Orthopaedics OSCE Past Questions 2023

• Rotations 1 and 2: Group 4C

1. Monteggia fracture

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: only 1 view
▪ 2 joints: involved joint (i.e. distal radioulnar joint) and joint below (i.e. proximal
radioulnar joint) both seen, but not joint above (i.e. glenohumeral joint)
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: misaligned
▪ Length: limb shortened
▪ Apposition: proximal ulnar fracture is poorly apposed (100% displacement)
▪ Rotation: not assessable due to X-ray inadequacy
▪ Angulation: proximal ulnar fragment angulated laterally
• Bones
o Right proximal ulnar fracture and proximal radioulnar joint dislocation
o No evidence of distal humerus involvement or osteoporosis
• Cartilage
o Joint space widening
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Moderate soft tissue swelling overlying right proximal radioulnar joint
o No joint effusions
• Other features
o N/A
ii. What is the diagnosis based on the above X-ray?
• Right Monteggia fracture
iii. What nerve would you be concerned about in this pathology?
• Posterior interosseous nerve, branch of the radial nerve
iv. How would you test for this nerve’s function?
• Sensory
o Paraesthesia or decreased/loss of sensation of posterior forearm and posterolateral
hand (up to PIP joints on digits 1-3), including 1st webspace
 • Motor
o Power: decreased on thumb and MCP extension
• Deformities
o Radial deviation of hand with wrist extension
v. What is the management of this pathology?
• Emergency management
o Stabilize according to ATLS principles (i.e. ABCDEs) and give analgesia
o Exclude compartment syndrome of the forearm
o Attempt closed reduction under anaesthesia
o After reduction, the forearm should be placed in full pronation and a backslab
applied to immobilise the involved joint
• Definitive management
o Surgery: closed reduction of the radial head and ORIF of proximal radioulnar joint
o Physiotherapy: a structured programme aimed at minimising muscle wasting and
maintaining mobility with emphasis on isometric exercises (proximal radioulnar joint
remains immobilized)
2. DDH

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: involved hip joint (i.e. right hip joint) seen, but joint distal (right knee
joint) not seen
▪ 2 occasions: only 1 occasion
▪ 2 sides: both sides shown
o Alignment: misaligned
▪ Length: limb length shortened
▪ Apposition: decreased apposition between right femoral head and acetabulum
▪ Rotation: rotation of right thigh, likely lateral
▪ Angulation: no angulation of the right femur
• Bones
o Right hip joint subluxation and dysplasia
o Left hip joint normal
o No associated fractures of the femur or pelvis
• Cartilage
o Right hip joint space out of alignment due to subluxation
 o Left hip joint normal
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Possible soft tissue swelling over right hip joint, but difficult to visualise due to
inadequacy of X-ray
o No soft tissue swelling or injury over the left hip joint
o Normal pelvic soft tissues
• Other features
o Disturbed right Shenton's line
ii. What is the diagnosis based on the above X-ray?
• Developmental dysplasia of the right hip (DDH)
iii. Name three radiographic lines that will assist in making your diagnosis.
• Shenton’s line
• Hilgenreiner’s line
• Perkin’s line
iv. What clinical tests can you use to help establish your diagnosis and how do you perform
them?
• Barlow test: infant is placed supine with the hips flexed to 90o and in neutral rotation, at
which point the examiner adducts the hips while applying a posterior force on the knees
to cause the heads of the femurs to dislocate posteriorly from the acetabula
• Ortolani test: infant is placed supine with the hips flexed to 90o and in an adducted
position, at which point the hips is gently abducted while lifting or pushing the femoral
trochanters anteriorly to relocate the hips into the acetabula
v. Describe the management of this condition.
• Age 0-6 months: Pavlik harness
• Age 6-18 months: hip spica ± abduction cast
• Age >18 months: hip ORIF
3. C-spine fracture

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: lateral view only
▪ 2 joints: involved cervical vertebra (i.e. C4) as well cervical vertebrae above and
below (down to C7) seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only one side able to be shown on spinal X-rays
o Alignment: misaligned
 ▪ Length: neck shortened
▪ Apposition: decreased apposition between C4 and the intervertebral discs
above and below
▪ Rotation: no rotation of the C-spine or neck
▪ Angulation: acute kyphotic C-spine angulation with straightening of normal
cervical lordosis
• Bones
o C4 vertebral fracture with posterior displacement and teardrop fragment anteriorly
o No associated fractures of the other cervical vertebrae
o No involvement of spinous processes or pedicles
• Cartilage
o Intervertebral discs above and below C4 vertebra both appear damaged
o C4/5 facet joints are misaligned
o Interspinous space widening
• Soft tissue
o Marked prevertebral soft tissue swelling (anterior to C4 vertebra)
o No soft tissue swelling or injury over the posterior aspect
• Other features
o Disruption to anterior and posterior vertebral lines
o Likely posterior ligamentous injury due to interspinous space widening
ii. What is included in the trauma series of C-spine X-rays?
• AP view
• Lateral view
• Swimmer’s view
• Open-mouth view
iii. What is the diagnosis based on the above X-ray?
• C4 vertebral fracture with posterior displacement and teardrop fragment anteriorly
iv. Describe the emergency management of this case.
• ATLS principles
o Stabilize according to ATLS principles (i.e. ABCDEs)
o C-spine immobilisation (using head blocks)
o Give analgesia as needed
• Temporary management
o Immobilise C-spine with rigid cervical (Philadelphia) collar ± cervicothoracic arthrosis
o If unstable, cervical traction is required to maintain reduction (skin or skeletal)
• Investigations
o C-spine trauma radiography series
o CT head and neck
4. Orthopaedic tourniquet
 i. What orthopaedic device is depicted above?
• An orthopaedic tourniquet
ii. What is the purpose of using the above orthopaedic device?
• To occlude blood flow to the limbs during orthopaedic surgery in order to create a
bloodless surgical field and decrease the perioperative blood loss
iii. List 5 complications of using the above orthopaedic device.
• Nerve injury (due to compression and ischaemia)
• Muscle injury (due compression and ischaemia)
• Vascular injury (due to compression of vessels)
• Skin injury (due to poor tourniquet placement and compression)
• Tourniquet pain
5. C-arm X-ray machine

i. What machine is depicted above?

• C-arm X-ray machine
ii. List 2 clinical uses for this machine in orthopaedics.
• Intraoperative imaging (e.g. ORIFs, fluoroscopy)
• Imaging in immobilised orthopaedic patients
iii. List 2 precautions that should be taken when using this machine?
• Wearing a led apron
• Minimising screening time (i.e. duration and frequency of X-ray imaging)
6. Growth plate injuries
A

i. What is the name of the classification system used for growth plate injuries?
• Salter-Harris classification
ii. Draw the above classification system.

Type I Type II Type III Type IV Type V

Straight across Above BeLow Through Erasure
 iii.Identify the labels A, B, C.
• A – proximal epiphysis
• B – diaphysis
• C – distal physis
iv. Name the carpal bones.
• Proximal row (radial-to-ulnar)
o Scaphoid
o Lunate
o Triquetrum
o Pisiform
• Distal row (radial-to-ulnar)
o Trapezium
o Trapezoid
o Capitate
o Hamate
v. Which carpal bone does not form part of the distal radioulnar joint?
• Pisiform bone
7. Osteomyelitis
A 54-year-old male presents to the orthopaedic OPD with a painful right foot and subsequent
inability to walk. On examination, a swollen and tender right 5th digit is found.

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: involved right 5th metatarsal head and metatarsophalangeal (MTP)
joint, but joints proximal and distal not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: misaligned
▪ Length: not assessable due to X-ray inadequacy
▪ Apposition: right 5th MTP joint is subluxed (due to joint destruction)
▪ Rotation: not assessable due to X-ray inadequacy
▪ Angulation: not assessable due to X-ray inadequacy
 • Bones
o Right 5th MTP joint severely disrupted and metatarsal head severely osteopenic with
periosteal reaction
o All proximal phalanges demonstrating osteopenia and mild misalignment
• Cartilage
o Right 5th MTP joint severely disrupted and subluxed
o Right 1st MTP joint demonstrating subchondral sclerosis
o No joint space narrowing, evidence of cartilage injury or loss (e.g. irregular bony
margins) in remainder of right MTP joints
• Soft tissue
o No soft tissue swelling or oedema
• Other features
o N/A
ii. What is the most likely diagnosis in this patient?
• Osteomyelitis of the right 5th metatarsal head
iii. List 7 long-term complications of this condition.
• Local
o Septic arthritis
o Sinus tract formation
o Contiguous soft tissue infection
o Abscess formation
o Pathological fractures
• Systemic
o Septicaemia
o Amyloidosis
8. Tib-fib fracture

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: involved left tibia and fibula with knee joint (above) and ankle joint
(below) seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
 ▪ 2 sides: only involved side, with normal side not seen
o Alignment: misaligned
▪ Length: limb length shortened
▪ Apposition: fractured fragments poorly-apposed
▪ Rotation: minimal leg rotation
▪ Angulation: bones angulated at different angles due to multiple fractures
• Bones
o Multiple left tibial and fibula fractures, including oblique, spiral and comminuted
fractures
o No involvement of left proximal or distal tibia and fibula
• Cartilage
o No left knee or ankle joint involvement
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Marked soft tissue injury, with swelling and haemorrhage along entire left leg
• Other features
o Open growth plates indicate that this X-ray is of a child/adolescent
ii. What is the name of the classification system used for these types of fracture?
• Gustilo-Anderson classification
iii. What is the classification of this fracture according to the above classification system?
• Gustilo-Anderson IIIC
o Laceration >10cm
o Severe comminution and extensive soft tissue injury
o Vascular injury (as indicated by large haemorrhage within leg) likely requiring repair
o Likely contaminated wound as well
iv. Describe the immediate management of this case.
• Stabilize according to ATLS principles (i.e. ABCDEs)
• Administer IV antibiotics (broad-spectrum) and tetanus prophylaxis
• Give adequate analgesia (e.g. morphine)
• Wash out open fracture site with sterile saline (to minimise wound contamination)
• Reduce fracture (under anaesthesia) and immobilise with orthopaedic dressing/bandage
v. List 5 immediate complications of these types of injury.
• Haemorrhage (with possible progression to hypovolaemic shock)
• Neurovascular injury
• Compartment syndrome
• Fat embolism
• Infection
9. Skin traction

i. What device is depicted above?

• Skin traction device
 ii.What is the maximum weight allowed with this device?
• 5.0kgs
iii.List 5 indications for use of this device.
• Temporary management of neck femur or acetabular fracture
• To maintain reduction of a dislocated hip
• To manage femoral shaft fractures in children
• To correct minor fixed flexion deformities of hip and knee
• To assist with management of lower back ache
iv. List 6 complications with use of this device.
• Skin excoriation
• Pressure sores over bony prominences (usually medial and lateral malleoli) and Achilles
tendon
• Common peroneal nerve palsy
• Compartment syndrome
• Impairment to circulation (may cause DVTs)
• Allergic reaction to adhesives used in skin traction
v. Name 2 other devices that will achieve the same effect as this device.
• Skeletal traction
• Gallows traction
10. Supracondylar fracture

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP and lateral views
▪ 2 joints: involved elbow joint seen, but joints proximal (i.e. glenohumeral joint)
and distal (i.e. wrist joint) not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: well-aligned
▪ Length: limb length normal
▪ Apposition: fractured fragments well-apposed
▪ Rotation: no rotation of humerus
▪ Angulation: no angulation at fracture site
• Bones
 o Supracondylar fracture of the humerus
o No involvement of proximal ulna or radius
• Cartilage
o No joint space widening or misalignment
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Soft tissue swelling over distal humerus
• Other features
o N/A
ii. What nerve would you be concerned about in this pathology?
• Anterior interosseous nerve, branch of the median nerve
iii. How would you test for this nerve’s function?
• Sensory
o N/A
• Motor
o Power: decreased flexion of interphalangeal joint of the thumb and the distal
interphalangeal joint of the index finger → cannot make the ‘OK’ sign
• Deformities
o N/A
iv. Describe the emergency management of this fracture.
• Stabilize according to ATLS principles (i.e. ABCDEs)
• Assess neurovascular status and for compartment syndrome
• Give adequate analgesia (e.g. morphine)
• Backslab in position that arm is in (do not force elbow to 90 degrees) and elevate
• Reduce fracture (under anaesthesia) and immobilise if displaced or unstable

• Rotations 1 and 2: Group 4D

1. Wrist drop

i. What is the diagnosis based on the above image?

• Left wrist drop
ii. What nerve is involved in this pathology?
• Radial nerve
iii. How would you test for this nerve’s function?
• Sensory
 o Paraesthesia or decreased/loss of sensation of posterior arm, forearm and
posterolateral hand (up to PIP joints on digits 1-3), including 1st webspace
• Motor
o Power: decreased on elbow, wrist, thumb and MCP extension
o Reflexes: decreased/absent triceps brachii and brachioradialis reflexes
• Deformities
o Triceps brachii and posterior forearm compartment wasting
iv. What other nerves innervate the hand?
• Median nerve
• Ulnar nerve
v. How would you test for these nerves’ function?
• Sensory
o Median nerve: paraesthesia or decreased/loss of sensation of thenar eminence,
anterolateral hand (including digits 1-3 and lateral half of digit 4) and posterior
aspects of digits 1-3 and lateral half of digit 4 distal to PIP joint
o Ulnar nerve: paraesthesia or decreased/loss of sensation of hypothenar eminence,
anteromedial hand (including digit 5 and medial half of digit 4) and posteromedial
hand (including digit 5 and medial half of digit 4 proximal to PIP joints)
• Motor
o Power
▪ Median nerve: decreased on elbow, wrist and MCP flexion; decreased thumb
opposition; decreased wrist abduction; decreased grip strength
▪ Ulnar nerve: decreased on wrist flexion and adduction; decreased digit
abduction, adduction and opposition
o Reflexes
▪ Median nerve: decreased/absent digit reflexes
▪ Ulnar nerve: decreased/absent digit reflexes
• Deformities
o Median nerve: anterior forearm and thenar eminence wasting
o Ulnar nerve: hypothenar eminence and intrinsic hand muscles wasting
2. Gallows traction

i. What device is depicted above?

• Gallows traction device
ii. What is the maximum patient weight allowed with this device?
• 12kgs
iii. List 2 indications for use of this device.
• To manage femoral shaft fractures in children < 12kgs and <2 years
• Preoperative management of hip dysplasia
iv. List 4 complications with use of this device.
• Skin excoriation
• Compartment syndrome
 • Impairment to circulation (may cause DVTs)
• Allergic reaction to adhesives used in skin traction
v. What must be done to ensure that the device is correctly set up and working?
• Device should result in child’s buttocks being slightly raised off the bed such that that a
flat hand can pass underneath
3. Osteomyelitis
A 32-year-old male presents to the CMJAH orthopaedic OPD with a painful left thigh and a
limp. On examination, a swollen and tender left thigh with multiple draining sinuses is found.

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: joint proximal (i.e. left hip) and distal (i.e. left knee) both seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: well-aligned
▪ Length: not assessable due to X-ray inadequacy
▪ Apposition: well apposed
▪ Rotation: no rotation of left femur
▪ Angulation: no angulation of left femur
• Bones
o Variable osteopenia and osteosclerosis of left femur with periosteal reaction and
irregular bony margins
o Large sequestrum with surrounding involucrum in middle 1/3 of femur
o No obvious cloaca
• Cartilage
o Minor joint space narrowing of left hip joint
o No evidence of cartilage injury or loss (e.g. irregular bony margins) in left knee joint
• Soft tissue
o Possible sinus tracts in lower 1/3 of femur
o No obvious soft tissue swelling or oedema of left thigh
• Other features
o N/A
 ii.
What is the most likely diagnosis in this patient?
•Osteomyelitis of the left femur
iii.
List 7 long-term complications of this condition.
•Local
o Septic arthritis
o Sinus tract formation
o Contiguous soft tissue infection
o Abscess formation
o Pathological fractures
• Systemic
o Septicaemia
o Amyloidosis
4. Growth plate injuries

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: only involved joint (i.e. left knee joint) seen, with joint proximal (i.e.
left hip joint) and distal (i.e. left ankle joint) not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with other side not seen
o Alignment: well-aligned
▪ Length: limb length normal
▪ Apposition: well apposed
▪ Rotation: no rotation of left femur or tibia
▪ Angulation: not assessable due to X-ray inadequacy
• Bones
o Linear fracture along medial portion of proximal tibial physis (above the physis)
o Distal femoral physis intact
o No other fractures
• Cartilage
o No joint space narrowing, evidence of cartilage injury or loss (e.g. irregular bony
margins) in left knee joint
• Soft tissue
o No obvious soft tissue swelling or oedema of left knee
• Other features
o N/A
 ii. What is the name of the classification system used for growth plate injuries?
• Salter-Harris classification
iii. Draw the above classification system.

Type I Type II Type III Type IV Type V

Straight across Above BeLow Through Erasure

iv. What is the classification of the growth plate injury in this case?
• Type II – above the physis
5. Cone callipers traction

i. What device is depicted above?

• Cone callipers traction
ii. List 5 indications for use of this device.
• C-spine fractures and/or dislocations
• C-spine degenerative discitis
• Atlantoaxial subluxation
• Occipitocervical instability
• Cervical nerve root compression/impingement
iii. List 5 contraindications for use of this device.
• Torticollis
• Osteoporosis of the spine
• Osteomyelitis of the spine
• Vertebral/spinal cord tumour
• Pregnancy
iv. List 5 complications with use of this device.
• Haemorrhage (temporal artery injury)
• Pressure sores
• Localised sepsis
• Neurological injury
• Muscle spasms
6. Plaster of Paris
 i. What orthopaedic dressing is pictured above?
• Plaster of Paris (POP)
ii. How would one know that this orthopaedic dressing is ready for application after its
preparation?
• POP is submerged in water and is ready for application once the material has stopped
bubbling.
iii. List 4 immediate complications of using the above orthopaedic dressing.
• Thermal burns to skin
• Limb ischaemia
• Compartment syndrome
• Local pain
iv. List 5 long-term complications of using the above orthopaedic dressing.
• Skin breakdown
• Pruritic dermatitis
• Pressure sores
• Skin infection (bacterial and/or fungal)
• Muscle atrophy (disuse atrophy) and joint stiffness
v. List 5 techniques to minimise risk of complications in application of this orthopaedic
dressing.
• Dressing limb with orthowool prior to application of POP (reduces pressure of POP on
limb)
• Ensuring that POP is not applied too tightly (minimises pressure over limb)
• Wrapping the POP with 50% overlapping (minimises pressure over limb)
• Smoothing out each layer of the POP wrapping (to minimise pressure points)
• Optimise skin before application of POP (e.g. clean skin, treat cutaneous wounds) to
reduce risk of infection
7. DDH

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: involved hip joint (i.e. right hip joint) seen, but joint distal (right knee
joint) not seen
▪ 2 occasions: only 1 occasion
▪ 2 sides: both sides shown
 o Alignment: misaligned
▪ Length: limb length shortened
▪ Apposition: decreased apposition between right femoral head and acetabulum
▪ Rotation: rotation of right thigh, likely lateral
▪ Angulation: medial angulation of the right femur
• Bones
o Right hip joint subluxation/dislocation and dysplasia
o Left hip joint normal
o No associated fractures of the femur or pelvis
• Cartilage
o Right hip joint space out of alignment due to subluxation/dislocation
o Dysplastic triradiate cartilage of right acetabulum
o Left hip joint normal
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Possible soft tissue swelling over right hip joint, but difficult to visualise due to
inadequacy of X-ray
o No soft tissue swelling or injury over the left hip joint
o Normal pelvic soft tissues
• Other features
o Disturbed right Shenton's line
o Right femoral head lies in upper and outer quadrant based on Hilgenreiner’s and
Perkin’s lines
ii. What is the diagnosis based on the above X-ray?
• Developmental dysplasia of the right hip (DDH)
iii. Name three radiographic lines that will assist in making your diagnosis.
• Shenton’s line
• Hilgenreiner’s line
• Perkin’s line
iv. List 2 clinical tests that you can use to help establish your diagnosis.
• Barlow test
• Ortolani test
v. Describe the management of this condition.
• Age 0-6 months: Pavlik harness
• Age 6-18 months: hip spica ± abduction cast
• Age >18 months: hip ORIF
8. Shoulder dislocation
 i. Describe the X-ray above.
• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: only involved joint (i.e. left glenohumeral joint), with joint below (i.e.
left elbow joint) not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: misaligned
▪ Length: limb lengthened
▪ Apposition: humeral head dislocated from glenoid cavity
▪ Rotation: not assessable due to X-ray inadequacy
▪ Angulation: not assessable due to X-ray inadequacy
• Bones
o Left anterior glenohumeral joint dislocation
o No fractures or evidence of osteoporosis
• Cartilage
o Joint space widening
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Moderate soft tissue swelling overlying glenohumeral joint
o No joint effusions
• Other features
o Mercedes Benz sign indicating anterior shoulder dislocation
ii. What is the diagnosis based on the above X-ray?
• Left anterior shoulder (glenohumeral joint) dislocation
iii. What nerve would you be concerned about in this pathology?
• Axillary nerve
iv. How would you test for this nerve’s function?
• Sensory
o Paraesthesia or decreased/loss of sensation of the “sergeant’s patch” area
• Motor
o Power: decreased on shoulder flexion, extension, abduction (15-90o) and external
rotation
• Deformities
o Deltoid muscle wasting
v. What is the emergency management of this pathology?
• Emergency management
o Stabilize according to ATLS principles (i.e. ABCDEs) and give analgesia
o Attempt closed reduction under anaesthesia
o After reduction, the arm should be placed in a position of adduction and internal
rotation in a collar and cuff sling
9. Paediatric orthopaedic pathologies
 i. Identify the pathology in each image above.
• A: rachitic rosary
• B: genu varum (bow legs)
• C: thoracolumbar scoliosis
ii. List 5 differential diagnoses for genu varum in children.
• Rickets
• Blount’s disease
• Skeletal dysplasia (e.g. achondroplasia)
• Asymmetrical growth (e.g. fracture, osteomyelitis, tumour)
• Physiologic bowing
iii. What blood tests should be done in a child with rickets?
• CMP
• PTH, 25-hydroxyvitamin D levels, ALP
• FBC and U&E
10. Compartment syndrome

i. Identify the pathology in the image above.

• Compartment syndrome of the right leg
ii. What are the classic features of the above pathology?
• Five P’s: pain, perishingly cold, pallor, paraesthesias, paralysis
iii. Describe the management of the above pathology.
• Emergency management
o Stabilize according to ATLS principles (i.e. ABCDEs)
o Give analgesia and prophylactic antibiotics
o Maintain adequate BP (to ensure adequate perfusion of compartment)
 o Remove excess clothing or dressings/casts from compartment and place limb in a
neutral position to assess neurovascular status
o Surgical consult
• Definitive management
o Surgery: fasciotomy
o Physiotherapy: a structured programme aimed at returning function to involved limb

• Rotations 3 & 4: Group 1B

1. DDH

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: involved hip joint (i.e. right hip joint) seen, but joint distal (right knee
joint) not seen
▪ 2 occasions: only 1 occasion
▪ 2 sides: both sides shown
o Alignment: misaligned
▪ Length: limb length shortened
▪ Apposition: decreased apposition between right femoral head and acetabulum
▪ Rotation: rotation of right thigh, likely lateral
▪ Angulation: medial angulation of the right femur
• Bones
o Right hip joint subluxation/dislocation and dysplasia
o Left hip joint normal
o No associated fractures of the femur or pelvis
• Cartilage
o Right hip joint space out of alignment due to subluxation/dislocation
o Dysplastic triradiate cartilage of right acetabulum
o Left hip joint normal
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Possible soft tissue swelling over right hip joint, but difficult to visualise due to
inadequacy of X-ray
o No soft tissue swelling or injury over the left hip joint
 o Normal pelvic soft tissues
• Other features
o Disturbed right Shenton's line
o Right femoral head lies in upper and outer quadrant based on Hilgenreiner’s and
Perkin’s lines
ii. What is the diagnosis based on the above X-ray?
• Developmental dysplasia of the right hip (DDH)
iii. Name three radiographic lines that will assist in making your diagnosis.
• Shenton’s line
• Hilgenreiner’s line
• Perkin’s line
iv. List 2 clinical tests that you can use to help establish your diagnosis.
• Barlow test
• Ortolani test
v. Describe the management of this condition.
• Age 0-6 months: Pavlik harness
• Age 6-18 months: hip spica ± abduction cast
• Age >18 months: hip ORIF
2. Compartment syndrome

i.Identify the pathology in the image above.

• Compartment syndrome of the right leg
ii.What are the classic features of the above pathology?
• Five P’s: pain, perishingly cold, pallor, paraesthesias, paralysis
iii.Describe the management of the above pathology.
• Emergency management
o Stabilize according to ATLS principles (i.e. ABCDEs)
o Give analgesia and prophylactic antibiotics
o Maintain adequate BP (to ensure adequate perfusion of compartment)
o Remove excess clothing or dressings/casts from compartment and place limb in a
neutral position to assess neurovascular status
o Surgical consult
• Definitive management
o Surgery: fasciotomy
o Physiotherapy: a structured programme aimed at returning function to involved limb
3. Tib-fib fracture
 i. Describe the X-ray above.
• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP and lateral views
▪ 2 joints: involved joint (i.e. right ankle joint) and joint below (i.e. left
tarsometatarsal joints) seen, but joint above (i.e. left knee joint) not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: well-aligned
▪ Length: limb length normal
▪ Apposition: fractured fragments well-apposed
▪ Rotation: no rotation
▪ Angulation: no angulation
• Bones
o Left fibula fracture, below the ankle syndesmosis
o No involvement of tibia (including medial and posterior malleoli) or tarsal bones
• Cartilage
o Ankle mortise intact
o No evidence of joint space narrowing, cartilage injury or loss (e.g. irregular bony
margins)
• Soft tissue
o Moderate soft tissue swelling overlying lateral malleolus
• Other features
o N/A
ii. What is the name of the classification system used for these types of fracture?
• Danis-Weber classification
iii. What is the classification of this fracture according to the above classification system?
• Danis-Weber A
o Stable infrasyndesmotic lateral malleolus transverse fracture
o Tibial plafond, deltoid ligament and medial malleolus intact
iv. Describe the immediate management of this case.
• Stabilize according to ATLS principles (i.e. ABCDEs) and give analgesia
• Reduce fracture (under anaesthesia) and immobilise with orthopaedic dressing or a
backslab
4. C-spine fracture
 i. Describe the X-ray above.
• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP and lateral views only
▪ 2 joints: involved cervical vertebrae (i.e. C5-6) as well cervical vertebrae above
and below (down to C7) seen, but T1 vertebra not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only one side able to be shown on spinal X-rays
o Alignment: misaligned
▪ Length: neck shortened
▪ Apposition: decreased apposition between C5 and the intervertebral discs
above and below
▪ Rotation: no rotation of the C-spine or neck
▪ Angulation: no angulation of the C-spine fracture
• Bones
o C5 vertebral fracture with posterior displacement
o C6 vertebral fracture but no displacement
o No associated fractures of the other cervical vertebrae
o No involvement of spinous processes or pedicles
• Cartilage
o Intervertebral discs above and below C5 vertebra both appear damaged
o C5-6 facet joints are misaligned
• Soft tissue
o Marked prevertebral soft tissue swelling (anterior to C5 vertebra)
o No soft tissue swelling or injury over the posterior aspect
• Other features
o Disruption to anterior and posterior vertebral lines as well as spinolaminar and
spinous process lines
ii. What is included in the trauma series of C-spine X-rays?
• AP view
• Lateral view
• Swimmer’s view
• Open-mouth view
iii. Describe the emergency management of this case.
• ATLS principles
 o Stabilize according to ATLS principles (i.e. ABCDEs)
o C-spine immobilisation (using head blocks)
o Give analgesia as needed
• Temporary management
o Immobilise C-spine with rigid cervical (Philadelphia) collar ± cervicothoracic arthrosis
o If unstable, cervical traction is required to maintain reduction (skin or skeletal)
• Investigations
o C-spine trauma radiography series
o CT head and neck
5. Spinal kyphosis

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: lateral view only
▪ 2 joints: involved spinal segments (i.e. thoracic and upper lumbar) seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only one side able to be shown on spinal X-rays
o Alignment: misaligned
▪ Length: spinal length shortened
▪ Apposition: vertebrae all still well-apposed
▪ Rotation: no rotation of spine
▪ Angulation: abnormally kyphotic angulation of thoracic and upper lumbar spine
• Bones
o Abnormal, severe kyphosis of the thoracic and upper lumbar spine
o Thoracic vertebral bodies markedly osteopenic, with anterior degeneration and
narrowing
o Upper lumbar vertebral bodies unable to be accurately assessed due to liver shadow
o Pedicles and spinous processes normal
• Cartilage
o Markedly irregular thoracic vertebral body margins with narrowing of intervertebral
discs
o Upper lumbar vertebral joint spaces normal
• Soft tissue
o No soft tissue swelling or oedema
• Other features
 o N/A
ii. What is the diagnosis in this case?
• Spinal TB (i.e. TB gibbus)
iii. What questions can be asked on history to support the above diagnosis?
• Main complaint
o “How long have you had this back problem?”
• Associated features
o “Do you have a cough?”
o “Do you have fevers or do you sweat excessively when you sleep?”
o “Have you had any unintentional weight loss recently?”
• Past medical history
o “Do you have HIV?”
o “Have you ever had TB before?”
o “What medications do you take?”
• Social history
o “Where do you live and how many people are in the house?”
o “Does anyone in the house have TB?”
o “Do you smoke?”
iv. What would be seen on clinical examination in this case?
• General exam
o Generalised wasting
o Anaemia
• Respiratory exam
o Inspection: productive cough
o Auscultation: bilateral crackles
• MSK exam
o Look: gibbus deformity of the thoracolumbar spine, “tripod sign” when sitting
o Feel: kyphotic deformity of the thoracolumbar spine
o Move: decreased ROM of the thoracolumbar spine
v. List 5 differential diagnoses in this case.
• Paediatrics
o Congenital spinal kyphosis
o Scheuermann kyphosis
• Adults
o Other spinal infections (e.g. pyogenic spondylitis)
o Spinal neoplasia (e.g. metastases)
o Degenerative conditions (e.g. osteoarthritis)
6. Wrist drop

i. What is the diagnosis based on the above image?

• Right wrist drop
 ii. What nerve is involved in this pathology?
• Radial nerve
iii. How would you test for this nerve’s sensory function?
• Sensory
o Paraesthesia or decreased/loss of sensation of posterior arm, forearm and
posterolateral hand (up to PIP joints on digits 1-3), including 1st webspace
iv. What other nerves innervate the hand?
• Median nerve
• Ulnar nerve
v. How would you test for these nerves’ sensory function?
• Sensory
o Median nerve: paraesthesia or decreased/loss of sensation of thenar eminence,
anterolateral hand (including digits 1-3 and lateral half of digit 4) and posterior
aspects of digits 1-3 and lateral half of digit 4 distal to PIP joint
o Ulnar nerve: paraesthesia or decreased/loss of sensation of hypothenar eminence,
anteromedial hand (including digit 5 and medial half of digit 4) and posteromedial
hand (including digit 5 and medial half of digit 4 proximal to PIP joints)
7. Osteoarthritis
A 65-year-old male presents to his GP complaining of pain in both hips, which has been
progressively worsening over the past few years. On examination, the patient has bilateral
joint line tenderness and stiffness at the hip joints.

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP view only
▪ 2 joints: involved joints (both hip joints) seen, but joints distal (knee joints) not
seen
▪ 2 occasions: only 1 occasion shown
▪ 2 sides: both sides shown
o Alignment: aligned
▪ Length: normal
▪ Apposition: femoral head well apposed in acetabulum
▪ Rotation: no rotation of the lower limbs
▪ Angulation: not assessable due to X-ray inadequacy
• Bones
o Bilateral moderate osteopenia of the proximal femur
o Bilateral osteophytes along femoral heads and acetabula
o Bilateral subchondral sclerosis and cysts of femoral heads
 • Cartilage
o Bilateral hip joint space narrowing with marked cartilage degeneration
• Soft tissue
o No soft tissue swelling or injury over the hip joints
• Other features
o N/A
ii. What is the diagnosis based on the above X-ray?
• Osteoarthritis
iii. Name two features of this condition that you would expect to find on the hands.
• Heberden’s nodes
• Bouchard’s nodes
iv. Describe the management of this condition.
• Non-surgical
o Non-pharmacological
▪ Patient education
▪ Lifestyle modifications (e.g. weight loss, exercise)
▪ Physiotherapy
▪ Assistive devices (e.g. orthoses)
▪ Joint rest and minimising weight-bearing
o Pharmacological
▪ NSAIDs (e.g. diclofenac) and paracetamol
▪ Intra-articular corticosteroid injections
▪ Intra-articular hyaluronic acid derivative injections
• Surgical
o Arthroplasty
o Arthrodesis
o Joint reconstruction
8. Knee dislocation

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: lateral view only
▪ 2 joints: involved knee joint seen, but joints proximal (i.e. hip joint) and distal
(ankle joint) not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
 ▪ 2 sides: only involved side, with normal side not seen
o Alignment: misaligned
▪ Length: limb length shortened
▪ Apposition: 0% apposition between tibia and femur
▪ Rotation: not assessable due to X-ray inadequacy
▪ Angulation: not assessable due to X-ray inadequacy
• Bones
o Anterior knee joint dislocation
o No associated fractures of the femur, tibia, fibula or patella
• Cartilage
o Joint space completely out of alignment due to dislocation
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Marked soft tissue swelling over knee joint and popliteal fossa
o Tibia and fibula protruding into soft tissue overlying knee joint
• Other features
o N/A
ii. What is the diagnosis based on the above X-ray?
• Anterior knee joint dislocation
iii. What immediate complication would you be concerned about in this pathology?
• Neurovascular compromise, including:
o Arteries: popliteal artery, anterior tibial artery, posterior tibial artery, peroneal artery
o Innervation: tibial nerve, common peroneal nerve, sural nerve
iv. Name two ligaments that are most likely damaged.
• Anterior cruciate ligament
• Posterior cruciate ligament
v. What is the emergency management of this pathology?
• Stabilize according to ATLS principles (i.e. ABCDEs) and give analgesia
• Exclude neurovascular compromise of the leg
• Attempt closed reduction under anaesthesia
• After reduction, the leg should be placed in 20-30 degrees of flexion and an above-the-
knee backslab applied to immobilise the involved joint
9. Gallows traction

i. What device is depicted above?

• Gallows traction device
ii. What is the maximum patient weight allowed with this device?
• 12kgs
iii. List 2 indications for use of this device.
• To manage femoral shaft fractures in children < 12kgs and <2 years
• Preoperative management of hip dysplasia
iv. List 4 complications with use of this device.
 • Skin excoriation
• Compartment syndrome
• Impairment to circulation (may cause DVTs)
• Allergic reaction to adhesives used in skin traction
v. How do you check to assess whether or not the device is working?
• Regular X-rays to assess adequacy of reduction and bone healing
10. Galeazzi fracture

i. Describe the X-ray above.

• Adequacy and alignment
o Adequacy: inadequate
▪ 2 views: AP and lateral views
▪ 2 joints: involved distal radioulnar joint (DRUJ) and joints distal to this seen, but
joint proximal (i.e. proximal radioulnar joint) not seen
▪ 2 occasions: only 1 occasion (i.e. before intervention)
▪ 2 sides: only involved side, with normal side not seen
o Alignment: misaligned
▪ Length: limb shortened
▪ Apposition: distal radius fracture is poorly apposed (nearly 100% displacement)
▪ Rotation: marked rotation of forearm
▪ Angulation: radius angulated medially and projecting dorsally
• Bones
o Distal radius fracture with DRUJ dislocation
o Possible greenstick fracture of radius just proximal to DRUJ
• Cartilage
o Distal radioulnar joint space widening
o No evidence of cartilage injury or loss (e.g. irregular bony margins)
• Soft tissue
o Distal ulna protrusion into overlying soft tissue medially
o Marked soft tissue swelling over distal forearm and DRUJ
• Other features
o N/A
ii. Name this eponymous fracture.
• Galeazzi fracture
iii. What specific injury is cause for most concern in this case?
• Injury to the posterior interosseous nerve, branch of the radial nerve
iv. Describe the emergency management of this fracture.
• Stabilize according to ATLS principles (i.e. ABCDEs) and give analgesia
• Exclude neurovascular compromise of the forearm
• Attempt closed reduction under anaesthesia
• After reduction, the elbow should be placed in 90 degrees of flexion with neutral
pronation-supination of the forearm and neutral flexion-extension of the wrist
• An above-the-elbow backslab must also be applied to immobilise the involved joint