoid missing important signs of disease. Here are some tips to prevent you from committing some common errors.
One Knee or Both Knees?
There is a lot to do in this station in the 5 or 10 minutes available. Candidates are often confused over whether they should examine one or both knees. If the instructions are not explicit, examine the knee that looks abnormal, or is said to be painful by the patient, and compare it with the other knee to interpret the findings from special tests. In the unlikely scenario that both knees appear normal, you must examine both knees fully and hence pace your work appropriately.
Don’t Inspect for Too Long
Do not spend too long looking at the knees. If they appear normal, say so and move on to avoid wasting time. Mention significant positive findings, but if time is short do not list all the negatives as there are unlikely to be many marks for doing this – and the examiner will probably ask you anything he or she deems important. If there is an obvious abnormality, state this at the start when presenting your findings. If this is not the case, follow the same routine that you used to examine when you are presenting your findings.
Joint Line Tenderness
Make sure you palpate the medial and lateral joint lines one at a time so that you can tell which side is causing pain. Look at the patient’s face for grimacing.
Examining Effusions
If there is a large effusion visible to the naked eye, perform the patellar tap test, and if there is no visible effusion perform the bulge test.
Assessing the Menisci
Ask the examiner before performing McMurray’s or Apley’s test because many examiners will not want you to actually perform them on the patient and may instead ask you to talk through how you would perform them. Apley’s test is generally easier and quicker to do.
Gait
If the patient is able to walk, make sure you examine the gait. Not only does this add valuable signs to your examination, but it also shows that you are thinking about the impact of the condition on the patient’s general functional ability. Remember, an examination is not complete without eliciting the effect of the disease on the patient’s functional ability.
Remember the Joint Above and the Joint Below
Do not forget to state that you would finish by examining the hip and ankle joints and the neurovascular function. Remember that hip fractures can sometimes present with knee pain.
Figure 20.1 Total knee replacement
Variations at This Station
- Task (7–10 minutes): ‘Perform a GALS screen of this patient’s musculoskeletal system and then examine the knees.’ You should aim to spend no more than 2–3 minutes performing the GALS screen at this station.
- Task (5–10 minutes): ‘This patient suffered an injury while playing football. Examine his knee and then give him some brief advice on management.’ This is the most difficult variation at this station. This type of scenario is frequently tested in finals OSCEs, and it is important to follow the generic structure:
- Confirmation of diagnosis (e.g. imaging)
- Conservative measures: Rest, Ice, Compression, Elevation
- Medical measures: analgesia
- Physiotherapy
- Safety netting for complications
- Future prevention
- Confirmation of diagnosis (e.g. imaging)
- Task (7–10 minutes): ‘This is a 19-year-old who recently sustained an injury playing football. Take a brief focused history and examine his knee.’ At this station, you must find out about the injury itself and how function has been limited after sustaining it. There are three key questions to ask in addition to this:
- Did the knee swell up after the injury?
- Does the knee give way when you try to turn?
- Does the knee lock?
- Did the knee swell up after the injury?
Questions You Could Be Asked
Arthritis
Q. What are the indications for surgery in osteoarthritis of the knee?
A. Arthroscopy if there is knee locking, and knee replacement for refractory pain/stiffness.
Q. How should rheumatoid arthritis in the knee be managed?
A. Medical: analgesia, disease-modifying antirheumatic drugs, anti-tumour necrosis factor alpha inhibitors. Surgery is used with refractory pain/stiffness, or secondary septic arthritis.
Acutely Swollen Painful Knee
Q. What would your next step be in the management of such a patient in A&E?
A. Admit and resuscitate the patient with respect to airway, breathing and circulation. Give empirical intravenous antibiotics (e.g. flucloxacillin or Augmentin), aspirate the joint and send the specimen for microscopy, culture and sensitivity and polarised light microscopy for crystals. Take a full history and examination to identify predisposing factors (e.g. intravenous drug use, diabetes, sickle cell disease).
Q. What are the differential diagnoses of an acutely swollen painful knee?
A. Septic arthritis, crystal arthropathy (gout or pseudogout), inflammatory disease (e.g. rheumatoid arthritis, systemic lupus erythematosus) and haemochromatosis.
Q. What investigations would you like to perform?
A. C-reactive protein level, blood culture, aspiration of the joint for microscopy, culture and sensitivity and microscopy under polarised light, and imaging (joint X-ray, MRI).
Knee Fracture
Q. What would your initial management be if you saw a patient with a knee fracture in A&E?
A.
- Resuscitate with respect to airway, breathing, circulation, and the examine the neurovascular status of the limb distal to the fracture.
- Reduce the fracture under anaesthesia
- Immobilise/restrict the fracture
- Take a focused history to elucidate the impact of the injury, the possible underlying causes of the fall, co-morbidities and other injuries (especially head injury)
- Request a specialist orthopaedic review
Q. What are the indications for a total knee replacement?
A. Osteoarthritis causing pain or stiffness that is refractory to medical treatment, rheumatoid arthritis with refractory joint pain, stiffness or deformity, and some cases of septic arthritis.
Patellar Dislocation
Q. What are the causes of recurrent dislocation of the patella?
A. A ‘high-riding’ patella, joint hypermobility, family history, connective tissue disease.
Q. What is the management of recurrent dislocation of the patella?
A. Exclusion of a secondary cause (e.g. connective tissue disease) and vastus medialis strengthening exercises
Knee Ligaments and Menisci
Q. What are the causes of collateral ligament injuries?
A. Typically sport-related injuries, such as being tackled from the side, and also car accidents in which impact has been from the side – it is quite common to see torn lateral collateral ligaments together with a common peroneal nerve palsy.
Q. How are torn cruciate ligaments managed?
A. Arthroscopic reconstructive surgery with a prosthetic ligament. If the patient not fit for general anaesthesia, conservative management includes knee support and physiotherapy to strengthen the surrounding musculature.
Q. How can meniscal tears be treated?
A. Arthroscopic joint washout, meniscal repair, meniscectomy.
Osgood–Schlatter Disease
Q. What advice do you give to a patient with Osgood–Schlatter disease?
A. Avoid painful activities such as running, squatting and jumping for up to 6 months. Analgesic medication can be used for symptom relief. Refer to physiotherapy for advice on quadriceps strengthening exercises.
Baker’s Cyst
Q. What are the important differential diagnoses of a ruptured Baker’s cyst?
A. Deep venous thrombosis, cellulitis.
Q. How can a Baker’s cyst present?
A. Popliteal fossa swelling, walking difficulty, swollen painful calf secondary to rupture.
Bursitis of the Knee
Q. What are the causes of bursitis?
A. Trauma (e.g. housemaid’s knee), infection, inflammatory disease (e.g. rheumatoid arthritis), idiopathic.
Q. How can it be managed?
A. Drainage of bursal fluid, treatment of the underlying cause (e.g. antibiotics, immunosuppressants), steroid injection
Paget’s Disease
Q. What are the complications of Paget’s disease?
A. Deafness, high-output cardiac failure, osteosarcoma, pathological fractures, secondary osteoarthritis.
Q. How is it diagnosed?
A. Isolated raised alkaline phosphatase level (usually very high), characteristic radiological features.
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