ISAWE Practice

A 24-year-old right-hand dominant carpenter presents with a 6-month history of right wrist pain following a fall. He has difficulty with his work due to weakness and pain. X-rays show a scapholunate interval of 4mm on PA view.

A 35-year-old mechanic presents 2 years after a closed midshaft humeral fracture treated with plate fixation. He has complete radial nerve palsy with no recovery despite initial observation. EMG confirms complete denervation with no reinnervation potentials.

A 60-year-old man presents with progressive flexion contracture of his left ring and little fingers. He has difficulty placing his hand flat on a table and reports the problem has worsened over 2 years. Clinical photograph shows typical Dupuytren's contracture.

A 30-year-old male warehouse worker falls on his outstretched hand and presents with a painful, deformed wrist. X-rays confirm a displaced distal radius fracture.

A 35-year-old male carpenter presents with a 1-month history of pain when hammering, cold intolerance, and paresthesias in his ring and little fingers. He uses his palm as a hammer at work.

You are asked by the examiner to describe the sites of nerve compression in the upper limb.

A 28-year-old male motorcyclist is brought to the emergency department after a high-speed collision. He has an obvious deformity of his right lower leg with a 6cm wound on the anterolateral aspect exposing bone and muscle. His vital signs are stable. The foot is pink, warm, and he can wiggle his toes. There is reduced sensation in the first web space.

A 35-year-old female is brought to the trauma bay after being hit by a car as a pedestrian. She has GCS 12 (E3V4M5), BP 85/60, HR 125. Primary survey reveals decreased breath sounds on the left with tracheal deviation to the right. She has an unstable pelvis on examination and obvious deformity of the left femur. Her left leg is pale and cool with weak pulses.

A 19-year-old male presents 8 hours after sustaining a closed tibial shaft fracture in a soccer match. He has had a below-knee backslab applied. He reports severe pain despite receiving IV morphine, and the nursing staff note the pain seems disproportionate to the injury. He reports tingling in his toes. On examination, the calf is tense and he has severe pain with passive toe extension.

A 16-year-old male presents with 3 months of progressive right knee pain. The pain is worse at night and not completely relieved by simple analgesia. He has noticed some swelling around the knee. He is otherwise well with no systemic symptoms. On examination, there is a firm mass palpable in the distal femur with restricted knee flexion to 100°.

You are asked to review the antibiotic prescribing practices on the orthopedic ward. The hospital antimicrobial stewardship team has noted high rates of broad-spectrum antibiotic use and prolonged prophylaxis courses. A 65-year-old diabetic patient is scheduled for primary total knee arthroplasty tomorrow, and the treating team has requested cefazolin plus vancomycin plus gentamicin for prophylaxis.

You are consenting a 55-year-old female for elective total hip arthroplasty for osteoarthritis. She is anxious and asks you to explain all the risks. She has read extensively online and specifically asks about leg length discrepancy, dislocation, infection, and 'metal poisoning.' She also wants to know what happens if she doesn't have the surgery.

A 75-year-old female presents after a fall onto her outstretched hand. She has immediate right shoulder pain and is unable to move her arm. She lives alone and is normally independent with activities of daily living. She has well-controlled hypertension and type 2 diabetes. On examination, there is significant bruising around the shoulder and arm with tenderness over the proximal humerus.

A 42-year-old male fell from a ladder onto his outstretched hand. He presents with severe right elbow pain and deformity. On examination, the elbow is swollen with reduced range of motion. There is tenderness over the lateral elbow and posterolaterally. Neurovascular examination is normal.

A 62-year-old right-hand dominant male presents with 2 years of progressive right shoulder weakness and pain. He cannot elevate his arm above shoulder height. He has failed physiotherapy and a subacromial cortisone injection. He works as a carpenter and wishes to continue working. Examination reveals active forward elevation to 90° with positive drop arm test and weak external rotation.

