CASE INFORMATION

Case ID: ORTH-2025-005
Case Name: Liam Reynolds
Age: 28 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L72 (Fracture)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively 1.2 Explains diagnosis and treatment plan clearly to the patient 1.5 Provides information on recovery, rehabilitation, and return to activity
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including mechanism of injury 2.3 Performs a targeted musculoskeletal examination 2.4 Orders and interprets appropriate imaging (X-ray)
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between different types of fractures and soft tissue injuries 3.4 Identifies high-risk fractures requiring urgent intervention
4. Clinical Management and Therapeutic Reasoning	4.1 Provides initial fracture management including splinting and pain relief 4.3 Refers for orthopaedic review if necessary 4.6 Advises on follow-up and prevention of complications
5. Preventive and Population Health	5.1 Discusses injury prevention strategies
6. Professionalism	6.2 Ensures patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Completes injury documentation (e.g., WorkCover, medical certificate if needed)
8. Procedural Skills	8.1 Demonstrates correct technique for immobilisation (splinting, casting)
9. Managing Uncertainty	9.1 Identifies fractures that may not be visible on initial imaging (occult fractures)
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages complications (e.g., neurovascular compromise, compartment syndrome)

CASE FEATURES

Young male presents with right wrist pain and swelling after a fall onto outstretched hand (FOOSH) while playing soccer.
Reports immediate pain and difficulty moving wrist, no open wounds.
No past fractures or significant medical history.
Concern about returning to work (manual labourer) and need for time off.
Requires X-ray interpretation, fracture classification, and appropriate management.
Discussion around splinting, pain relief, orthopaedic referral, and follow-up care.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Liam Reynolds
Age: 28 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Nil regular medications

Past History

No previous fractures or major injuries

Social History

Works as a construction worker, relies on full use of his hands.
Plays soccer recreationally, fell while attempting to break a fall.

Family History

No history of osteoporosis or metabolic bone disease.

Smoking

Non-smoker.

Alcohol

Drinks occasionally, 2-3 standard drinks per week.

Vaccination and Preventative Activities

Up to date with tetanus vaccination.

SCENARIO

Liam, a 28-year-old construction worker, presents to your clinic with right wrist pain and swelling following a fall onto an outstretched hand (FOOSH) while playing soccer. He describes immediate pain, swelling, and difficulty moving his wrist, particularly with gripping and wrist extension.

There is no visible deformity or open wound, and he denies numbness or tingling in the fingers. He is concerned about whether his wrist is fractured, whether he will need time off work, and how long recovery will take.

EXAMINATION FINDINGS

General Appearance: Uncomfortable, supporting the right wrist with the left hand.
Inspection: Mild swelling over the dorsal wrist, no open wounds.
Palpation:

Tenderness over anatomical snuffbox (scaphoid region) and distal radius.
No gross deformity.
No pain over metacarpals or elbow.
Range of Motion:
Reduced wrist extension and flexion due to pain.
Pain on radial deviation.
Neurovascular Status:
Capillary refill <2 seconds, normal radial pulse.
Sensation intact in all fingers.

INVESTIGATION FINDINGS

Wrist X-ray:

Undisplaced distal radius fracture with no intra-articular involvement.
Scaphoid views: No visible fracture, but clinical suspicion remains high.

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to assess Liam’s injury?

Prompt: Ask about mechanism of injury, force of impact, and dominant hand.
Prompt: Assess for red flags (e.g., numbness, weakness, persistent severe pain).

Q2. What are the most likely diagnoses, and what features support your conclusion?

Prompt: Explain why this is likely a distal radius fracture.
Prompt: Discuss clinical suspicion for scaphoid fracture despite normal X-ray.

Q3. What is the initial management plan for Liam?

Prompt: Discuss pain relief, immobilisation (splinting), and follow-up imaging.
Prompt: Identify when to refer for orthopaedic review.

Q4. What are the key complications to watch for, and how would you prevent them?

Prompt: Explain the risk of scaphoid non-union, malunion, and stiffness.
Prompt: Identify signs of neurovascular compromise or compartment syndrome.

Q5. How would you counsel Liam on return to work, activity modification, and follow-up?

Prompt: Provide realistic expectations for healing and return to work.
Prompt: Discuss physiotherapy, gradual mobilisation, and strength recovery.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to assess Liam’s injury?

A thorough history is essential to confirm the mechanism of injury, assess for complications, and guide appropriate management.

1. Mechanism of Injury

How did the injury occur? (FOOSH, direct impact, rotational force)
What surface did he fall on? (Hard vs soft ground)
Did he experience an immediate loss of function?

2. Pain and Functional Impact

Pain characteristics: Onset, severity (VAS score), radiation, aggravating/alleviating factors
Functional limitations: Difficulty gripping, lifting, or wrist movement
Previous similar injuries or chronic wrist pain?

