Trial OSCE exam: 'Clarence&Sarah5' by ClaireGo

You are taking part in a trial exam created by ClaireGo. There are 9 OSCEs in this exam (90 minutes).
 

You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

A 45-year-old man has been brought to ED after falling from a ladder. He has sustained an isolated right shoulder injury. Your registrar has assessed, suspects a shoulder dislocation and has ordered an x-ray. The patient has received analgesia and is otherwise stable.

View attached:   Attachment 1   Attachment 2

Instructions for the candidate

You are a consultant in the ED. You have been asked to interpret the xray and assist with management.

You are to explain the xray findings to patient and gain informed consent for any procedure required. You will then perform the procedure. A junior registrar will be present who is keen to learn.

Domains being examined

  • Medical Expertise
  • Communication
  • Scholarship and Teaching
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

Patient:
You are a right-hand dominant, self-employed painter. You have never dislocated your shoulder before. You are otherwise healthy, other than smoking. No allergies. You are concerned about returning to work and long-lasting loss of function.

Your shoulder is quite painful and you are unable to move it. You have normal movement and sensation in your hand. Your arm is most comfortable in abduction and slight external rotation.

Registrar:
You have assessed the shoulder as a likely dislocation, and the arm is neurovascularly intact (but you did not assess the axillary nerve, if asked).
You have not yet reduced a shoulder. The only techniques you've heard of are the old 'stockinged foot in axilla' for counter traction and the Cunningham method you saw on social media. You would like to learn as many different techniques as possible, so keep prompting for more.

For the examiner

Inform the candidate if sedation for the procedure is warranted, another consultant will be managing the sedation and gaining consent for this separately, as required.

After informed consent has been gained, you can indicate that procedural sedation has been successfully achieved and reduction can go ahead.

The shoulder will be difficult to reduce.

Domains Assessment Objectives

Medical Expertise
Proficiency in shoulder reduction, with knowledge of multiple techniques and their complications

Communication
Clear explanation of procedure and complications

Scholarship and Teaching
Well structured teaching approach and answering of questions

Other Assessment Notes

1. Interpretation of xray

2. Informed consent
- clear explanation of anterior shoulder dislocation
- layman's explanation of reduction
- complications of procedure (nerve injury, fracture)
- long-term complications (instability, chronic pain, loss of function)

3. Procedural diversity
- Cunningham - gentle traction and trapezius massage - takes long time
- Stimson: prone with traction/weight on arm +/- flexed elbow
- Scapular manipulation: traction at 90 degrees forward flexion, stabilise upper scapula, manipulate lower scapula medially
- External rotation: hold the arm in adduction, flex the elbow and slowly externally rotate
- Milch: abduction, external rotation and gentle traction
- Traction-countertraction: constant traction on the arm in a slightly abducted position +/- external rotation +/- lateral pressure on proximal humerus
- Spaso: traction vertically in forward flexed arm with gentle external rotation

4. Postreduction care
- recheck neurovascular
- repeat x-ray
- sling to limit abduction and external rotation
- analgesia
- ortho f/up

Bonus points - intra-articular lignocaine

Images courtesy of Dr Frank Gaillard (Radiopaedia.org) at http://radiopaedia.org/cases/anterior-shoulder-dislocation