A 35 year old man presents with pins and needles and a burning sensation in the skin of his upper-outer left thigh. This has been going on for the past three weeks. He reports that the symptoms are exacerbated by walking and improve when he sits and rests. He denies any leg weakness, back pain, incontinence or sensory symptoms elsewhere. 

He is frustrated as the symptoms bother him whilst walking his dog. He has to stop regularly to sit down and wait for the symptoms to settle.

Examination is unremarkable.

What is the most likely diagnosis?

A 34 year old man presents with acute onset lower back pain for the past two days. The pain seemed to start while lifting weights. He carried on lifting weights, thinking it would settle, but once he finished his workout and sat down for 30 minutes the pain got a lot worse. He has been struggling with mobility, as movements exacerbate the pain. He says this makes him feel weak but he has still been able to mobilise around his house and get a taxi to the GP practice. He says it has been difficult to pass urine or open his bowels because his back is uncomfortable whilst standing or sitting on the toilet. He denies any saddle anaesthesia, retention or incontinence. He is aware of when he needs to pass urine and open his bowels. He has no sensory symptoms in his lower limbs. He has been sleeping ok but says it can be difficult to find a comfortable position. He was previously fit and well.

On examination, he walks slowly while leaning forward, with his hand on his lower back. He is generally tender across his lower back. There are no focal areas of tenderness. His paraspinal muscles are tense and tender. He has full power and normal reflexes and sensation in his lower limbs. Abdominal examination is unremarkable with no palpable bladder. Rectal examination reveals normal tone and sensation. His BMI is 32. Physical observations are normal.

Which of the following will be most helpful in guiding management? 

A 64 year old man presents to his GP with a 3-week history of worsening pain in his pelvis. After an assessment, his GP makes a provisional diagnosis and prescribes a medication. 

After three days of taking this medication, he presents back to the GP with pain in his right ankle. He walks his dog twice a day and has noticed on the past three walks that his ankle is very sore, particularly when pushing off with his foot. It is also noticeably tender and has been aching at rest. 

On examination, he indicates that the pain is at the back of his ankle, approximately 2-6cm above the calcaneus bone.  He is tender in this area. Simmonds’ calf squeeze test is negative.

Which of the following medication is most likely to have been prescribed at the initial consultation?

A 54 year old woman presents with bothersome symptoms in her left hand. Over the past 8 weeks, she has been experiencing numbness, burning and tingling in her index and middle fingers and thumb. She confirms that her little finger is unaffected. This occurs more in the evenings and causes her to wake frequently through the night. She feels the need to shake her hand when the symptoms occur but is unsure if this helps. She has a past medical history of hypothyroidism and type 2 diabetes. 

On examination, there is reduced grip strength in her left hand. The thenar eminence is slightly smaller on the left side than the right, and she has weakness in thumb movements. Phalen’s and Tinnel’s tests are positive. 

Which of the following investigations is most likely to be used to confirm the diagnosis?

A 53 year old man is brought to A&E by ambulance after being hit by a car travelling approximately 20 miles per hour whilst riding his bicycle. He has multiple bruises and grazes and cannot weight bear on his right leg. The skin is intact on his right leg. An x-ray reveals a proximal fracture of his tibia. He is admitted to the orthopaedic ward with a plan for surgical fixation of the fracture at the next available opportunity. 

Four hours after admission, the junior doctor is called as he is complaining of severe pain in his leg below the knee. He describes pain throughout his entire lower leg and finds it very difficult to get comfortable. 

On examination, he is visibly distressed and affected by severe pain. The skin is intact on his leg. The right leg appears swollen compared with the left. It is pale on examination. The leg feels “woody” and hard on palpation. The dorsalis pedis and posterior tibial pulses are palpable.

The orthopaedic registrar is called to review the patient.

Given the likely diagnosis, what is the definitive management?

A 72 year old man presents with a two-year history of worsening right knee pain. He explains that he has been active his whole life and used to play a lot of cricket. He previously walked 6 miles a day but now can manage less than a mile, as his right knee and thigh ache more and more the further he goes. This aching seems to gradually fade into the background once he gets home from the walk. He is not bothered by symptoms at rest or during the night but he is aware of the potential for pain with movement. He can feel a bit stiff in the morning, but this eases within minutes. He feels otherwise well.