A 6-year-old boy is referred with a 6-week history of left hip pain and limp. The pain is intermittent and localized to the groin and anterior thigh. He has no history of trauma or recent illness. On examination, he has an antalgic gait. Left hip examination reveals reduced abduction and internal rotation. He is able to straight leg raise without difficulty.

A newborn male is noted to have bilateral foot deformities at birth. The feet are held in a rigid position with the forefeet inverted and adducted, the heels in varus, and the ankles in equinus. There is deep medial creasing. The pregnancy and delivery were uncomplicated. General examination is otherwise normal.

A 13-year-old female is referred by her GP after her mother noticed asymmetry in her back. She has no pain. She has recently had her first menstrual period. On examination, there is a right thoracic rib prominence on forward bending (Adam's forward bend test). The pelvis is level and leg lengths are equal.

A 16-year-old male presents with a 3-month history of progressive pain and swelling around his left distal femur. The pain is present at rest and disturbs sleep. He denies fever, weight loss, or trauma. He was previously fit and healthy. On examination, there is a firm, non-tender mass in the distal thigh with overlying warmth. Knee range of motion is mildly restricted.

A 68-year-old female with known metastatic breast cancer presents with progressive left thigh pain over 6 weeks. The pain is present at rest and worse with weight-bearing. She is able to walk with a stick but is fearful of falling. She is currently on endocrine therapy with good systemic disease control. Her ECOG performance status is 1.

A 52-year-old male presents with a painless mass in his left thigh that he first noticed 4 months ago. It has gradually enlarged. He has no constitutional symptoms. On examination, there is a firm, deep-seated mass in the anterior thigh measuring approximately 8cm, mobile in the transverse but not longitudinal plane. There is no overlying skin change or regional lymphadenopathy.

An 8-year-old girl with spastic diplegic cerebral palsy (GMFCS level IV) is referred with progressive hip pain and difficulty with positioning for sitting. She uses a wheelchair for mobility and requires assistance with transfers. Hip X-rays have been performed as part of routine surveillance. Her parents are concerned about her comfort and ability to participate in daily care.

A 14-year-old boy with Duchenne muscular dystrophy (DMD) presents with progressive spinal curvature. He lost independent ambulation at age 10 and now uses a power wheelchair. He is on corticosteroids and his cardiac function is stable (EF 55%). His respiratory function shows FVC 65% predicted. His parents are concerned about his progressive lean to one side when sitting.

A 25-year-old male presents with progressive foot deformity and ankle instability. He reports recurrent ankle sprains since adolescence and now has difficulty with footwear. He has a family history of similar foot problems (father and sister). On examination, he has bilateral cavovarus feet with claw toes. There is weakness of ankle dorsiflexion and eversion. Sensation is reduced in a stocking distribution.

A 72-year-old female underwent primary total knee arthroplasty 3 weeks ago. She presents with increasing knee pain, warmth, and swelling over the past 5 days despite oral antibiotics from her GP. She is systemically unwell with fevers to 38.5°C. On examination, the knee is warm, erythematous, and has a tense effusion. The wound is intact but surrounding cellulitis is present.

A 4-year-old boy presents with refusal to weight-bear on his left leg for 2 days. He has been febrile to 39°C and is irritable. He had an upper respiratory tract infection 1 week ago. On examination, he holds the left hip in flexion, abduction, and external rotation. Any attempt to move the hip causes severe pain. The knee examination is normal.

A 45-year-old male smoker with type 2 diabetes presents with a chronically draining sinus on his tibial diaphysis. He had an open tibial fracture 2 years ago treated with intramedullary nailing. The fracture united but he has had intermittent discharge from the wound since surgery. On examination, there is a sinus tract over the anterior tibia with seropurulent discharge. The surrounding skin shows chronic inflammatory changes.

A 28-year-old male motorcyclist presents after a low-speed collision. He reports immediate pain and swelling in his right knee with a sensation that it 'moved out of place' at the time of injury. On examination, there is a large effusion. The knee is unstable with positive anterior drawer, Lachman, and posterior drawer tests. There is also significant valgus and varus laxity at 30° flexion. The foot is warm with palpable pulses.

A 42-year-old male recreational basketball player presents 24 hours after feeling a sudden 'pop' in his left calf during a game. He describes feeling like he was struck in the back of the leg. He has significant difficulty walking. On examination, there is swelling and bruising over the Achilles tendon region. Thompson's test is positive (no plantarflexion with calf squeeze). There is a palpable gap in the tendon. He is otherwise healthy with no prior Achilles problems.

An 18-year-old female elite soccer player presents 6 weeks after an ACL injury during a game. She has completed initial rehabilitation and swelling has resolved. She has full range of motion. Examination confirms ACL deficiency with positive Lachman and pivot shift tests. MRI confirms complete ACL rupture with no meniscal injury. She wishes to return to competitive soccer.

A 35-year-old male motorcyclist is brought to the trauma center following a high-speed collision. He has a GCS of 15 and is hemodynamically stable after initial resuscitation with 2 units of blood. Primary survey reveals isolated lower limb injuries. Secondary survey confirms a deformed left thigh and leg. There is an open wound over the proximal tibia with exposed bone. The foot is warm with palpable dorsalis pedis pulse.

A 45-year-old female pedestrian was struck by a car traveling at 50km/hr. She arrives at the trauma center hypotensive (BP 80/50) with tachycardia (HR 125). Her GCS is 14 (confused). Primary survey reveals abdominal distension and pelvic instability on physical examination. A pelvic binder has been applied by paramedics. She is receiving massive transfusion protocol.

A 28-year-old male is transferred from a regional hospital following a motor vehicle accident. He has bilateral femoral shaft fractures, a closed tibial shaft fracture, and a Grade II liver laceration. He is intubated and ventilated. Initial base excess is -8 and lactate is 4.5. He has received 6 units of blood. His temperature is 35.5°C. The bilateral femoral fractures are currently immobilized in Thomas splints.

A 28-year-old male manual laborer presents with 8 months of wrist pain following a fall. He was initially treated in a cast for 6 weeks but pain has persisted. He reports aching with gripping activities and reduced grip strength. On examination, there is tenderness in the anatomical snuffbox and with axial loading of the thumb. Range of motion is reduced by approximately 30%.

A 35-year-old chef presents to the emergency department 4 hours after a knife laceration to his left palm while preparing food. He has a transverse laceration across the palm at the level of the proximal palmar crease. The index finger rests in relative extension compared to the other digits. He is unable to flex the DIP joint of the index finger, and FDS function is weak. The digital nerves appear intact with normal sensation.

A 55-year-old right-hand dominant woman presents 4 months after conservative treatment of a distal radius fracture. She reports persistent wrist pain, weakness, and difficulty with activities of daily living. Her cast was removed at 6 weeks but she has not regained function. On examination, there is a visible 'dinner fork' deformity. Wrist flexion is 30 degrees, extension 25 degrees. Grip strength is 40% of the contralateral side. She has no median nerve symptoms.

A 48-year-old office worker presents with 3 months of neck pain radiating into her right arm. The pain is worse with neck extension and rotation to the right. She describes numbness in her thumb and index finger, and weakness when lifting objects. She has tried physiotherapy and NSAIDs with minimal relief. Examination reveals weak biceps and brachioradialis on the right, reduced biceps reflex, and diminished sensation in the C6 dermatome.

A 42-year-old man presents to the emergency department with severe low back pain and bilateral leg pain that started 24 hours ago. He reports new onset difficulty voiding with reduced urinary stream and had to strain to empty his bladder this morning. He has also noticed numbness around his buttocks and inner thighs. He has a history of chronic low back pain but this is different. Examination shows bilateral L5 and S1 weakness, reduced perianal sensation, and decreased anal tone.

A 28-year-old male fell 4 meters from scaffolding, landing on his feet. He has severe thoracolumbar pain and is unable to stand. He has no neurological deficit in his lower limbs. Examination reveals a palpable step at T12-L1 and significant midline tenderness. He is hemodynamically stable with no other injuries identified on secondary survey. Rectal examination is normal.

A 12-year-old obese boy presents with a 3-week history of left groin and knee pain. He walks with a limp and prefers to keep his leg externally rotated. His BMI is 32 kg/m². He has no history of trauma. On examination, there is limited internal rotation of the left hip, and when the hip is flexed, it falls into obligatory external rotation. The right hip appears normal.

An 18-month-old girl is referred by her GP because she started walking at 15 months and has an obvious waddling gait. Her left leg appears shorter than the right. She had a normal newborn hip examination. On examination, she has asymmetric thigh folds, limited abduction of the left hip (45° vs 70° right), and a positive Galeazzi sign. The Trendelenburg test is difficult to assess at this age.

A 6-year-old boy presents with a 2-month history of right hip pain and limp. The pain is worse with activity and he has been reluctant to play with friends. There is no history of trauma, fever, or recent illness. On examination, he has an antalgic gait favoring the right leg. Right hip examination shows reduced internal rotation (10° vs 40° left) and reduced abduction (30° vs 50°). He is afebrile with normal inflammatory markers.

A 19-year-old male presents with a 3-month history of progressive right thigh pain. The pain is worse at night and not relieved by rest. He has no history of trauma. On examination, there is a firm mass in the proximal thigh with localized tenderness. He has full range of motion of the hip. There is no lymphadenopathy. His blood tests show mildly elevated alkaline phosphatase and LDH.

A 68-year-old woman with known breast cancer presents after a fall at home. She has severe pain in her right thigh and is unable to weight-bear. She completed treatment for breast cancer 5 years ago and was recently diagnosed with bone metastases. Her pain in the thigh had been increasing for 3 weeks before the fall. On examination, her right leg is shortened and externally rotated. She is hemodynamically stable.

A 45-year-old man presents with a 6-month history of a slowly enlarging mass in his posterior thigh. He reports no pain initially but now experiences mild aching after prolonged sitting. There is no history of trauma. On examination, there is a 10cm deep mass in the posterior thigh. It is firm, poorly mobile, and appears fixed to underlying structures. There is no overlying skin change. Neurovascular examination of the leg is normal.

A 72-year-old woman presents with progressive right hip pain 12 years after cemented total hip arthroplasty. The pain is activity-related, localized to the groin and thigh, and she walks with a limp. She denies fever, night sweats, or constitutional symptoms. Her inflammatory markers are normal. She had an uncomplicated primary THA and was doing well until 2 years ago.

A 65-year-old man with type 2 diabetes presents with increasing pain in his left knee 18 months after total knee arthroplasty. He had a wound healing problem initially with prolonged drainage for 3 weeks. For the past 2 months, he has had rest pain, swelling, and warmth. On examination, there is a moderate effusion, warmth, and tenderness. His CRP is 85 mg/L and ESR is 65 mm/hr.

An 80-year-old woman falls at home and is unable to weight-bear. She had a cemented total hip arthroplasty 8 years ago and was doing well. She is on bisphosphonates for osteoporosis. On examination, her right leg is shortened and externally rotated. She is hemodynamically stable with no other injuries.

A 58-year-old right-hand dominant male carpenter presents with progressive right shoulder pain and weakness over 12 months. He reports difficulty with overhead activities and has noticed muscle wasting around the shoulder. He has failed 3 months of physiotherapy. On examination, he has significant supraspinatus and infraspinatus wasting. Active forward flexion is limited to 90°. He has weakness of external rotation and a positive drop arm test.

A 22-year-old male rugby player presents following multiple episodes of anterior shoulder dislocation. His first dislocation occurred 2 years ago during a tackle. He has had 5 further dislocations since, the most recent occurring during minimal activity. On examination, he has full range of motion but marked apprehension with abduction and external rotation. There is no generalized ligamentous laxity.