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3 MAY 2006

ALL questions must be answered - Question 1 (50%) & Questions 2 & 3 (25% each)

Question 1 (One Hour)

A3 year old boy is referred to you from a rural hospltattor on-going management of a painful and swollen left knee. He has been an in-patient at the other hospitaltor 5 days.

The treating General Practitioner's referral letter states

"..he presented with a 2 week history of pain and limp. Sweling and warmth of the left knee was noticed. On admission the white cell count was slightly raised, ESR was 35, CRP 40, temperature 37.8 Celsius and radiographs of the left knee normal.

I aspirated the knee on the day of the admlsslon and obtained cloudy synovial fluid but no growth on culture. The child has not clinically improved despite intravenous Flucloxacillin. Repeat ESR and CRP remain about the same.

lam worried l am missing something. Thanks for your ongoing management.."

The parents are very worried about the lack of improvement and ask you some probing questionsin relation to the lack of a definitive diagnosis. They are openly critical of the management ot their child's illness in the first hospital

1. Detail your assessment of this child's physical illness. (25 marks)
2. Analyse reasons for the lack of clinical response at the first hospital. (25 marks)
3. Describe your management of thts patient. (20 marks)
4. The parents express concern that their child is not recovering and are openly critical of the General Practitioner's care. Examine possible reasons for their dissatisfaction. Summarise how you would handle this situation. (30 marks)

Question 3 (30mins)

• History
  • A 25 year old kindergarten teacher, previously wel, presents with a 12 month history of increasing left hip pain.
  • Initially a diffuse buttock ache, now, more severe and localized to her groin. Symptoms occur getting in and of her car and while swimming. There is an occasional click. More recently there has been night pain. Her symptoms are worsening and only temporarily relieved by anti-inflammatory agents and mild analqeslcs.
  • 14 months ago her sister underwent a major pelvic operation for a similar problem at another hospital. Her sister is disappointed with the result because she is limping and uses a cane. It took 6 months before she returned to office work.
• Examination
  • B.M.I. 33. Slight quadriceps and gluteal wasting. No malalignment or leq length discrepancy. An antalgic gait and a positive Trendelnberg test. No fixed deformity.
  • Both hips have a symmetric range of motion. Both have 70 degrees of internal rotation, The left hip is painful at extreme flexion and internal rotation. When extended and externally rotated there is a sense of discomfort and instability.
• Imaging
  • Plain xray
    • Right hip - Normal.
    • Left hip - Wiberg C-E angle of 12 degrees with lateral sourcil thickening and slight loss of joint space laterally. An xray with the hip abducted shows the femoral head is covered and the hip is congruent.
  • MR scan:
    • labral tear and a small cyst anterosuperiorly with moderate articular cartilage erosion. The patient wants help. She is struggling to work and has stopped exercising. She has observed her sisters disappointment at her result, but she would be prepared to undergo surgery because "she will do better than her sister".

1. What is your analysis of the problem? (20 marks)
2. What surgery would you ultimately recommend for her and why? Discuss briefly, alternative surgical options (15 marks)
3. What are the important elements of informed consent in this clinical situation? (15marks)

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