He recently saw another doctor who arranged an x-ray of his right knee. It is reported as normal. 

Based on the history, which of the following investigations is most appropriate to consider?

A 56 year old man presents with acute pain at the base of his big toe on the left side. His symptoms started 24 hours ago, and the area rapidly became red, warm and very tender to touch. He does not remember any injuries or trauma to his foot and has been mainly sedentary for the past few days. He denies any fevers and feels otherwise well in himself. 

He has a background of obesity, gastro-oesophageal reflux disease, hypertension and chronic kidney disease. He takes ramipril, amlodipine, indapamide and omeprazole. He is a non-smoker and drinks 3 pints of lager per day.

On examination, there is erythema, swelling and acute tenderness of the metatarsophalangeal joint of the big toe on the left side. The area is warm to the touch. The skin is intact, and the dorsalis pedis and posterior tibial pulses are easily palpated.

Blood pressure: 146/91. Heart rate: 80. Respiratory rate: 16. Oxygen saturations: 98%. Temperature: 36.8°C.

What is the most appropriate initial management?

A 68 year old woman presents with right-sided shoulder pain for the past three months. It has been gradually getting worse and is preventing her from doing activities around the home, particularly anything that involves lifting overhead, such as putting cups and plates away in high-up cupboards. The pain is also noticeable when getting dressed. The shoulder can be stiff if she has been doing a lot of activities, and she thinks there is some restriction in movement. She denies any systemic symptoms such as fevers and is not bothered by the pain at night time. She otherwise feels well. She has a history of high cholesterol and mild hypertension, which are both well controlled with atorvastatin and ramipril.

On examination, there is tenderness at the front of the shoulder. On movement of the shoulder, the pain is most notable when the arm is abducted past 170 degrees and when bringing the arm across her body towards the opposite shoulder. 

What is the most likely diagnosis?

A 76 year old woman is brought to A&E by ambulance after falling in the supermarket. She reports slipping on washing up liquid, which had been spilt on the floor. She had no loss of consciousness or head injuries. She complains of pain in her right hip. She usually takes 2 mile walks every day. She is a member of a table tennis club and enjoys dancing. She has a past medical history of hypothyroidism and takes levothyroxine.

On examination, she has a shortened, abducted and externally rotated right leg. She is unable to weight bear or straight leg raise with the right hip. Cardiovascular, respiratory and neurological examinations are normal.

X-rays of her hip reveal an intertrochanteric fracture on the right side. 

Her case is discussed at the orthopaedic trauma meeting. What definitive management is most likely to be recommended?

A 30 year old man presents with pain in his right wrist, which has worsened over the past two months. He has a three month old son, and he finds that carrying him exacerbates the pain. He indicates that the pain is on the radial aspect of the wrist, near the base of the thumb, and radiates down his forearm.

On examination, there is tenderness and mild swelling to the radial aspect of the wrist. The skin is a normal colour and remains intact. The pain is exacerbated by having him make a fist with his thumb inside the fingers, then adduct the wrist, deviating it in an ulnar direction.

What is the most likely diagnosis? 

A 13 year old boy presents with a painful, hard lump on the front of his knee, below the kneecap. It started with mild symptoms and has gradually progressed over the past 4 months. He plays football for both his school and local club and finds that during and after playing his knee is particularly sore at the site of the lump. It is tender to touch. He avoids kneeling down and putting weight on the lump. He is not bothered by it while resting or at night time. He is otherwise fit and well and has no other symptoms.

On examination, there is a lump on the anterior aspect of the knee, below the kneecap. The lump is tender to touch. There is no joint swelling or tenderness elsewhere. Resisted extension of the knee causes soreness localised to the lump. He has full passive range of motion in his knee and hip.

What is the likely diagnosis?

A 64 year old man is under the care of the diabetic foot clinic for a deep ulcer on the plantar aspect of the foot in the area of the second metatarsal. He is admitted to hospital with a low-grade fever of 37.9°C, lethargy and loss of appetite. He is started on IV antibiotics. 