3. Red Flag Symptoms

Neurological symptoms: Numbness, tingling, or weakness (median nerve compromise)
Vascular symptoms: Coldness, pale/blue fingers, delayed capillary refill (vascular injury)
Persistent severe pain/swelling despite immobilisation (Compartment Syndrome risk)

4. Handedness and Work Implications

Is the dominant hand affected?
Impact on work as a construction worker? (lifting, tool use, return to work concerns)

5. Past Medical History

History of osteoporosis, previous fractures, or metabolic bone disease
Regular medication use (steroids increase fracture risk)

A detailed history guides appropriate investigations, treatment, and follow-up planning.

Q2: What are the most likely diagnoses, and what features support your conclusion?

1. Distal Radius Fracture – Most Likely

FOOSH injury – common mechanism for distal radius fractures
Pain and swelling over the distal radius
X-ray confirmation of undisplaced distal radius fracture

2. Possible Scaphoid Fracture – Must Consider

Tender anatomical snuffbox despite no fracture on initial X-ray
High clinical suspicion – scaphoid fractures may not be visible acutely
Risk of avascular necrosis (AVN) – necessitates precautionary management

3. Differential Diagnoses

Wrist sprain or ligamentous injury: If no fracture but persistent pain
Triangular Fibrocartilage Complex (TFCC) injury: If pain on ulnar deviation
Occult fracture: If persistent pain with normal initial imaging

Given the mechanism of injury and clinical findings, the working diagnosis is a distal radius fracture with possible scaphoid involvement requiring further imaging.

Q3: What is the initial management plan for Liam?

1. Immobilisation

Wrist splint or below-elbow backslab
Ensure neutral wrist position to prevent deformity

2. Pain Management

Paracetamol + NSAIDs (e.g., ibuprofen 400 mg TDS) for pain relief
Avoid strong opioids unless severe pain

3. Further Imaging and Follow-up

Repeat X-ray in 10–14 days if clinical suspicion of scaphoid fracture
Consider MRI/CT if persistent pain

4. Work and Activity Advice

Rest and avoid weight-bearing activities
Discuss return-to-work options (light duties if necessary)

5. Referral Considerations

Refer to orthopaedics if:
- Fracture is displaced, comminuted, or intra-articular
- Persistent pain suggesting occult scaphoid fracture

This approach ensures safe initial management and prevents complications.

Q4: What are the key complications to watch for, and how would you prevent them?

1. Malunion and Functional Impairment

Risk: Poor healing leading to wrist stiffness or chronic pain
Prevention: Proper immobilisation, early physiotherapy

2. Scaphoid Non-Union and Avascular Necrosis

Risk: High if scaphoid fracture is missed
Prevention: Early diagnosis (MRI/CT if necessary), immobilisation with thumb spica splint

3. Median Nerve Compression (Carpal Tunnel Syndrome)

Risk: Swelling causing nerve impingement
Prevention: Monitor for numbness/weakness, avoid overtight splinting

4. Compartment Syndrome (Rare but Serious)

Risk: Increased pressure in wrist leading to ischaemia
Prevention: Monitor pain, pallor, pulselessness, paresthesia, paralysis – urgent fasciotomy if present

Proactive monitoring and follow-up prevent long-term disability.

Q5: How would you counsel Liam on return to work, activity modification, and follow-up?

1. Expected Healing Time

6–8 weeks for bone healing, full strength by 3 months
Scaphoid fractures may take longer (up to 12 weeks)

2. Return to Work Advice

Light duties may be required for 6+ weeks
Avoid heavy lifting, repetitive strain activities

3. Rehabilitation and Preventing Stiffness

Early physiotherapy once pain improves
Gradual wrist mobilisation and strengthening exercises

4. Follow-Up

Review in 2 weeks for repeat X-ray if scaphoid fracture suspected
Ensure proper bone healing before returning to full work duties

Providing clear recovery expectations and work modifications supports Liam’s rehabilitation.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering mechanism of injury, red flags, and work impact.
Accurate diagnosis, differentiating distal radius fracture from occult scaphoid fracture.
Appropriate initial management, including immobilisation, pain relief, and follow-up imaging.
Identification of complications, such as malunion, nerve compression, and AVN.
Patient-centred communication, ensuring clear expectations for healing and work return.

PITFALLS

Failing to consider scaphoid fracture if X-ray is normal but snuffbox tenderness is present.
Inadequate pain management, leading to poor compliance with immobilisation.
Not warning about potential complications (e.g., malunion, AVN, chronic pain).
Poor documentation of work capacity, affecting return-to-work planning.
Missing compartment syndrome signs, leading to delayed emergency intervention.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD