Sunday, 6 May 2018

CBO April 2018..adakah kamu sudah bersedia??

Viva 1
Examiner 1
1. Tell me about bone grafts?
2. Tell me about principles of fracture fixation ( absolute / relative stability and examples)
3. Post fracture fixation rehab principles . Gave example on intraarticular

Examiner 2 (prof Azhar)
1. Tell me about callous formation
2. Why you do compression plating.
3. Commonited femur shaft fracture done bridging plate with lock plate ( absolute or relative stability)
4. What is ( with unit) strain, stress. What is ductile, brittle and toughness
5. How does MRI and bone scan work? Clinical application of bone scan and why
6. What is student T test.  How to compare means of two different group

Examiner 3 ( Ms noh)
1. Tell me why a diabetic ends up with lower limb amputation ( pathophysiology of diabetic foot)
2. Preoperative management of DFU in sepsis
3. Why do a burgress flap?  Myodesis or myoplasty and why?
4. Post operative complications of bka

Examiner 1 ( Mr ng UM sports)
1. Lag screw principles
2. Shown an x-ray of elbow dislocation with coronoid #. Diagnosis? Then what you want to do?  How to approach coronoid fracture
3. Proximal radius approach.  If extend what muscle to release ( PT)? If released need to repair PT?
4. Anterior shoulder approach

Examiner 2 ( prof Jamari hand UKm)
1. Trigger finger release
2. Proximal pole scaphoid approach and steps of fixation. Screw length. Drilling technique
3. Radial nerve cut with humerus fracture. Methods of repair. Shortening Vs graft.
4. Tendon transfer principles. How to do side to side repair

Examiner 3 ( prof Anand)
1. Neck of femur in 50 year old.  Everything from reduction to how to put screw. Screw size
2. Equinas foot child. How to know where to release? Steps in gastroc recession. Post Op Care.

Monday, 18 December 2017

Soalan Exam lagi..

CBO 2015 

Bila nak jawab entah la...

Jangan malas aA..jangan..

1. Lag screw principle

2. Tension band plate
    - discuss too about antiglide and neutralizing plate

3. Surgical approach to NOF in elderly sampai reaming of femoral canal..
    - pantang, jangan sebut THR..

4. How do you do CTR
    - explain hand landmark
    - what do you do if the nerve already atrophy

5. How do you do open discectomy for slip disc at L4/L
    - sampai removal of disc
    - position of pituitary forceps etc

6. How do you approach T12 anteriorly using thoracosubdiaphragmatic abdominal approach

7. Explain regarding tibial pin insertion
    - Upper tibia
    - Supracondylar pin
    - Calcaneal pin

8. How do you do CMR for
   a. posterior elbow dislocation
   b. Anterior shoulder dislocation
   c. Posterior hip dislocation
   d. Metaphyseal fracture radius in a child

9. Approach for septic hip in a child

10. How do you approach radial head fracture- to replace/resect
      - safe zone for fixation

11. Approach for fracture proximal third radius

CBO 2015 - VIVA

1. What do you understand by aseptic technique
     Maintenance of OT sterility, step taken when there is outbreak of infection post-operatively
     When to open back OT after cleaning
     Where to take swab in OT

2. Tuberculous cold abscess and Psoas abscess
     TB treatment regime, duration, mechanism of action each anti TB

3. Approach to a child with osteosarcoma and treatment

4. Elderly lady with NOF farcture
   - discuss the management, treatment as well as discussion of antiporotic in detail

5. Pink pulseless hand in child with supracondylar fracture humerus

6. Discuss musculoskeletal injury in Nepal earthquake

7. Management of humerus fracture with radial nerve palsy

8. Knee instability, how to scope..step by step

9. Tendinitis vs tendinoses

10. Principle of biopsy

11. Basic surgical skill

Monday, 2 October 2017

soalan exam...

1. Panjabi konsep regarding the stability of spine ?
A. Passive : bone, ligaments
B.  Active : all the B1.muscle surrounding
B2. neural ( nerve )
2. Why lower part of cervical spine commonly involved in facet dislocation ( area C3-C7 )?

3. Allen and Ferguson classification ?

 4. If there is unifacet level C5/C6 ...what will the pt presented ( level of neurology involved ) ?                        

5. What is the x ray findings for 
A. Unilateral facet dislocatio
B. Bilateral facet dislocation
C. ? Retropulsed disc                        

6. What is White & Panjabi classification for spine instability?         
7. Indication?                        
 Indication for operation?                        

 8. How do you do awake closed reduction and traction for patient?           
9. How do you surgically  approach for facet dislocation...

 10.... controversies regarding approach of ;
A. MRI whether to do before or after reduction?

11. Contraindication of closed reduction with traction ?   
12. How do do confirm whether there is end of spinal shock?   
Why is it important to know regarding the end of spinal shock ( ESS )     
13. Difference between spinal shock & neurogenic shock?

14. What vasopressor that you give during neurogenic shock and why?

15. What your opinion regarding methylpred drug administration ?

16. What is your opinion regarding early surgery in spinal shock patient?     
17. Definition of degenerative disc disease ( DDD )?                        
Pathophysio of DDD?                        

18. Function of spine?                        

19. Definition of spinal instability?                        

20. Landmark for pedicle screw insertion?

Recurrent carpal tunnel

-scar size. Is it beyond the distal wrist crease? Feel scar - in incomplete Ada area of fibrosis and the rest of scar is soft. Ask pt to grip-ade puckering of skin surface

Area of tenderness. Wasting


No need to do LOAF, sensation median nerve, - sebab mmg soalan dia recurrent cts. Phalen & durkan pun X perlu buat

3 site of compression:
0. Cervical
0. Cubitel tunnel
0. Median nerve

Tinel sign : 2 function. For provocative & to monitor progression of repaired nerve 
 Is Tinel sign good? Yes coz in cts in shows nerve still firing the impulse 

Double crush phenomenon-2 site of compression

High median nerve (compression)
  1. Supracondylar process- 1% on Xray
0. Laceratus fibrosis-open arm, pronate, flex elbow
0. Arcade of struthers-
0. Pronator teres- lawan pronation 
0. Fds finbrous arcade -test fds middle finger 

What is recurrent motor branch variant anomaly?
-extraligament 50%
-sub ligament 30%
-transligament 20%
-from ulnar border of median nerve
-on top of tlc 

How u do cts release?

Lumbrical syndrome?
-due to hyperthrophy of lumbrical. When pt flexion, lumbrical tend to get into compartment & cause numbness at median nerve

Endoscopic cts?
-less scar tenderness
-improved short term grip

Disadvantage : incomplete release tlc, neurapraxia, cannot see other pathology eg: ganglion, portal at ulna side so can injured structure at guyon canal  

common question prof razak regarding LLD

1. Esp in clinical...
How to confirm pt ada LLD 
A. By clinical
B. Bycradiological                        

2. When do you intervene 
Atau... Mx when there is 
A. LLD 1 to 3 cm
B. LLD >3 cm till 5 cm
C. LLD more than 5 cm..      
When do you consider amputation in LLD pt ?                        
3. When you consider 😂                        

 4. How to extrapolate the  future LLD in children  ( ada formula okay )         
 5. How many cm / percentage growth contibuted by 
B. Neck of femur
C. Distal femur
D. Prox tibia
E. Distal tibia                   

proximal femur - 3 mm / yr 
distal femur - 9 mm / yr 
proximal tibia - 6 mm / yr 
distal tibia - 5 mm / yr

By clinical..
Leg length discrepancy (LLD) is a measurable difference in the overall length of the two legs, which can be true, apparent or functional: 
True –an absolute difference in leg lengths, clinically measured from ASIS to medial malleolus. 
Apparent –where there is a measurable difference owing to positioning but the actual limb lengths may be the same. Clinically measured from xiphisternum or umbilicus to the medial malleolus. 
Functional –the difference the patient perceives (corrected clinically by blocks under the short limb).

By radiological:
1.Radiographs:teleoroentgenography (scanography) -measure discrepancy with single exposure from 2m away
2. bone age hand films

1. What is batson plexus

2. How does TB spine occur ( pathophysiology )                  
3. Which part of spine that is commenest to be involved in TB spine and why?           
4. Why is it psoas abscess can occur in TB pt? How to differentiate due to pyogenic infection ?     
 5. What is the watershed area at the thoracic region         
6. Define gibbus                        

 7. Define cold abscess                        

 8. TB spine cause what type of urinary incontinence?
Overflow incontinence? ( define ) or hypotonic bladder ? 

 Due to weakness in the muscle at the back...Petit triangle and .... triangle?        
 9. Radiological findings  difference between pyogenic, TB spine and metastatic disease     
10. Why disc not involved in TB or involved late in the disease...

Sebab... jawapan kontroversi 💪🏼

Soalan prof hafiz...

Portals for arthroscopy post TKR.

Clinical presentation & Mx of prosthetic joint infection at 1wk post-op, 2wk, 1month, >3months

Pathogenesis of osteomyelitis involving Staph aureus, TB & Pseudomonas.

1. Where is the mechanoreceptor / innervation of the meniscus situated

2. Hilton Law ?                        

 3. Histology of the meniscus...
What is the function of the orientation of the meniscus?                        

: 4. What is the fuction of the meniscus?                        
Hilton law: nerve dat croses d joint will also supply d joint. This explains why injury to d nerve at the thigh causes pain over knee jt oso...yeke??...belasah je                    
 5. What is the proprioception located in the meniscus?
Percentage of contibution ?

 6. How does meniscus act as a load spreader?
( biomechanics )?                        

 7. What is insertional ligaments...and how does it helps the meniscus?          
 8. How does meniscus help in lubricating the knee joint?

 1.Shock absorber
2. Allow slight rotational motion at d knee
3. Increase surface area for knee jt articulation                        
 Ni yg humprey n wrisberg tu ke miss?                        
 Bagus adzhar...ada lagi satu function 🤔

2A. What rotational motion that you are talking about?                        
 Yep 👏🏻👏🏻💪🏼

9. Teribble triad? Mechanism of injury?                        
 1.acl injury
3.medial meniscus                        

 10. What is common injury in acute knee?
Chronic injury...which part of ligament and meniscus involved and why?                   
11. Explain how to do Mc Murray examination of the knee ( favourite question masa clinical examination ) 😰

13. How do you do Thessaly test? The accuracy?

14. What or How do you classify the meniscus tear?        
 15. When do you decide to repair meniscus during scope?      
 16. Technique for suture repair?                        

 17. How do you scope ? ( esp for final year)

Wednesday, 24 August 2016

Peringatan Hidup


*Satu hari, seorang guru sekolah menulis di papan hitam:*

*9 × 1 = 7*
9 × 2 = 18
9 × 3 = 27
9 × 4 = 36
9 × 5 = 45
9 × 6 = 54
9 × 7 = 63
9 × 8 = 72
9 × 9 = 81
9 × 10 = 90

*Apabila dia telah selesai, dia memandang kepada pelajarnya, dan mereka semua ketawa pada beliau. kerana jawapan yg pertama itu yang merupakan jawapan yg salah.*

Kemudian guru itu berkata,saya menulis jawapan pertama itu salah dengan sengaja.. kerana saya mahu anda untuk belajar sesuatu yang penting.

*Ini adalah untuk memberitahu anda bahawa bagaimana dunia di luar sana akan melayan anda.*

"Anda boleh lihat yang saya tulis dengan TEPAT sekali utk 9 jawapan yg lain, tetapi tiada seorang pun yang mengucapkan tahniah kepada saya untuk itu!

*Anda semua ketawa dan mengkritik saya kerana satu perkara salah yang saya lakukan.*

Jadikan ini suatu pelajaran..

*"Dunia tidak akan menghargai kebaikan yang kamu buat walaupun satu juta kali, tetapi akan mengkriti kamu jika hanya sekali sahaja kesilapan yg kamu buat.."*

Thursday, 21 July 2016

Pengalaman sebagai Orthopod 4


pagi semalam masa round ngan OORU team..

tgh review pt pelvic..then team arthro dtg..diketuai senior surgeon Arthro ..bertanyakan pendapat dan cadangan tentang satu kes arthroplasty di team Arthro..

diorang bincang2..then team Arthro berlalu pergi..
kami sambung review pt pelvic kami..

tiba-tiba..Prof bersuara..

automatik bila Prof bersuara..kami akan berpaling..

"meh saya nak citer.."katanya sebagai pendahuluan..

"ada buku pasal how to be a good leader..dia beritahu cara2 nak jadi ketua yang baik..
first thing..u must capable to do many things..i'm not that kind of person..(sambil gelak)..saya bukan jenis macam tu..maybe younger generation like u all..maybe later 
u (sambil tunjuk kat sorang lagi specialist) boleh.."

-sambung lagi-kami tak interrupt pun bila Prof bercakap.-

"tapi the most important thing ialah..the leader able to accept the comments, any complaints, dia terima..any opinion dia boleh ambik..

nak jadi lebih baik..dia kena dptkan pendapat org lain..dia maybe dah pangkat besar..lama dlm bidang pengalaman org lain..ilmu org lain..pendapat org lain..itu yg penting untuk jadi ketua..

jadi..ketua kena pandai menerima dan perbaiki diri dengan menerima teguran dan pendapat org lain.."


*sy taip berdasarkan ape yg prof cakap..

Friday, 8 January 2016

Art of Debridement..

Art of Debridement..

not just removing infected and unhealthy tissue..but.. u differentiate the part that need to be remove and part that u want to keep
- the eyes cannot see what the mind doesn't now
- kena banyak assist buat debridement, tanya ur superior how to decide..
- study and banyakkan tengok nanti baru la dapat tahu yang mana slough, granulation tissue, necrotic tissue, etc
- yang penting anatomy la..kena tahu function each tendon tu..contoh..patient dah hilang jari little finger, so extensor tendon to 5th toe tu boleh la remove kalo dah infected..tak yah sibuk nak cover la..kikis skit2 la..

2. how to learn to debride..assist..assist and assist..
- jangan ingat masuk OT..alah..assist je..tak dapat nak buat..tak yah masuk...
itu satu assumption yang merugikan anda..
masuk je..jangan risau..setiap operation tu adalah ilmu baru untuk kita..
masuk dan tengok serta perhati betul2..

3. only assist? still not enuff..u have to observe..OBSERVE..not just see..OBSERVE
- beza bila masuk OT, assist semata2..
- jangan setakat masuk jadi retractionist or suctionist semata2..
- atau tersengguk..
- perhati dengan ilmu..observant..tanya..tanya..kenapa itu kena buang..camner nak cover soft tissue and bone..

4. how u HOLD AND HANDLE the instrument so that u can pick and remove that u dun want..without risking ur colleague to injury..
- instrument perlu bila nak buat debridement. eg mayo scissors, bone currete, scalpel etc
- pegang betul2..cara nak pegang tu pun kena perhati bila ur superior buat debridement.
- biar ergonomik..jangan sampai terpusing2 tangan tu pegang instrument..
- halakan scissors tu pada structures yang nak buang..bila handle pun tak betul..maka masa yang diambil untuk siapkan kes pun lama..dan makin bleeding la patient..
- yang penting..jangan riskan assistant anda dengan injury..
- tak heran ada yang sampai instrument terpelanting..
- jangan cederakan diri sendiri..
- macam mana nak tahu cara pegang yang betul?...tengok senior pegang camner..senior nak ajar..bukan setakat boleh ajar ikut phone..or verbally..kena pegang instrument tu..tunjuk dulu..junior tengok dan paham...

5. how to minimize bleeding..not just cauterize the's on how u cut the tissue..
- dah nampak 3cm infected and sloughy skin and soft tissue nak kena buang..janganlah potong sikit sikit..sekali potong..akan bleed..potong lagi..bleed lagi..
- kalo dapat kes necrotising fasciitis yang kena buat radical debridement..kalo potong skit2..bayangkan bila nak habih..dan bayangkan berapa banyak bleeding yang berlaku..
- so kena la plan.assess..yang mana nak buang..margin kat mana etc..zerrraaappp terus

6. how u extend the wound..
- plan camner nak extend the wound..kalo masih baru..discuss dengan superior..suggested skin incision..kena tengok dan assess..kemana infection tu tracking..
eg: wound kat kaki..tend to spread proximally, by tracking through achilles tendon..
     wound kat leg, boleh tarcking proximally via the tensor fascia lata..
- salah extend..healthy skin and tissue boleh deprive of blood supply and later on boleh jadi necrosis..

7. how u prevent the healthy tissue from infected..
- ada yang buat debridement, cucuk mayo scissors then bukak..cucuk2..
- make sure u nampak dan assess mana tissue yang healthy dan mana yang tak..jangan main jolok je..
- kalo main jolok je..dari depth yang healthy pun akan jadi infected sebab anda dah introducekan infection masa duk cucuk tadi..
- bukak betul2 dengan blade..TENGOK..

8. see what u cut..dun just chopped and chopped..
- tak boleh disangkal la..bila jadi assistant ni..ada yang mengantuk..lagi2 kalo kes pukul 3-4 pagi..
- so ada la saat tertido dan lupa nak suck the blood guna Yankeur tu.
- as a surgeon..clear the operation field dulu.. dap dulu blood clot ke, pus ke..identify dulu soft tissue, baru la u cut..
- ni bukan ayam yang boleh main potong potong dan potong..

9. knows the anatomy..
- anatomy..
- kena la tahu..
- basic nih..

10. knows how to protect the important structures such as tendon..neurovascular bundles and bones..

11. patience..

12. dun greedy..

13. post op wound..keep review and review..even the pt from different wards..ask the incharge what did the superior said about the post op wound..

14. if not satisfied..u should feels bad and try to u put the pt on risk of anaesthesia..again..

15. PLAN UR OPERATION..plan..plan..not during pt already in OT..but early during ur oncall days..go to ward..see the wound..and plan straight away..if not sure..ask the superior..

16. the art not ending here..still many u should learn..and i'm still learning..

the most important the patient heals well..

Wednesday, 28 October 2015

Pengalaman sebagai Orthopod 3

sambung lagi


memandangkan saya ni kebanyakan tajuk berkait dengan kehidupan saya di tempat kerja..
tahun ni dah tahun keempat saya sebagai MO Ortho..masih baru dan masih banyak nak belajar.

Ada junior yang tanya, macam mana saya boleh dapat keyakinan untuk buat operation sendiri..operation simple la..yang sub tu mestilah masih takut..
maksud diorang, boleh buat plating femur tibia sendiri, radius ulna sendiri..dari tak reti kepada reti la skit..
then saya share la kisah saya masa di bawah didikan pakar2 yang sangat excellent tu..

seawal saya day 5 di Jabatan Ortho, dah dipanggil oleh Mr. HOD untuk buat removal of plate femur budak umur 13 tahun. Hari yang sama, saya onkol..biasa kalo onkol, kena la round wad dan attend new case serta setelkan wardwork sementara rakan2 lain masuk OT..tapi masa tengah round tu, dapat call kena masuk OT stat..apekah..??

rupanya Bos tengah tunggu sebab nak ajar buat removal of femur plate..berdebar masa tu..Day 5 baru..mana la tahu camner nak buat, approach ape, potong mana etc sebab masa HO malas giler nak ambik tahu pasal ni kan..

Bos ajar step by step, Bos instruct..means, skin incision dia cuma tunjuk je, kita yang buat..sampai la bukak fascia, guna osteotome, bukak screw and jahit..first case of the day masa OT elektif..
Terharu sangat masa tu..dapat belajar one to one dengan boss plus tips and tricks..
So bila dapat pengalaman macam tu..Bos expect next time kita buat sendiri la..yes..under supervision.
Bos bagi senior yang hebat giler untuk supervised termasuk la operation2 lain..

setiap kali scrub in, mesti ada je benda baru yang dipelajari..enjoy sangat..
Seniors dan Bosses juga sangat baik dan percaya kat MO dia ni sebab exposure masa kat sana sangat la banyak..

Percaya camner tu?

Banyak kali kena..kena tinggal ngan Bos kat OT, buat kes sendiri..
contohnya Percutaneous K wire Supracondylar Humerus Gartland 3..dibuat secara emergency, masa oncall.. so kalo oncall ada kes macam tu, standby la..
masa awal2 tu, memang la Bos panggil..dah lama2 asyik assist je, kena la buat sendiri..
pernah satu malam, ada kes tu, call la Mr. HOD ni..
       "Bos, patient dah hantar ke OT, nanti Bos datang eh, saya prepare patient nanti.."
       " OK, nanti saya datang. Awak proceed dulu.."
Bila dah ready semua, saya start la buat CMR bagai..sampai 15 minit try, just me and balik Bos gtau tak dapat masuk..
       " Baru 15 minit, belum sejam..buat la dulu.."

akhirnya dapat..
rupanya, dapat tahu Bos datang tapi dia intai jer dari luar sambil mintak PPK or MA jadi mata2 dia untuk update progress op..ahhahaha..

banyak lagi la kes lain yang gtu..kena tinggal..
first plating femur pun gtu..dengan seorang HO perempuan sahaja..takder MO lain..
anaesth masa tu baik..dia rilex je..dah kul 5 petang masa tu..
          " Buat je op tu aA..takpe..jangan 1st plating femur sendiri kan..cuba buat sendiri..nanti dah lama2, confident la nak buat sendiri.."

see...cooperative and sporting tak dia?..

Setiap kali masuk OT, memang seniors dan specialist akan ajar step by step..tak pernah miss..gelak2 jugak tapi mulut mengajar..
so setiap satu tu..ada je benda yang direvise dan diingatkan selalu..siap dengan reasoning..

So, pada yang masih baru..dah banyak kali masuk OT..assist..observed..anda perlukan keyakinan untuk buat sendiri..
dan untuk mencapai keyakinan dan keberanian tu, perlu ada senior yang supportive..bukan supportive dari segi  "meh aku buat, cepat skit.."..tapi dari segi.."buat dulu..ada masalah takleh setel baru panggil.." itu pun dah cukup..
ataupun..kalo senior tu gatal sangat tangan nak scrub..jadi la retractologist ke..suctionist ke..
kalo complicated sangat or lama sangat, then baru interrupt..

Junior MO pun kena paham, u boleh buat sendiri jika tiada kekangan masa OT..macam last case ke..if first case dah susah..perlu senior untuk masuk supaya kes seterusnya tak ditunda ke hari lain..

Bagi peluang pada junior..sebab itu caranya saya belajar dulu..

contoh..plating radius..biasa surgeon duk sebelah radius, assistant duk sebelah ulnar..
tapi bila junior nak buat, bagi dia duduk sebelah radius, senior sebelah ulnar..sebab junior ni nak oriented approach macam dalam buku..bila dh OK, duduk la mana2 pun, in shaa Allah boleh buat..