An MRI scan of his foot confirms osteomyelitis. 

What is the most likely causative organism?

A 55 year old man presents with an aching sensation over the outside of his left hip. This has been going on for the past 6 weeks, ever since he went on a hiking trip with his daughter and her fiancé, which included climbing Snowdon. He thought it would be a good idea to keep exercising to strengthen the muscles and has been going for regular walks, but this has only made the pain worse. Now he is starting to worry that there might be something sinister causing his symptoms. He finds it difficult to find a comfortable position to lie in, as pressure on the area is very uncomfortable. Once he is asleep, the pain does not wake him up. He denies any groin, lower back or knee pain. Otherwise, he feels well in himself. 

On examination, there is tenderness to the lateral aspect of his left hip. There is no swelling or changes to the skin. Resisted abduction, internal rotation and external rotation of the hip exacerbate the pain. 

What special clinical test may be helpful in supporting the most likely diagnosis?

A 50 year old woman presents with a six-month history of intermittent numbness and pins and needles in her left hand. The symptoms affect her index, middle and ring finger, and thumb. She looked online and made a self-diagnosis of carpal tunnel syndrome. She has been using a wrist splint at night to keep her wrist in a neutral position, with no improvement in symptoms. She wants to know what surgery for carpal tunnel syndrome involves. 

What structure is cut during surgery?

A 28 year old woman presents with pain in the lower third of her thigh. She describes it as a deep ache. This has been getting progressively worse over the past 3 months. At first, she thought she had pulled a muscle, as she was training for a half-marathon at the time, but the pain is gradually getting worse rather than better. Her symptoms do not seem to be related to exercise and tend to be worse at night. 

On examination, there is tenderness and subtle swelling of the distal femur. The knee joint is normal on examination. 

What is the most appropriate next step in management?

A 33 year old man is being seen in the orthopaedic clinic after a right knee injury. The injury happened two months ago whilst playing competitive basketball. It occurred while he was changing direction with his knee twisted in an awkward position. He felt a sudden “pop” sensation and the knee locked up. The knee quickly became swollen, painful and stiff. He attended A&E, where he had an x-ray to rule out a fracture and was given crutches and a knee brace. Since the initial swelling and pain have subsided, he is left with a feeling of instability and episodes where the knee locks. The range of motion in the knee is slightly restricted. He still has some pain and swelling.

The last time he was seen in the clinic, an MRI scan was arranged. The report suggests a meniscal tear. 

What is the most appropriate next step in management?

A 22 year old mathematics student presents with a swollen, tender left elbow. It has been getting gradually worse over the past 6 weeks and is interfering with her studies, as she likes to lean on her elbow while reading and working through problems. She feels otherwise well in herself and denies any fevers or systemic symptoms. 

On examination, there is a fluctuant, mildly tender swelling covering the posterior aspect of the elbow. There are no skin changes and there is a full, unrestricted range of motion in the elbow joint. The joint appears unaffected. She is systemically well. 

What is the most likely diagnosis?

A 68 year old man is considering an elective total hip replacement for severe left-sided osteoarthritis. He has had worsening pain and stiffness in the hip for over ten years. He has managed so far with regular physiotherapy and multiple steroid injections but has reached a point where he feels ready for surgery. He is asking about possible complications. 

Which of the following is least likely to be recommended to prevent complications?

A 72 year old man presents with new lower back pain. This came on gradually over the past two weeks. He puts it down to doing a lot of gardening recently, which resulted in his legs feeling tired and heavy. The pain does not radiate to his legs. He has noticed some difficulty passing urine and has had two episodes of urinary incontinence and one episode of faecal incontinence. He puts these down to previously having had prostate cancer, successfully treated with radiotherapy. When specifically asked, he admits it does feel numb around his back passage.

On examination, power is 4/5 bilaterally in his lower limbs, with slightly reduced tone and reflexes. He also has reduced anal tone and sensation on a rectal examination. His bladder is not palpable on abdominal examination.

What is the most appropriate next step in management?

A 45 year old woman presents with a painful ring finger on her left hand. Movement of the finger feels uncomfortable and creates a clicking sensation. The finger often gets stuck in a flexed position and requires the other hand to release it, which can be quite painful. Symptoms seem to be worst in the morning and improve throughout the day. 

On examination, a small, tender nodule is palpable at the base of the ring finger, just below the MCP joint on the palm of the hand.

What is the most likely diagnosis?

An 82 year old man presents with a two-week history of left shoulder pain. It started after a fall while playing rugby with his great-grandson. Immediately after the fall, it felt sore but he did not feel he needed to attend A&E. He put his arm in a sling and kept it immobilised. Over the following days, it seemed to get more painful, and he noticed weakness when trying to lift his arm out to the side. He finds it difficult to get comfortable at night and the pain is affecting his sleep. He has noticed some improvement in the pain since the injury, but he says the weakness is still present. 

On examination, there is slightly less muscle bulk around his left shoulder in comparison to the right. There is no tenderness or swelling of the bones or joints on palpation. Shoulder movements are painful. He can internally and externally rotate the shoulder against some resistance. There is more significant weakness and pain on abduction of the shoulder. He cannot hold his left arm against gravity at 90 degrees of shoulder abduction. There is good range of motion and strength in his right shoulder.

The tendon of which muscle is most likely to be affected?

A 62 year old man presents to A&E after falling whilst on his way to the bathroom during the night. He describes how he tripped over a washing basket while walking across the landing in the dark and fell onto his outstretched hand. He now has pain in his right wrist, particularly near the base of his thumb. 

On examination, there are no obvious deformities on inspection, but the radial aspect of the wrist is mildly swollen. The pain is exacerbated by resisted pronation of the wrist. There is tenderness on palpation of the anatomical snuffbox.

An x-ray is arranged, which confirms a fracture.

The orthopaedic registrar reviews the patient and explains that it is important with this particular type of fracture to proceed with surgery as soon as possible, as treating it without surgery carries a greater risk of the bone dying and the fracture failing to heal.

What bone is likely to be fractured in this scenario?

A 71 year old man presents with a five-year history of right knee pain. He is presenting now as he recently noticed increased pain and swelling at the back of his knee. He says the pain initially started to occur when he went out running, and increasingly became more noticeable with everyday activities. He does not get any pain at rest, only with movement and weight-bearing on the knee. He says the knee can be a bit stiff when he first gets going but quickly loosens up. Two weeks ago he noticed increased pain and a feeling of tightness at the back of his knee. When feeling the area, he noticed the swelling. He is worried as he had a friend that died of bone cancer. 

On examination, he has bulky knee joints bilaterally. There is no tenderness to the joint line. There is crepitus while moving the joint, and a slight restriction in the range of motion at the extremes of flexion and extension. There is a soft, round, fluctuant, non-pulsatile lump in the popliteal fossa when the leg is extended. This lump disappears when the leg is flexed. The lump is not pulsatile.

Which investigation will be most helpful in confirming the cause of the swelling? 

A 36 year old man presents with right-sided elbow pain. He recently moved into a new house and has been putting together a lot of flat-pack furniture and putting up shelves. This seems to have triggered his pain. The pain is on the outer aspect of his elbow and has a throbbing, aching nature. It has been stopping him from playing golf, something he is very passionate about, as he struggles to grip the club while swinging. He is right-handed.

On examination, there is tenderness over the outer aspect of his right elbow. Stretching the extensor muscles of the forearm while palpating the lateral epicondyle exacerbates the pain.

What is the most likely diagnosis?

A 58 year old woman is seen by her GP after a left wrist fracture. She was standing on a chair to change a lightbulb, lost her balance and feel off onto her outstretched hand. She was seen in A&E, where a cast was applied. She was followed up in the fracture clinic, where the cast was removed and she was discharged. The discharge letter requested that her GP review her risk of future fractures. She says she leads a healthy lifestyle, with a balanced diet and regular exercise. She does not smoke or drink alcohol and has no significant ongoing medical problems.

A DEXA scan is arranged, which shows a T-Score at the hip of -2.1.

What term best describes her bone mineral density?

A 70 year old man presents with pain and weakness in his buttocks and legs. He says that his symptoms have gradually gotten worse over the past 6 months. He describes the symptoms as a general ache and fatigue, as though they are getting tired from a very long walk. His symptoms start when he is walking any distance beyond 50 yards, and gradually get worse until he sits and rests. He has a tendency to lean forwards while walking, as standing up straight seems to make the symptoms worse. Sitting and resting improve the symptoms. He is a retired builder and says he has always been “as strong as an ox”, although he has struggled with lower backache since the last few years of work. He is frustrated as he feels these symptoms are ruining his retirement plans, as he wants to travel the world.

On examination, he has a full, pain-free range of motion in the joints of his lower limbs. Lower limb neurological examination is unremarkable. His peripheral pulses are intact. His ankle-brachial pressure index (ABPI) is 0.9.

What is the most likely diagnosis?

A 68 year old man presents with restricted movement of his right ring finger. This has been gradually getting worse over the past two years. He has been managing ok, but he is concerned that it will progress and affect his motorcycle riding, which he has been doing since he was 16. He has a background of type 2 diabetes. He admits to smoking and drinks most of a bottle of red wine every evening.

On examination, he is unable to extend his right ring finger. A thick, nodular cord can be palpated from the palm of his hand to the affected finger. The overlying skin is thickened and pitted. He is unable to place his hand flat on the table with the palm facing down.

Given the probable diagnosis, which of the following is an established management option?

A 22 year old man is being followed up in the orthopaedic clinic for recurrent right anterior shoulder dislocations. He first dislocated his shoulder while surfing, where a wave pulled him underwater while his arm was outstretched. He has since had several episodes of dislocation, mostly whilst participating in sports, each requiring a trip to hospital for relocation.

He is being seen with the results of recent magnetic resonance arthrography.

Which of the following is most likely to be seen on the MRA?

A 23 year old woman presents after an acute knee injury on the right side. She is a semi-professional football player. While playing in a recent match, she was changing direction when she felt a pop in her knee, followed by rapid onset pain and swelling. She fell to the ground and was not able to weight bear afterwards. She attended A&E, where she had an x-ray, showing no bony injury, and was given crutches to help her mobilise. Since then, the pain and swelling have improved, and she is able to weight bear again. However, the knee feels as though it is giving way, and she lacks confidence with weight-bearing on her right leg. She has not been able to return to sports.

On examination, with the knee flexed to 90 degrees, it is possible to pull the proximal tibia anteriorly in relation to the femur without feeling a clear endpoint to the movement.

Given the likely diagnosis, what is the definitive treatment?

A 68 year old woman is worried about her risk of osteoporosis. She recently started prednisolone as a treatment for polymyalgia rheumatica, and has read that treatment with steroids can increase the risk of fractures. Her mother suffered a hip fracture in her 70s and never made a full recovery. She tries to live a healthy lifestyle, with a balanced diet, regular walks and avoiding alcohol and smoking. 

She weighs 58 kg and is 168 cm tall.

Using the FRAX tool, her ten-year probability of fracture a major osteoporotic fracture is 28%. The NOGG guidelines recommend starting treatment. Her GP discusses starting treatment with alendronic acid.

Which of the following is recommended before starting treatment?

A 45 year old man presents to his GP with sudden onset left ankle pain while playing cricket the day before. He says it felt like something snapped. At first, he thought that the ball had hit him in the back of the ankle. Since then, he has struggled to walk and has been using crutches given to him by his brother. 

On examination, the left ankle appears more dorsiflexed compared with the right. There is tenderness to the Achille’s tendon on the left side. He is unable to plantarflex the ankle against resistance. When squeezing the calf on the left side, there is no movement in the ankle or foot.

What is the most appropriate initial management?

A 78 year old man presents with a lump on the back of his wrist. This has been gradually enlarging over the past two months. It does not cause him any pain and has not affected the function of his hand or wrist. He feels otherwise well in himself and has no other symptoms or lumps. He thought he had better report it as it could be something sinister. 

On examination, he has a 2cm, firm, non-tender, well-circumscribed lump on the dorsal aspect of the right wrist. It is mobile under the skin. It is possible to transilluminate the lump with a torch. There are no skin changes. 

Given the likely diagnosis, what would be contained within the lump?