Orthopaedics 🦴

A 15 year old boy presents with a limp and pain in the left knee. The pain started acutely. He finds it very difficult to weight bear. Physical examination shows the leg is externally rotated and 2 cm shorter. There are limitations of flexion, abduction and medial rotation of the hips. As the hip is flexed, it externally rotates. What is the SINGLE most likely diagnosis?

A 30 year old male presented to the Emergency Department with the complaint of swelling in his left hand. He states that he works in a textile factory and while operating one of the machines, his left hand got stuck in the machine. This incident occurred five hours ago. He has already taken some over the counter medication for pain relief, which proved to be not very helpful. When the patient noticed that the pain was not relieved and that his fingers began swelling, he then presented to hospital. The swelling appears to be distributed evenly all over the fingers of his left hand and he has noticed that it has been increasing since his accident. An X-ray was arranged but yielded no evidence of a fracture. On examination, the patient appears to be in obvious pain and clutches his left arm to his abdomen. Swelling is present over his fingers and there is a limited range of movement, namely of flexion and extension. What is the SINGLE most appropriate step in the management of this patient?

A 50 year old man attends his GP surgery with a painless soft swelling on the back of his right knee. He is unsure how long it has been there. There was no associated injury. On examination, there is a swelling at the region of the popliteal fossa which is approximately 2 cm in diameter. The mass is non-tender, round, smooth and fluctuant. He finds it difficult to fully extend his right knee compared to his left. The swelling becomes tenser on the extension of his right knee. What is the most likely diagnosis?

A 60 year old man is brought to the Emergency Department with a fractured hip. He has been having progressive hearing loss and was recently diagnosed with cardiac failure 6 months ago. His blood results show the following:

Alkaline phosphatase 900 U/L (30-150)

Aspartate transaminase (AST) 28 U/L (5-35)

Alanine transferase (ALT) 30 U/L (5-35)

Serum calcium (total) 2.7 mmol/L (2.1-2.6)

Phosphate 1.2 mmol/L (0.8-1.4)

What is the SINGLE most likely diagnosis?

A 16 year old boy was rushed to A&E following a road traffic accident. He was found to have swelling and deformity in his right thigh. A femur fracture is suspected. Primary survey has been done and his airway was found to be patent however, examination of his right leg reveals no proximal or distal pulses. There is no visible wound or loss of blood but the patient is severely hypotensive. What is the SINGLE most likely structure to be involved in this patient’s fracture?

A 33 year old woman has been having pain in her left shoulder for the past few months. The pain started after she joined the gym and started lifting heavyweights. She is unable to lift her left arm over her shoulder due to pain. Pain is triggered by both raising and lowering her left arm. She occasionally wakes up at night with pain in the shoulder. There is no evidence of muscle wasting. On examination, pain is present when she abducts her left arm to 80°. She is able to externally rotate the arm without pain. She does not have any reduction in passive movements of the glenohumeral joint. What is the SINGLE mostlikely diagnosis?

An 8 year old boy has developed progressive limping for the past few months. He has pain in his right groin and right hip. There is no history of trauma or fall. On examination, there is a decrease in the range of movement in internal and external rotation of the right hip. X-ray findings show a flattening and sclerosis of the right femoral head with lucencies seen within the metaphysis. What is the SINGLE most likely diagnosis?

A 26 year old man complains of severe pain while trying to grasp objects. It started when he fell during a skiing trip. His thumb hit the ground with a valgus force being placed onto his abducted metacarpophalangeal joint. On physical exam, there is collateral laxity at the thumb-metacarpophalangeal joint with bruising over the joint. He complains of tenderness over his metacarpophalangeal joint, particularly over the ulnar border. What is the SINGLE most likely diagnosis?

A 67 year old woman has been feeling unwell over the past week. She has a fever and a painful right knee. She is unable to bear weight because of her knee pain. She suffers from rheumatoid arthritis and is on methotrexate. There is no history of trauma. On examination, the right knee is swollen and erythematous. There is a presence of moderate effusion surrounding the entire joint line. Her right knee has increased warmth and is exquisitely painful on movement. She is unable to flex her knee. She has a temperature of 38.1°C and a heart rate of 95 beats/minute. Her blood pressure is 100/60 mmHg. What is the SINGLE most appropriate investigation?

