High-yield, image-based scenarios (ISAWE) designed to simulate the intermediate case clinicals and written papers.
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A 45-year-old man presents following a high-speed motor vehicle accident as a restrained driver. He reports severe right hip pain and is unable to move his leg. On examination, his right leg is shortened, internally rotated, and adducted. Dorsalis pedis and posterior tibial pulses are palpable. He has decreased sensation in the first dorsal web space and weakness of ankle dorsiflexion.
A 42-year-old recreational tennis player presents to the emergency department after feeling a sudden "pop" in his left heel while lunging for a shot. He felt as if someone had kicked him in the back of the leg. He was unable to continue playing and has difficulty walking. On examination, there is a palpable gap 5cm proximal to the heel. The Thompson test is positive bilaterally compared (no plantar flexion on squeezing the calf). He can weakly plantar flex using his toe flexors.
A 24-year-old male semi-professional soccer player presents with right knee instability 8 weeks after a non-contact pivoting injury during a match. He describes his knee "giving way" when changing direction. MRI confirms complete ACL rupture with intact medial and lateral menisci. Clinical examination reveals grade 2 Lachman (soft endpoint), positive pivot shift, and full range of motion. There is no effusion. He wishes to continue competitive sport. MRI images are provided showing the ACL rupture.
A 28-year-old male professional rugby player presents following a direct blow to his right shoulder during a tackle. He complains of pain over the top of his shoulder and difficulty lifting his arm. Examination reveals a prominent step deformity at the AC joint with tenderness. There is no neurovascular deficit. He is keen to return to contact sport. Shoulder radiographs are provided.
A 28-year-old male motorcyclist is brought to the emergency department after a high-speed collision. He was found with no movement in all four limbs at the scene. On arrival, he is conscious with BP 70/40, HR 55. He has complete loss of motor and sensory function below the clavicles. He has priapism and absent anal tone. His C-spine is immobilized.
A 13-year-old girl is referred by her school nurse with a positive forward bend test. She had menarche 6 months ago. Her mother noticed asymmetry in her waist and shoulders. She has no back pain, no neurological symptoms, and no family history of scoliosis. On examination, she has a right thoracic prominence on forward bending and her shoulders and pelvis appear level.
A 55-year-old obese female nurse presents with progressive right medial ankle pain and flattening of her arch over 2 years. She reports fatigue with prolonged standing and lateral foot pain after walking. She cannot rise onto tiptoes on the right side. Clinical examination reveals pes planus with hindfoot valgus, forefoot abduction ("too many toes" sign), and tenderness along the posterior tibial tendon. Single-leg heel rise is weak and painful with no inversion of the hindfoot. The hindfoot corrects to neutral passively. Weight-bearing radiographs and clinical photographs are provided.
A 52-year-old woman presents to the emergency department following a twisting injury to her right ankle while walking down stairs. She heard a "crack" and was unable to weight-bear. On examination, there is significant swelling around the ankle with tenderness over both malleoli. The foot is neurovascularly intact. AP, lateral, and mortise radiographs reveal a displaced fracture of the distal fibula at the level of the joint line with a transverse medial malleolar fracture. The medial clear space is widened to 6mm.
A 22-year-old male rugby player presents with recurrent right shoulder dislocations. His first dislocation occurred 2 years ago during a tackle, requiring Emergency Department reduction. He has since had 5 further dislocations, with the most recent occurring while putting on a jacket. He reports apprehension with the arm in abduction and external rotation and avoids certain positions. He wishes to continue playing rugby. Clinical photographs and imaging are provided.
A 28-year-old man presents after diving into a shallow pool and striking his head on the bottom. He has severe upper neck pain and is holding his head with his hands. He is neurologically intact. CT scan shows a burst fracture of C1 with bilateral lateral mass displacement. Open-mouth odontoid view shows combined lateral mass displacement of 8mm.
A 76-year-old woman presents after sudden onset of left thigh pain while walking across her living room. She has been on alendronate for 9 years for osteoporosis. She reports prodromal left thigh pain for 4 months. Examination reveals a shortened, externally rotated left leg with proximal thigh tenderness. She also mentions occasional right thigh discomfort.
A 38-year-old male presents with a 6-month history of progressive right hip pain. He has a background of systemic lupus erythematosus treated with long-term corticosteroids. He reports groin pain aggravated by weight-bearing and at rest. Examination reveals reduced internal rotation and an antalgic gait. Radiographs and MRI of the hip are provided.
A 72-year-old female presents with a distal radius fracture after a fall from standing height. She has a history of previous vertebral compression fracture and takes no medications for bone health. Her DXA scan shows T-score of -3.2 at lumbar spine and -2.8 at femoral neck. She asks about treatment to prevent future fractures. Laboratory results and DXA report are provided.
A 38-year-old roofer presents after falling 3 metres from scaffolding, landing on his feet. He has severe bilateral heel pain and swelling and is unable to weight bear. He also reports low back pain. Examination reveals bilateral heel ecchymosis extending to the plantar arch (Mondor's sign), tense swelling, and tenderness over the calcanei. The right heel has posterior skin tenting with blanching.
A 35-year-old construction worker fell 3 meters from scaffolding, landing on his feet. He has severe bilateral heel pain and is unable to weight-bear. On examination, both heels are swollen with ecchymosis extending to the plantar surface. The hindfoot width is increased bilaterally. Radiographs show decreased Böhler's angle and widening of the calcaneus. CT scan reveals a three-part fracture of the posterior facet on the left (Sanders III) and a two-part fracture on the right (Sanders II).
A 52-year-old woman presents with a 6-month history of numbness and tingling in her right hand that wakes her at night. She shakes her hand to relieve symptoms. The symptoms affect her thumb, index, and middle fingers. She has noticed weakness when gripping objects and occasionally drops things. She works as a supermarket checkout operator. On examination, there is reduced sensation to light touch over the median nerve distribution. Thenar wasting is present. Phalen's and Tinel's tests are positive.
A 45-year-old woman presents to the emergency department with a 2-day history of worsening low back pain and bilateral leg pain. She now reports difficulty passing urine and has not opened her bowels for 24 hours. On examination, she has reduced perianal sensation bilaterally and a post-void residual of 350mL.
A 72-year-old man presents after falling forward onto his forehead. He has disproportionate weakness in his arms compared to his legs. He can wiggle his toes but cannot grip or extend his fingers. He has a band of numbness across both arms and reports burning pain in his hands. He has a history of neck stiffness for years. Examination shows 2/5 power in upper limbs, 4/5 in lower limbs, and intact bladder function.
A 35-year-old man is brought in after a motorcycle accident. He was found with neck pain and left arm weakness. On examination, he is neurologically intact except for weakness of left triceps (3/5) and numbness in the left middle finger. His head is rotated slightly to the right and he resists attempts at movement. His cervical spine is immobilized.
A 62-year-old man presents with a 12-month history of progressive difficulty walking and hand clumsiness. He reports difficulty buttoning shirts and notices his handwriting has deteriorated. He also describes intermittent electric shock sensations down his spine with neck flexion. He has mild neck pain but his main complaints are functional limitations.
A 48-year-old office worker presents with a 6-week history of left arm pain radiating from the neck to the middle finger. He describes associated numbness and tingling. The pain is worse at night and exacerbated by neck extension. He has tried physiotherapy and NSAIDs with limited relief. On examination, he has weakness of left triceps (4/5), reduced triceps reflex, and a positive Spurling test on the left.
A 62-year-old male with Type 2 diabetes mellitus of 18 years duration and diabetic peripheral neuropathy presents with a swollen, warm right foot for 6 weeks. He denies significant trauma but recalls "twisting" his ankle while gardening. He has no pain but reports difficulty fitting into his shoe. His diabetes is poorly controlled (HbA1c 9.2%). Clinical examination reveals a diffusely swollen, warm (3°C warmer than contralateral) right midfoot with palpable bony prominences plantar-medially. Sensation is absent to monofilament testing. Pedal pulses are palpable. There is no break in the skin. Weight-bearing radiographs are provided.
A 28-year-old female netball player presents with recurrent right ankle sprains over 4 years since an initial severe inversion injury. She reports 6 significant giving-way episodes requiring time off sport in the past year, with persistent ankle pain and swelling after activity. She has completed supervised physiotherapy for 4 months without improvement. Clinical examination reveals anterior drawer test grade 2+ positive, talar tilt 12° (contralateral 5°), tenderness over the ATFL, and mild peroneal weakness. She has flexible joints throughout (Beighton 6/9). Stress radiographs and MRI are provided.
A 31-year-old woman presents 4 months after an injury sustained while hiking overseas. She had limited medical care at the time and now has a stiff, deformed elbow. She has pain with attempted use and significant functional limitation. The elbow is held in approximately 60° flexion with minimal further motion.
A 22-year-old male is reviewed 8 hours after sustaining a closed tibial shaft fracture in a soccer match. He has had an intramedullary nail inserted and is in a below-knee backslab. Nursing staff report he is requiring escalating opioid analgesia and the pain seems disproportionate to his injury. He reports tingling in his toes. On examination, the calf is tense and he has severe pain with passive toe extension.
A 48-year-old accountant presents with a 6-month history of numbness in his right small finger and ulnar half of the ring finger, worse at night and when using his phone. He has noticed weakness of grip and dropping objects. On examination, there is decreased sensation in the ulnar 1.5 digits, positive Tinel's at the cubital tunnel, and a positive elbow flexion test at 30 seconds. The first dorsal interosseous and hypothenar eminence appear wasted. Froment's test is positive. Cross-body adduction of the small finger is weak.
A 32-year-old new mother presents with 3 months of radial wrist pain, worse when lifting her baby. She notices swelling over the radial styloid and pain with thumb movement. She has difficulty opening jars and gripping. On examination, there is tenderness and swelling over the first dorsal compartment. Finkelstein's test reproduces her pain. There is no crepitus with movement. Thumb and finger range of motion is full.
A 68-year-old woman presents with a 2-year history of bilateral leg pain and heaviness when walking. She can walk approximately 200 meters before needing to stop and sit or lean forward. Standing and walking uphill are particularly difficult. Her symptoms are relieved by sitting or leaning on a shopping trolley. She has tried physiotherapy and epidural injections with limited relief.
A 45-year-old right-hand dominant male tradesman presents 5 days after feeling a "pop" in his right elbow while lifting a heavy object. He reports pain in the antecubital fossa and difficulty with elbow flexion and forearm supination. On examination, there is bruising in the antecubital fossa, loss of normal biceps contour, and a palpable mass in the upper arm. Hook test is positive (unable to hook finger under biceps tendon). MRI of the elbow is provided.
A 70-year-old woman with osteoporosis presents after a fall at home. She has obvious thigh deformity with shortening. X-rays show a comminuted supracondylar femur fracture with intra-articular extension. There is no vascular compromise. She has a well-functioning TKA in the other knee.
A 58-year-old right-hand dominant female presents to ED 2 hours after falling onto an outstretched hand while walking her dog. She has immediate pain, swelling, and deformity of the right wrist. She has well-controlled type 2 diabetes and osteopenia on recent DEXA. On examination, there is a dinner fork deformity, dorsal swelling, and tenderness. She has intact radial pulse and normal finger sensation and movement.
A 62-year-old man of Northern European descent presents with progressive difficulty straightening his right ring finger over the past 2 years. He is a retired builder with a history of heavy alcohol use and type 2 diabetes. On examination, there is a palpable cord from the palm to the proximal phalanx of the ring finger. The MCP joint has a 35° fixed flexion contracture and the PIP has a 25° contracture. He cannot place his palm flat on the table. The small finger has a nodule but no contracture. Sensation is intact.
A 28-year-old cricketer presents with inability to extend his right ring finger DIP joint after being struck on the fingertip while fielding. The DIP rests in approximately 30° flexion. He can actively flex but cannot actively extend the DIP. There is tenderness over the dorsum of the DIP joint. X-ray shows no fracture. Separately, his teammate presents with a PIP joint injury where the finger is stuck in flexion at the PIP with the DIP hyperextended.
A 28-year-old male motorcyclist presents following a high-speed collision. He has severe left hip pain and is unable to weight bear. The leg is shortened and externally rotated. He has no other injuries identified. This is an isolated injury to an otherwise healthy young man.
A 28-year-old male professional footballer presents with 18 months of progressive right groin pain. The pain is worse with prolonged sitting, squatting, and kicking. He describes mechanical catching and limited range of motion. He has failed physiotherapy and cortisone injection. He wishes to continue playing professionally. Clinical examination and imaging are provided.
A 32-year-old chef presents 4 hours after sustaining a laceration to the volar aspect of his right ring finger while preparing food. The wound is over the proximal phalanx. On examination, the finger rests in relative extension compared to adjacent fingers. He is unable to flex the DIP joint when the PIP is held. He also cannot flex the PIP when adjacent fingers are held extended. Sensation is intact to both digital nerves. There is no active bleeding.
A 35-year-old male motorcyclist presents following a high-speed collision. He has obvious deformity of his left upper limb with swelling of the arm and forearm. He can move his fingers but has wrist drop. He is haemodynamically stable and this is his only significant injury.
A 35-year-old male motorcyclist is brought to the trauma center following a high-speed collision. GCS is 15 and he is hemodynamically stable after initial resuscitation with 2 units blood. His left thigh and leg are deformed with an open wound over the proximal tibia exposing bone. The foot is warm with palpable dorsalis pedis pulse but decreased sensation in the first dorsal web space.
A 22-year-old male had a closed reduction of a distal radius fracture 8 hours ago and is now in a below-elbow cast. The nursing staff is concerned as he is requiring escalating doses of opioid analgesia and is complaining of severe pain. The pain seems out of proportion to the injury.
A 35-year-old male presents 4 months after closed treatment of a midshaft tibial fracture. Radiographs show persistent fracture lines with minimal callus formation. He has pain with weight-bearing and tenderness at the fracture site. He has been non-weight-bearing and is a smoker (20 pack-years). Radiographs at 4 months are provided.
A 58-year-old male accountant presents with progressive pain and stiffness of his right great toe over 2 years. He reports pain with walking, especially push-off, and difficulty squatting. He cannot wear dress shoes due to dorsal prominence. He has tried NSAIDs and orthotics with minimal relief. He is active and wants to maintain recreational walking. Clinical examination reveals palpable dorsal osteophyte at the first MTP joint, with dorsiflexion limited to 20° (contralateral 60°) and pain at end-range. The plantar aspect of the joint is relatively preserved. There is no significant hallux valgus. Gait shows shortened stride with early heel-off. Weight-bearing radiographs are provided.
A 54-year-old female primary school teacher presents with progressive pain and deformity of her right great toe over 3 years. She reports difficulty fitting into standard footwear and pain over the medial eminence when walking. She has tried wider shoes and padding without relief. Clinical examination reveals obvious bunion deformity with hallux valgus angle estimated at 35°. The first metatarsal head is prominent medially with overlying bursa. The hallux is reducible but the first MTP joint is stiff with 40° dorsiflexion. Second toe shows early hammer toe deformity with crossover tendency. Weight-bearing radiographs of the foot are provided.
A 35-year-old man presents to ED with a 2-day history of increasing pain and swelling in his right middle finger. He sustained a puncture wound to the fingertip 4 days ago while working in his garden. On examination, the finger is swollen and held in flexion. There is tenderness along the entire flexor sheath. Passive extension is extremely painful. He is febrile (38.4°C). His WCC is elevated at 15 × 10⁹/L.
A 32-year-old man is brought in after a high-speed motor vehicle accident. He was an unrestrained driver who hit the steering wheel with his face. He complains of severe neck pain and holds his neck in his hands. He is neurologically intact. CT cervical spine shows bilateral C2 pars fractures with anterior translation of C2 on C3.
A 35-year-old man presents after an arm wrestling injury. He reports sudden pain and a "crack" in his right arm during the contest. His arm is deformed, and he immediately noticed he could not lift his wrist or extend his fingers. Examination confirms wrist drop, inability to extend MCP joints, and numbness over the dorsal first web space.
A 28-year-old right-hand dominant manual laborer presents with 12 months of progressive right wrist pain and stiffness. He cannot recall any specific injury. Pain is worse with gripping and loading the wrist. On examination, there is dorsal wrist tenderness over the lunate, reduced grip strength, and decreased wrist range of motion (40° extension, 30° flexion). X-ray shows a sclerotic lunate with preserved carpal alignment. Ulnar variance is -3mm.
A 28-year-old footballer presents after landing awkwardly on a plantar-flexed foot. He experienced immediate severe midfoot pain and was unable to continue playing. On examination, there is marked midfoot swelling with plantar ecchymosis. He has point tenderness over the TMT joints and pain with passive abduction of the forefoot. Weight-bearing radiographs show loss of the normal alignment between the 2nd metatarsal and middle cuneiform with widening of the interval between the 1st and 2nd metatarsals.
A 42-year-old office worker presents with a 6-week history of left leg pain radiating from the buttock to the calf and foot. The pain is worse with sitting and coughing. He has tried physiotherapy and NSAIDs with limited relief. On examination, SLR is positive at 30 degrees on the left, he has weakness of left ankle plantar flexion (4/5), and absent left ankle jerk.
A 70-year-old retired farmer presents with a 3-year history of bilateral leg heaviness and pain when walking. He can manage approximately 100 meters before needing to stop and lean forward or sit down. He finds walking uphill harder than downhill, and can cycle without problems. His symptoms are relieved within minutes of sitting. He has tried physiotherapy and two epidural injections with temporary relief.
A 30-year-old farmer presents following a farm machinery accident. He has a severe injury to his right leg with extensive soft tissue loss, exposed bone, and contamination. The foot is pale and cool with absent pulses. He is haemodynamically stable with an isolated injury.
A 35-year-old female presents with right knee pain and mechanical symptoms following a twisting injury 6 weeks ago. She reports intermittent locking, catching, and giving way. The knee swells after activity. Clinical examination reveals joint line tenderness medially, positive McMurray test with a painful click on external rotation, and a small effusion. The knee has full range of motion with no ligamentous instability. MRI of the knee is provided.
A 67-year-old man with known prostate cancer presents with 6 weeks of progressive back pain and 5 days of increasing leg weakness. He is now unable to walk unaided. On examination, he has 3/5 power in both legs, brisk reflexes, and a sensory level at T10. Bowel and bladder function are currently normal.
A 17-year-old male presents to the Emergency Department with right thigh swelling 12 days after a motorbike accident. He was initially treated conservatively for minor pelvic injuries. On examination, there is a large, fluctuant swelling over the lateral thigh with skin that appears mobile over the underlying fascia. The overlying skin has some abrasions but no open wounds.
A 48-year-old female office worker presents with a 12-month history of burning pain in the ball of her right foot radiating to the 3rd and 4th toes. Pain is worse in narrow shoes and high heels, with relief when removing footwear and massaging the foot. She describes occasional "electric shock" sensations. Clinical examination reveals tenderness in the third intermetatarsal space with positive Mulder's click. Sensation is diminished in the adjacent sides of the 3rd and 4th toes. Ultrasound of the forefoot is provided.
A 32-year-old male motorcyclist is brought to the Emergency Department following a collision. His right knee is grossly unstable, swollen, and deformed. Initial assessment reveals a GCS 15, hemodynamically stable patient. The knee shows circumferential swelling with ecchymosis, and there is no palpable dorsalis pedis or posterior tibial pulse. The limb is cool compared to the contralateral side. Anteroposterior stress testing shows gross laxity in all planes. X-rays and CT angiography are pending.
An 82-year-old woman presents after a fall at home. She has neck pain and restricted movement. She has a history of hypertension, osteoporosis, and atrial fibrillation on warfarin. She is neurologically intact. Her INR is 3.2 on presentation.
A 28-year-old motorcyclist presents to the emergency department following a high-speed road traffic accident. His left leg is deformed with an 8cm wound over the anterolateral tibia. There is exposed bone and moderate soil contamination. He is hemodynamically stable with no other apparent injuries. Distal pulses are palpable but weak.
A 62-year-old female is scheduled for total hip arthroplasty for primary osteoarthritis. She asks about the different material options for her hip replacement. Her surgeon needs to discuss bearing surfaces, fixation methods, and material properties. She has good bone quality and is moderately active.
A 55-year-old woman presents after a direct blow to the knee from falling onto the kneecap. She is unable to perform a straight leg raise. There is significant swelling with a palpable gap over the patella. Distal neurovascular examination is intact.
A 35-year-old male motorcyclist presents following a high-speed collision. He is hypotensive (BP 80/50) with tachycardia (HR 130). GCS is 14 (confused). The pelvis is unstable on examination. Paramedics have applied a pelvic binder. There is blood at the urethral meatus. He is receiving IV fluids via large bore cannulae.
A 32-year-old male sustains a deep laceration to the medial aspect of his elbow from broken glass. He presents with numbness in the small finger and ring finger (ulnar half), weakness of finger abduction, and a positive Froment's sign. Examination reveals absent sensation in the ulnar nerve distribution and weakness of intrinsic muscles. The wound is clean and explored, revealing complete transection of the ulnar nerve. Intraoperative photograph is provided.
An 82-year-old woman presents after a fall at home. She had a cemented total hip arthroplasty 8 years ago for osteoarthritis. She was previously mobile with a frame but had progressive hip pain for the past 6 months before the fall. She cannot weight bear and the leg is shortened and externally rotated.
A 72-year-old male presents 8 months after primary right total knee arthroplasty with persistent wound drainage for 3 weeks and increasing knee pain. He had an uneventful initial recovery but developed a superficial wound infection at 3 weeks post-op treated with oral antibiotics. He is febrile (38.2°C) with a swollen, warm, and erythematous knee. The wound has purulent discharge. Inflammatory markers show CRP 156mg/L and ESR 78mm/hr. Radiographs and aspiration results are provided.
A 35-year-old rock climber presents after falling 4 metres, landing on his feet. He has severe right ankle pain with marked swelling and fracture blisters. The foot is neurovascularly intact but compartments feel tense. He also reports bilateral heel pain and low back pain.
A 45-year-old man presents after a fall from 4 meters, landing on his feet. He has severe pain and swelling of his right ankle with visible deformity. On examination, the ankle is markedly swollen with fracture blisters developing. The skin is tented anteriorly. There is a fractured fibula and the tibial plafond is comminuted on initial radiographs. CT scan confirms a high-energy pilon fracture with articular impaction and metaphyseal comminution.
A 32-year-old unrestrained driver presents following a high-speed motor vehicle collision. GCS is 12 (E3V4M5), BP 85/60, HR 130, temperature 34.8°C. Primary survey reveals decreased breath sounds on the left with tracheal deviation. He has an obvious deformity of the right thigh and an unstable pelvis on examination. Blood gas shows pH 7.18, base excess -8, lactate 6.2. INR is 1.8 and he has received 4 units blood en route.
A 35-year-old right-hand dominant female presents 6 months after ORIF of a left radial head fracture (Mason II). She complains of progressive elbow stiffness affecting her work as a hair stylist. Examination reveals flexion to 100° and extension deficit of 40°. Supination is 60° and pronation 70°. There is no instability and neurovascular examination is normal. CT scan and radiographs are provided.
A 25-year-old male presents following a motor vehicle collision where he was an unrestrained driver. He has anterior chest pain and difficulty swallowing. On examination, there is a palpable depression over the medial clavicle on the left side. He has no respiratory distress but feels like there is something stuck in his throat.
A 72-year-old right-hand dominant female presents following a fall onto her outstretched hand. She complains of severe left shoulder pain and inability to move her arm. She has a background of osteoporosis and takes alendronate. On examination, there is swelling and bruising around the shoulder with tenderness over the proximal humerus. Neurovascular examination is intact. Shoulder radiographs and CT are provided.
A 55-year-old male with type 2 diabetes presents with 3 weeks of progressive back pain, fever, and malaise. He has been treated for a urinary tract infection recently. His temperature is 38.5°C, WBC 18,000, CRP 180. On examination, he has severe tenderness over the lumbar spine and has developed leg weakness over the past 48 hours.
A 58-year-old right-hand dominant male carpenter presents with a 12-month history of progressive right shoulder pain and weakness. He reports difficulty with overhead activities and night pain affecting sleep. There was no specific injury. Clinical examination reveals positive Jobe's test (supraspinatus weakness), positive external rotation lag sign, and weakness of external rotation in adduction. There is no pseudoparalysis. Range of motion shows 150° forward flexion and 40° external rotation. MRI of the shoulder is provided.
A 24-year-old male motorcyclist presents after a fall onto his outstretched right (dominant) hand. He has pain and swelling on the radial side of the wrist. On examination, there is tenderness in the anatomical snuffbox and over the scaphoid tubercle. Axial loading of the thumb reproduces pain. Wrist movements are restricted by pain. Standard wrist X-rays appear normal but a scaphoid view shows a minimally displaced waist fracture.
A 55-year-old motorcyclist presents after a high-speed collision with multiple injuries. Chest injuries have been managed by the trauma team (rib fractures and haemothorax). He has significant right shoulder pain and difficulty moving his arm. On examination, there is bruising over the scapula and shoulder with painful limited range of motion. Peripheral neurovascular status is intact.
A 14-year-old boy is referred with progressive "round back" deformity noticed by his parents over the past 2 years. He has occasional mid-back aching that worsens with activity. He is otherwise healthy and has no neurological symptoms. On examination, he has a fixed thoracic kyphosis that does not correct with hyperextension. His Adams forward bend test shows a smooth thoracic roundback. He is Tanner stage 3.
A 62-year-old man with known ankylosing spondylitis presents after a fall from standing height. He has severe neck pain and is unable to move his head. He has progressive weakness in all four limbs over the past 2 hours. He has a long-standing rigid kyphotic spine. On examination, he has 2/5 power in upper limbs and 3/5 in lower limbs with hyperreflexia.
A 35-year-old man is brought in after diving into shallow water. He has neck pain and weakness in both arms worse than his legs. He has numbness in a cape distribution. CT shows a C5 burst fracture with 50% canal compromise. His motor exam shows 3/5 power in biceps and deltoids bilaterally, 4/5 in triceps, and 4/5 in lower extremities.
A 28-year-old motorcyclist is brought to the emergency department following a high-speed collision. He has a deformed right foot and ankle with the foot held in equinus. He is unable to move his toes and has diminished sensation in the first web space. Radiographs reveal a displaced fracture through the talar neck with posterior subluxation of the talar body. The tibiotalar joint appears intact. CT scan confirms a Hawkins Type II fracture with additional comminution.
A 42-year-old male recreational basketball player presents 2 days after an acute Achilles tendon rupture while playing. He felt a sudden "pop" with immediate inability to push off. He was treated initially with a plaster backslab. Physical examination confirms the diagnosis with a palpable gap 4cm proximal to insertion and positive Thompson test. He is keen to return to sport and asks about treatment options. MRI of the ankle is provided.
A 45-year-old right-hand dominant male presents after falling from a ladder onto his outstretched right hand. He has significant elbow swelling, pain, and inability to move his elbow. Examination reveals gross instability. Neurovascular examination shows intact radial, median, and ulnar nerve function with palpable pulses. Elbow radiographs and CT scan are provided.
A 34-year-old tennis player presents with 4 months of ulnar-sided wrist pain after a fall onto his outstretched hand. Pain is worse with gripping and rotation, especially on his backhand stroke. On examination, there is tenderness at the ulnar fovea and positive DRUJ ballottement. The piano key sign is positive. Ulnar variance appears neutral. MRI shows a tear at the ulnar attachment of the TFCC.
A 28-year-old construction worker fell from scaffolding approximately 4 meters. He has severe back pain and weakness in both legs. On examination, he has 3/5 power in hip flexors bilaterally, reduced sensation below L1, and intact perianal sensation with voluntary anal contraction. He has no other injuries.
A 32-year-old woman presents to the emergency department after falling while skiing. Her thumb was caught in the ski pole strap and forced into radial deviation. She has immediate swelling and pain at the base of the thumb. On examination, there is ecchymosis and swelling over the ulnar aspect of the thumb MCP joint. Stress testing reveals 40° of laxity compared to 15° on the contralateral side, with no firm endpoint. A palpable mass is felt at the ulnar MCP joint. X-ray shows no fracture.
A 52-year-old motorcyclist presents following a high-speed collision. His right knee is swollen and deformed with a large hemarthrosis. He is unable to weight bear and describes severe pain. On examination, there is tense swelling around the knee, bruising, and valgus instability. The leg compartments feel tense. Distal pulses are palpable but the common peroneal nerve territory shows decreased sensation.
A 32-year-old motorcyclist presents after a collision. He is unable to weight bear with obvious deformity of the left leg. GCS 15, isolated injury. On examination, the leg is swollen but the skin is intact. Pedal pulses are palpable and sensation is intact.
A 62-year-old retired female teacher presents with severe right ankle pain over 5 years, progressively limiting her walking distance to 200 meters. She has post-traumatic ankle arthritis following a pilon fracture 12 years ago treated with ORIF. She requires daily analgesia and a walking stick. Clinical examination reveals a stiff, painful ankle with 15° total arc of motion (10° dorsiflexion, 5° plantarflexion), neutral hindfoot alignment, and no significant ligament laxity. The subtalar joint is well-preserved. She is a non-smoker with well-controlled Type 2 diabetes (HbA1c 6.5%). Weight-bearing radiographs and CT are provided.
A 25-year-old male unrestrained driver is brought to the Emergency Department following a high-speed motor vehicle accident. He complains of severe right hip pain and is unable to move his leg. On examination, the right leg is shortened, internally rotated, and adducted. There is no distal neurovascular deficit. A secondary survey reveals no other significant injuries. Pelvic radiograph is provided.
A 55-year-old woman with type 2 diabetes presents with 6 months of painful clicking in her right ring finger. She now notices the finger locks in flexion in the morning and she must use her other hand to straighten it. On examination, there is tenderness over the A1 pulley region at the metacarpal head. A nodule is palpable on the flexor tendon. The finger triggers with active flexion and extension, with an audible click. She has similar but milder symptoms in her middle finger.
A 45-year-old man from India presents with 4 months of progressive back pain, weight loss, and night sweats. He has developed weakness in both legs over the past 2 weeks and difficulty walking. He has a history of treated pulmonary TB 10 years ago. On examination, he has a thoracic kyphotic deformity, spasticity in both legs, and hyperreflexia with upgoing plantars. He has 3/5 power in hip flexors bilaterally.
A 22-year-old man presents following a motor vehicle collision. He had a posterior knee dislocation that was reduced in the Emergency Department. On examination, the knee is now reduced but the foot is pale, cold, and pulseless. He can wiggle his toes but sensation is diminished in the foot.
A 68-year-old male is scheduled for elective total hip arthroplasty for osteoarthritis. His past medical history includes hypertension, type 2 diabetes, and a previous DVT in the contralateral leg 5 years ago following immobilization for an ankle fracture. He is on aspirin 100mg daily. BMI is 32. He asks about blood clot prevention after surgery.