A 66 year old woman presents to her GP with complaints of severe back pain that radiates to her left lower limb that has been ongoing for the past 6 days. The pain is described as a sharp shooting pain that shoots down the left leg. She denies any urinary retention or faecal incontinence. She has been taking regular paracetamol and ibuprofen. What is the most appropriate pain relief to prescribe?

A 78 year old woman fell with an outstretched hand after slipping on ice on the pavement. She presents to the Emergency Department with a deformity of the right wrist. On examination, her wrist is tender to touch. There is no scaphoid tenderness. Her distal sensation and pulses are intact. An X-ray of her right wrist shows a posterior and radial displacement of the distal fragment of the radius. What is the SINGLE most appropriate management?

A 30 year old lady was playing volleyball when her hand got injured with the volleyball. The right hand is not swollen and there is tenderness under the root of the thumb. Wrist movement, particularly pronation followed by ulnar deviation is painful X-ray of the wrist show no presence of fractures. What is the SINGLE most appropriate next step in management?

A 44 year old man complains of pain in the ring finger of his left hand, predominantly at the base of the finger. He finds that his finger is usually bent in the mornings when he wakes up and he has to straighten it with his other hand. It usually then straightens with a ‘click’. What is the SINGLE most likely diagnosis?

A 7 year old boy falls on his right hand with the arm extended. He has severe pain around the elbow. X-ray imaging show a supracondylar fracture of the humerus. The distal fragment is displaced posteriorly. His limb looks pale. What is the SINGLE most likely structure to be damage?

A 4 year old boy attends the paediatric out-patient clinic accompanied by his mother. His mother reports that her child complains of pain in his right hip. She says that her son cannot bear weight on his right hip and finds it painful to walk but that he doesn’t appear to be in pain upon rest. His symptoms started less than 48 hours ago. Examination reveals a happy and well-nourished child that does not appear to be in any distress. Pain is elicited upon active movement of his right hip and passive movement of his right hip demonstrates a limited range of movement. There is no swelling or redness noted around his right hip but he has a temperature of 37.9°C. Blood test was taken and results are shown below.

White cell count 9 x 10^9/L

Erythrocyte sedimentation rate (ESR) 20

What is the SINGLE most likely diagnosis in this patient?

A 38 year old painter has developed burning pain around his right lateral elbow that radiates to his forearm. The pain started two months ago and has gradually worsened over time. The pain is worse when he lifts heavy objects and he finds that his grip strength when using his right hand is reduced. Upon examination, there is tenderness over the lateral epicondyle of his right arm and pain is elicited upon resisted extension of his right wrist. Which is the SINGLE most likely muscle group affected here?

A 28 year old female presents to Accident & Emergency (A&E) following a road traffic accident. She was walking on the pavement when a group of cyclists accidentally swerved off the bicycle path and into her. She presents now with a complaint of right ankle pain. Examination reveals a tender and swollen right ankle with absent dorsalis pedis and posterior tibial pulses. The patient’s right ankle also appears to have an obvious deformity and she is unable to bear weight on her right foot. Aside from being in tremendous pain, the patient’s observations are normal and she has no other complaints. What is the SINGLE best immediate action in this situation?

A 74 year old woman has a history of a Colles’ fracture three weeks ago after falling on a concrete floor with her right hand. She is otherwise fit and well. What is the SINGLE most appropriate investigation to assess her risk for further fracture?

An 80 year old woman with mild dementia at a nursing home tripped and fell on her hand. She was brought into the Emergency Department with tenderness throughout her wrist. Distal pulses and sensation of her hand is in tact. Her hand looks well perfused. X- ray revealed a fracture of the distal end of the radius with a 10 degree dorsal angulation. What is the SINGLE best management for her?

A 33 year old woman with a previous history of pain at the left wrist following a fall on her outstretched hand 4 months ago presents with pain in the same wrist below the thumb. She has not seek any medical advice or treatment prior to this. She says that the pain is aggravated when she holds her baby. What is the SINGLE most likely cause?

A 78 year old lady has been brought in after a fall in her home. She is now complaining of pain in her right hip and is unable to walk or weight bear. On examination, the right leg is noted to be shorter than the left and is externally rotated. What is the SINGLE most likely diagnosis?

A 33 year old man has just finished his shoulder arthroplasty a few hours ago under interscalene brachial plexus nerve block. He is unable to fully open his left eye. On examination, there is ptosis and miosis. He does not have a slurred speech. What is the SINGLE most likely cause of this complication?

A 2 year old girl presents with a painless limp. On examination, there is unequal skin folds and the left leg is shorter than the right leg. What is the SINGLE most likely diagnosis?

A 58 year old female patient has poorly controlled asthma. She is currently on inhaled salbutamol, inhaled salmeterol, inhaled beclomethasone and on long term oral prednisolone. She has been told during her recent visit to her dentist that she suffers from gum disease which resulted in her tooth loss. What SINGLE condition is she likely to be suffering from?

A 81 year old man has been suffering from lower back pain for the past few years. He lives in the care home. He has no known medical problems aside from hypertension and type 2 diabetes mellitus. Over the past few weeks, he started becoming increasingly weak on his legs with unexplained falls. He developing faecal incontinence over weeks which was followed shortly by difficulty in voiding and urinary incontinence. He needs assistance to get out of his bed for an assessment. He has no sensation of the buttocks. Pinprick sensation around the perianal margin is not felt. What is the SINGLE most likely diagnosis?

A 33 year old woman who is 39 weeks pregnant is concerned about her child having developmental dysplasia of the hip as she suffered from developmental dysplasia of the hip when she was a child and had to undergo corrective surgery. Which one of the following is a risk factor for developmental dysplasia of the hip?

A 60 year old woman has pain and stiffness in her right hip joint. The pain has been worsening over the past 6 months. The pain increases in intensity as the day progresses and it is usually least painful in the morning. She has noticed nodules in the joints of the fingers of her hands. A recent blood test shows

Haemoglobin 92 g/L

White cell count 9.8 x 10^9/L

Platelets 250 x 10^9/L

What is the SINGLE most likely diagnosis?

A 15 year old boy presents with fever and pain in the right lower thigh. The pain has been ongoing for the past one month. On examination, there is a 2 cm by 2 cm mass at the lower third of his thigh which is red, warm and tender. An X-ray shows bone destruction with overlying onion-skin layers of periosteal bone formation and a soft tissue mass. What is the SINGLE most likely diagnosis?

A 33 year old pregnant woman presents with right knee pain worse when moving the joint. The pain has been present for the last 4 months but it is worsening. The pain is noted to be worse at the end of the day. X-ray shows decreased joint space in the right knee. Blood results show a CRP of 12. What is the SINGLE most appropriate management?

A 12 year boy was playing in the park with his younger brother when he accidentally fell onto his outstretched hand. He was subsequently brought to A&E with the complaint of pain around his elbow. Upon examination, generalised swelling was found around the elbow region and he flinches away in pain when the doctor tries to touch his elbow. He was found to have a limited range of motion at his elbow, and passive rotation of his arm yields significant pain. Examination of the radial nerve reveals tenderness over the radial tunnel and the patient complains of pain when his fingers are extended against resistance. What is the SINGLE most likely type of fracture in this patient?

A 58 year old woman fell with an outstretched hand. She presents with dinner fork deformity on the right wrist and tenderness over the right arm and wrist. Distal pulses of the limb is felt however she complains of numbness of the right hand. What is the SINGLE most likely associated nerve injury?

A 35 year old male typist suffered a wrist injury after falling on his right outstretched hand. He was treated with a scaphoid cast with the probable diagnosis of a scaphoid fracture. The cast was removed after 2 weeks from the injury for a repeat X-ray. After removing the cast, he noted that he he had difficulty in moving his right thumb, index and middle finger. There was also a tingling sensation on those fingers. What is the SINGLE most likely management that would improve his symptoms?

A 33 year old woman has complaints of pain in her right arm and shoulder when she abducts it. The pain is worse at night and disturbs her sleep. She finds it difficult to perform task which involve lifting her arm such as combing her hair. She has recently moved to a new house and was involved in carrying heavy items. There is no history of trauma. What is the SINGLE most likely cause of her pain?

A 71 year old man has sustained a hip injury from a fall down the stairs. He has been given intravenous paracetamol but remains in severe pain at his right hip. A hip X-ray reveals a right fractured neck of femur. He is known to have atrial fibrillation and takes rivaroxaban. His blood tests show the following:

Haemoglobin 141 g/L (130-180) White cell count 9 x 10^9/L (4-11)

Platelets 370 x 109/L (150-400)

Sodium 142 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5)

eGFR >90 mL/min

What is the SINGLE most appropriate management?

A 2 year old boy is brought to the paediatric A&E by his mother who is concerned about his right leg. He fell from a chair a few hours ago and since then has not been moving his right leg. He refuses to walk or stand. On examination, there is no obvious bruising or deformity. There is severe tenderness at the medial shin of his right leg. An X-ray of the leg reveals no deformity or visible fractures. What likely type of fracture does this child have, if any?

A 6 year old boy tripped and fell on his left elbow. He presents with his mother to the A&E with a swollen elbow and inability to supinate his forearm or fully extend his elbow. He is holding his left arm with his other hand and refuses to let anybody touch his elbow due to pain. A plain x-ray was requested which is seen below:

What is the SINGLE most likely diagnosis?

A 61 year old man sustained a distal radial fracture 2 years ago when he fell down the side of the road. He does not smoke. He has a body mass index of 22 kg/m2. He has no significant medical history. He would like to decrease his risk of fractures in the future. What is the next SINGLE most appropriate action?

A 67 year old woman presents to the emergency department with pain in her left grain. She falls from a chair in the waiting area and now is in severe pain and is not able to move her left leg. She takes alendronate regularly. What is the SINGLE most likely diagnosis?

A 21 year old woman had a fall where her hand was forced backwards, resulting in a hyperextension injury of the wrist. She has significant pain and swelling in the wrist just below the base of the thumb. The pain worsens when she moves the thumb or tries to pinch. She was seen in the A&E, where she had x-rays which showed no bony injury. Her wrist was immobilised, and she was discharged with a follow-up appointment in the fracture clinic. Which bone is suspected to have fractured?

A 75 year old man has sustained a right femoral neck fracture from a fall down the stairs. He has been given intravenous morphine as a bolus dose but remains in severe pain at his right hip. An ECG shows that he is in atrial fibrillation. He is not taking any regular medications. His blood test show the following:

Haemoglobin 141 g/L (130-180)

White cell count 9 x 10^9/L (4-11)

Platelets 370 x 10^9/L (150-400)

Sodium 142 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5)

eGFR >90 mL/min

He has a heart rate of 85 beats/minute and a respiratory rate of 11 breaths/minute. The orthopaedic team plan to take him to the theatre for an open reduction and internal fixation. What is the SINGLE most appropriate management?

A 55 year old woman has a history of a recent radial fracture. In the last decade, she had a colles’ fracture in the right forearm and supracondylar humerus fracture of the left arm. She used to take corticosteroids for 2 years as part of managing her inflammatory bowel disease. What is the SINGLE most appropriate investigation to perform?

A 33 year old woman has complaints of pain in her right arm and shoulder when she abducts it. The pain is worse at night and disturbs her sleep. She finds it difficult to perform task which involve lifting her arm such as combing her hair. She has recently moved to a new house and was involved in carrying heavy items. There is no history of trauma. What is the SINGLE most likely cause of her pain?

A 24 year old man falls on an outstretched hand while playing football. He comes in complaining of pain at the base of the thumb. On physical examination, he is tender to palpate over the anatomic snuff-box. Wrist movement, particularly pronation followed by ulnar deviation is painful. X-rays are read as negative. What is the SINGLE most appropriate next management?

A 59 year old woman is being investigated for chronic back pain. X-ray of her spine was reported to be normal. Bone scans revealed multiple lesions in the skeleton suggestive of metastatic disease. What is the SINGLE most likely site of the primary?

A 61 year old man has developed a sudden onset of right calf pain and swelling. He had a right popliteal mass which was present for 3 weeks which is no longer present. He suffers from osteoarthritis and takes regular paracetamol and ibuprofen tablets. On examination, his right midcalf is 2 cm larger than his left. The right calf is red, erythematous and tender. There is moderate effusion on the right knee. What is the SINGLE most likely diagnosis?

A 60 year old man attends for a follow up to discuss his reports. He presented a week ago with the complaint of dull pain in his right leg for the past 3 months. The pain persists on rest and affects the quality of his sleep. He also feels more tired and complains of worsening shortness of breath on exertion. He drinks about 20 units of alcohol a week for the past several years. He has a 20 pack-year smoking history. On examination, his right leg appeared anteriorly bowed, and the region was warmer in comparison to the surrounding skin and that of the opposite leg. An X-ray of the area confirms the anterior curvature of the tibia and indicates cortical sclerosis and a coarse trabecular pattern of the same.

Alkaline phosphatase 2900U/L (30-150)

Aspartate transaminase (AST) 30U/L (5-35)

Alanine transferase (ALT) 33U/L (5-35)

Serum calcium (total) 2.5mmol/L (2.1-2.6)

Phosphate 1.2mmol/L (0.8-1.4)

Gamma-glutamyl transferase (GGT) 59 U/L (8-60)

Bilirubin 16 pmol/L (3-17)

Which of the following is the SINGLE most likely diagnosis?

A 33 year old builder attends his GP surgery with back pain. Three days ago he lifted a heavy concrete during work which resulted in a sudden pain in his back. The pain has gatten worse. He describes the pain as 5/10 on a pain scale. He is able to walk with minimal pain. Examination reveals he has pain in both lumbar spine flexion and extension. What is the SINGLE most appropriate medication to prescribe?

Acute and severe cases may warrant short diazepam prescription
A 53 year old man has pain in the back of bath of his lower limbs radiating to his feet for three weeks. The pain starts to radiate downwards from his back after standing for about 10 minutes. The pain is relieved by bending forward or sitting down. What is the SINGLE most appropriate investigation?

A 28 year old man was involved in a road traffic accident where he sustained a right tibial shaft fracture. He was treated as a surgical emergency and taken to the operating theatre to perform stabilize the fracture with intramedullary nails. A plaster of Paris was applied. The following day, he developed severe pain in his right calf. He was given intravenous morphine but continues to have significant pain. On palpation, the right calf is very tense. There is significant pain on passive stretching of his toes. He has palpable pedal and posterior tibial pulses on his right foot. His cast was removed, but the pain did not improve. There is an altered sensation in his right calf compared to his left. What is the SINGLE most appropriate action?

A 61 year old woman fell down her stairs and sustained a fractured neck of femur. She is admitted in the hospital and has her surgery booked for the following day. Her blood test shows the following:

Haemoglobin 77 g/L (115-160)

Mean cell volume 71 fL (76-96)

Mean cell haemoglobin concentration 300 g/L (300-360)

Platelets 160 x 10^9/L (150-400)

What is the SINGLE most appropriate next action?

A 20 year old fit man suddenly develops severe lower back pain as he is getting up from bed. There is greater pain when he is lying supine with his leg raised. He gives a description of an electric shock pain moving down his left leg. What is the SINGLE most likely diagnosis?

A 64 year old diabetic woman presents to the GP surgery with an acutely painful, swollen and hot right knee joint. There is limited range of movement and movements are painful in all directions. There is redness around the joint. An effusion surround the entire joint is obvious. There is no history of trauma. She has a pulse rate of 70 beats/minute, and a temperature of 37.8°C. What is the SINGLE most likely diagnosis?

A 33 year old man was painting his wall when he slipped from the ladder and fell from a height of 8 feet landing on his feet. On examination, his left foot is tender and swollen. Which SINGLE bone is most likely to have been fractured?

A 50 year old man presents to the Emergency Department with acute back pain radiating down to his right leg. He is unable to weight bear. There is no history of trauma. The pain is relieved when lying down. What is the SINGLE most appropriate investigation?

A 58 year old man has pain in his left knee for 2 years. The pain has been gradually worsening over a period of 2 years. The pain is worse in the evening after a day of walking. He reports a sensation of the inability to straighten the leg at times. His medical history includes a recent peptic ulcer. On examination, there is crepitus and tenderness along the joint line and a small effusion. He takes 1 g of paracetamol 4 times a day and applies topical ibuprofen on his left knee regularly but would like more pain relief. What is the SINGLE most appropriate action?

A 57 year old woman with breast cancer currently undergoing chemotherapy complains of worsening thoracic spine tenderness and paraesthesia to her left foot over the past few weeks. She feels shooting pains down her left leg over the past few days. She takes oramorph (oral morphine sulphate) regularly for pain. What is the SINGLE most appropriate imaging to request?

A 33 year old man who suffers from chronic lower back pain has shooting pain coming down his left leg. He has reduced sensation of the dorsum of his left foot. On examination, he experiences pain while performing a straight leg raise test of his left leg at 45 degrees. There is weakness in left ankle dorsiflexion. Which nerve root is likely to be compressed?

A 24 year old man presents to A&E after an injury to his hand while playing basketball. Examination of his hand reveals an avulsion of the extensor digitorum tendon from the distal phalanx. What is the SINGLE most likely deformity?

A 81 year old man presented to his GP with the complaint of pain in his right hip that radiates to his right knee. He says that he noticed the pain a few months ago but that it has recently become a lot worse and has now begun to disturb his sleep at night. He mentions as well that the pain is worse when he walks but that it becomes relieved somewhat upon rest. He denies the possibility of having sustained trauma to his hip and denies having any joint stiffness in the morning. Physical examination reveals a limp on his right side. Hip examination reveals pain upon passive movement of the joint as well as a reduced range of motion upon active movement. A mild degree of crepitus can also be appreciated. What is the SINGLE most likely diagnosis?

A 13 year old boy presents with pain in the groin. He is seen limping. There was no history of trauma. The pain started a few weeks ago but has been worsening. There are limited hip motions, and as the hip is flexed the thigh goes into external rotation and cannot be rotated internally. When the boy is lying down, the left leg is 2 cm shorter than the right leg and it is externally rotated. What is the SINGLE most likely diagnosis?

A 40 year old man presents to the Emergency Department with calf and heel pain. He was playing football when he suddenly felt a pop at the back of his left leg followed by pain at his calf. He says he felt as if someone kicked his leg from behind however no one was near him at that time. He describes himself as an infrequent football player. He has a history of a deep venous thrombosis on his left calf 5 years ago. On examination, Thompson test reveals absent plantar flexion. What is the SINGLE most appropriate action?

A 24 year old football player presents to the Emergency Department following a hard kick to his right calf during a football match. He is in extreme pain despite increment of intravenous morphine doses given in the hospital. His right calf shows extensive bruising and swelling. On palpation, his right calf is tense. Passive movements of his toes aggravate the pain. He has a weak dorsalis pedis and posterior tibial pulse on his right leg. The X-ray of the lower limb is unremarkable. What is the SINGLE most appropriate action?

A 15 year old boy complains of pain in his leg which usually settles within an hour of taking aspirin. The pain is described as a dull pain which is persistent but is usually worse at night. What is the SINGLE most likely diagnosis?

• A 15 year old male presents to his GP with the complaint of knee pain. He complains of being unable to sleep at night due to pain in his right knee. Further questioning reveals that he has been having intermittent unilateral pain in his right knee for the past seven months which has gradually worsened. He is concerned because he has had to give up football due to this pain. He has no other complaints and he has no significant past medical history. Examination of the knee reveals a 1 cm by 1 cm smooth, fixed, tender mass on the medial side of his right knee at the level of the tibial tuberosity. He is able to bear weight on the knee however, his gait appears to be slightly antalgic. The rest of the knee examination revealed no other abnormalities but small lymph node was found in the ipsilateral inguinal canal. What is the SINGLE mostlikely diagnosis in this patient?

A 65 year old man attends the Emergency Department with sudden pain in his right hip. The pain started earlier in the day when he bent down to tie his shoe. He finds difficulty walking with his right leg and was assisted to the Emergency Department by his son. He had a total right hip replacement 2 weeks ago for a femoral neck fracture. On examination, his right limb is shorter, and his right hip appears to be flexed, abducted and externally rotated. There is right gluteal bruising seen. What is the SINGLE most appropriate investigation?

A 12 year old boy attends the Emergency Department with pain after falling off his bicycle. A lateral X-ray of his wrist shows a fracture at the distal radius with the distal fracture fragment displaced anteriorly. What is the SINGLE most likely diagnosis or deformity?

A 65 year old man would like advice on reducing his risk of a osteoporotic fracture. He has a parental history of hip fracture. He is a smoker. He has a body mass index of 17.7 kg/m2. He has no history of fractures. He has a medical history which includes diabetes mellitus. What is the next SINGLE most appropriate action?

A 34 year old male presents with the complaint of back pain. It occurred two days ago when he and his family were moving home. He says that the pain radiates to his left foot and becomes much worse when he coughs. Examination reveals a loss of deep tendon reflexes on his left leg and a positive straight leg raising test. He has sensory loss over the anterior aspect of the knee. What is the SINGLE most likely cause of this patient’s symptoms?

A 28 year old man was involved in a road traffic accident. He has severe pain in his shoulder and upper arm. There is loss of shoulder and arm function with bruising seen at the anterior shoulder on examination. X-ray shows a fracture of the neck of humerus. What is the SINGLE most associated neurovascular injury?

An 8 year old boy presents with significant pain, swelling and bruising on his right hand and right wrist. He tells you that he tripped while playing handball and fell on an outstretched hand. He has no neurovascular deficits. The child’s wrist reveals marked swelling. What is the most likely fracture to be seen on the X-ray?

A 7 year old boy fell on his outstretched arm and presents with pain around the right elbow. On examination, a radial pulse is absent on the affected hand. There is ecchymosis in the antecubital fossa with gross deformity. What is the SINGLE most likely diagnosis?

A 33 year old man has injured his back 2 weeks ago. He was moving houses and had to shift a number of heavy furniture. He does not have pain shooting down the legs. He is able to walk. The pain is located around L3. He has a normal straight leg raise test on bath his legs. He has no significant medical history. What is the SINGLE most appropriate action?

A 22 year old football goalkeeper was brought to the Emergency Department with a locked right leg and the inability to extend the knee greater than 30 degrees. The injury occurred when he tried to catch the ball and, instead, landed with his leg twisted. What is the SINGLE most likely diagnosis?

A 7 year old boy fell in the playground with arm outstretched an hour ago. He is now seen to be holding his forearm complaining of pain. Examination of his forearm reveals tenderness but no sign of deformity or swelling. An X-ray was performed. What is the SINGLE most likely diagnosis?

A 29 year old man is seen in the orthopaedic clinic following an injury 4 weeks ago when he twisted his right knee while playing basketball. He complains of pain at the medial aspect of his right knee. There was marked swelling of his knee a few hours from the injury which resolved in a few days. He has stopped running because of the pain. It is worse on weight-bearing. He has the sensation of his knee locking occasionally. On examination, he has a normal gait. There is marked tenderness on palpation over the medial joint line. Apley test shows decreased rotation and pain on medial rotation compared to the lateral rotation. A McMurray test shows evidence of locking and pain on the right knee during extension of the fully flexed knee with tibia externally rotated with varus stress applied. What is the SINGLE most appropriate action?

A 33 year old waitress was playing basketball when she fell and injured her right wrist and hand. She presented to the Emergency Department the following day when the injury prevented her from working. The right hand is not swollen. There is tenderness under the root of the thumb. There is severe pain when moving her thumb. The symptoms are worse when she is trying to grasp with her hand. X-ray of the wrist shows no presence of fractures. What is the SINGLE most appropriate next step in management?

 A 33 year old woman fell from playing volleyball and hit her right knee 3 days ago. She reports a twisting motion of her knee followed by sharp pain. A valgus stress test of her right knee is seen to be positive. She has an antalgic gait. What is the SINGLE most likely structure that is injured?

A 63 year old man has knee pain and back pain for the last 3 months which is progressively worsening. Bowing of the tibia is noted on examination. He also has pronounced kyphosis. His recent blood results show the following:

Alkaline phosphatase 2100 U/L (30-150)

Aspartate transaminase (AST) 20 U/L (5-35)

Alanine transferase (ALT) 23 U/L (5-35)

Serum calcium (total) 2.4 mmol/L (2.1-2.6)

Phosphate 1.0 mmol/L (0.8-1.4)

What is the SINGLE most likely diagnosis?

A 79 year old man had a fall 2 days ago and since then he is unable to bear weight on his right leg. He presents with deformity and tenderness over the right hip area. X-ray shows fracture of the acetabulum. What is the SINGLE most likely associated nerve injury?

A 59 year old man sustained a left proximal femur fracture 6 months ago when he fell down from the side of his bed. He subsequently had a DEXA scan which reveals a bone mineral density T-score of (-2.2). He does not smoke. He has a BMI of 23 kg/m2. He drinks 4 units of alcohol a week. He estimates his calcium intake to be 350 mg/day. What is the SINGLE most appropriate action?

A 59 year old man sustained a left proximal femur fracture 6 months ago when he fell down from the side of his bed. He subsequently had a DEXA scan which reveals a bone mineral density T-score of (-2.2). He does not smoke. He has a BMI of 23 kg/m2. He drinks 4 units of alcohol a week. He estimates his calcium intake to be 350 mg/day. What is the SINGLE most appropriate action?

An 85 year old man has sustained a hip injury from a fall down on the pavement. His right hip is in severe pain. He has a medical history of ischaemic heart disease and atrial fibrillation. On examination, he has a shortened right leg and it is externally rotated. He weighs 47 kg. A hip X-ray reveals a right fractured neck of femur. Intravenous paracetamol has been given. He is waiting to undergo surgery. What is the SINGLE most appropriate management?

A 48 year old woman presented to her general practitioner with the complaint of new onset right shoulder pain and thoracic spine pain. She says that the pain started a few weeks ago. Initially, it was just a minor discomfort but now it is a constant dull ache, which becomes worse when she lies down. She has had no relief with regular paracetamol or ibuprofen, which she purchased over the counter. She believes that the pain is probably due to her intense gym session last week and has presented today for further evaluation of her pain. Upon further questioning, she reveals that she was diagnosed with breast cancer one year ago. She finished her treatment successfully a few months ago and says that her oncologist reported to her that she was in remission. Upan examination of her shoulder, tenderness could be elicited over the shoulder joint and the surrounding areas. Her left shoulder appears to be normal and an upper limb neurological examination reveals no further abnormalities. An X-ray of her right shoulder was done which showed some degenerative changes. What is the SINGLE most appropriate investigation that you will perform to aid in the management of this patient?

A 62 year old woman with a history of Colles’ fracture 8 months ago is sent for a DEXA scan by her GP which shows a T-score of -2.5. She fell down from the chair when she sustained her fracture. She has reached menopause at age 51. She is a smoker who smokes 4 cigarettes a day for the past 12 years. She does not drink alcohol. Which of the following is the most appropriate management of this patient?

A 44 year old man slipped while he was coming down the stairs and he fell on his outstretched arm. X-rays demonstrate an oblique fracture of the middle to distal thirds of the humerus. He is unable to dorsiflex his right wrist. What is the SINGLE most likely associated nerve injury?

A 53 year old man has pain in his left knee for several months. A left knee X-ray shows loss of the medial joint space in the knee, with articular surface sclerosis, the formation of subchondral cysts and marginal osteophyte. The pain is most prominent when he is walking. After a long day of walking, he can sometimes have knee pain at night. He takes regular aspirin for secondary prevention of myocardial infarction. His other regular medications include macrogol for constipation. What is the most appropriate medication to prescribe orally for his pain?

A 26 year old primigravida pregnant woman at 34 weeks gestation presents with tingling and numbness with occasional pain of her right hand in addition to altered sensation over her right middle and index finger. Tinel test is negative. What is the SINGLE most likely diagnosis?

A 62 year old man has bone pain at his hips and back for the past 4 months. He has no history of trauma. He has not last weight. On further investigation, alkaline phosphatase was found to be elevated in his blood.

Alkaline phosphatase 720 U/L (30-150)

Aspartate transaminase (AST) 30 U/L (5-35)

Alanine transferase (ALT) 33 U/L (5-35)

Serum calcium (total) 2.5 mmol/L (2.1-2.6)

Phosphate 1.2 mmol/L (0.8-1.4)

An X-ray shows multifocal sclerotic patches in the skull. What is the SINGLE most likely diagnosis?

A 61 year old female with a history of osteoporosis suddenly falls on her outstretched hand while shopping. She is tender over the wrist and there is visible deformity of the wrist. X-ray of the wrist shows a fracture at the distal radius with a dorsally displaced distal fragment. What is the SINGLE most likely deformity?

A 77 year old woman has sustained a fracture of the distal radius after a fall in the pavement earlier in the day. Her right wrist is noticeably swollen. An X-ray shows minimal displacement of the right distal radius. What is the SINGLE most appropriate next action?

A 64 year old man presented with 6 months of lower back pain. His past medical history includes type 2 diabetes, COPD and hypertension. In the last year, he has had at least 3 episodes of COPD exacerbation that required hospital admission. His GP arranged a DXA scan for Bone Mineral Density (BMD) assessment, and the results are seen below:

T-score lumbar spine: -2.6

T-score neck of femur: -2.3

What is the most appropriate management?