CASE INFORMATION

Case ID: FX-003
Case Name: Daniel Thompson
Age: 32 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: L72 (Fracture)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates clearly and effectively with the patient regarding injury assessment and management. 1.2 Provides patient-centred education on the injury, prognosis, and recovery expectations. 1.3 Addresses concerns empathetically, ensuring patient understanding of treatment and follow-up.
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history, including mechanism of injury, symptoms, and functional impact. 2.2 Interprets clinical findings to determine fracture severity and need for imaging.
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between simple and complex fractures and determines appropriate management. 3.2 Identifies red flags that may require urgent referral (e.g., neurovascular compromise, open fracture).
4. Clinical Management and Therapeutic Reasoning	4.1 Provides initial fracture care, including pain management and immobilisation. 4.2 Advises on appropriate follow-up with imaging, orthopaedic referral, or emergency escalation if needed.
5. Preventive and Population Health	5.1 Discusses injury prevention strategies, particularly in occupational or sports settings.
6. Professionalism	6.1 Demonstrates ethical and professional conduct in decision-making and patient interactions.
7. General Practice Systems and Regulatory Requirements	7.1 Ensures proper documentation and compliance with workplace injury or compensation requirements.
8. Procedural Skills	8.1 Provides or arranges appropriate immobilisation (e.g., splinting, buddy taping, or referral for casting).
9. Managing Uncertainty	9.1 Recognises when specialist referral is required and provides appropriate safety-netting advice.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises signs of complications, including infection, compartment syndrome, or non-union.

CASE FEATURES

Consideration of workplace compensation or insurance documentation if required.
A 32-year-old male presents with wrist pain and swelling after a fall on an outstretched hand while playing soccer.
The case involves assessing the severity of a possible fracture and determining the need for imaging.
The patient needs pain relief, immobilisation, and appropriate referral or follow-up.
Discussion around return to work, activity modifications, and prevention of future injuries.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take a focused history regarding the mechanism of injury, symptoms, and impact on function.
Explain your assessment of the injury, including differential diagnoses and the need for imaging.
Provide an appropriate management plan, including pain relief, immobilisation, and referral if necessary.
Address the patient’s concerns, including return to work, recovery expectations, and injury prevention.

SCENARIO

Daniel Thompson is a 32-year-old construction worker who presents with wrist pain and swelling after a fall during a weekend soccer match. He reports that he was running and tripped, landing on his outstretched right hand. The pain was immediate and sharp, and his wrist started to swell within 30 minutes. He took paracetamol, which helped slightly, but the pain is still severe when he moves his wrist.

Daniel is worried about whether he has broken a bone and whether he will need time off work. His job involves heavy lifting and manual labour, so he is concerned about his ability to return to work. He has no previous fractures, and he is otherwise healthy, taking no regular medications.

Your role is to assess whether he has a fracture, determine the appropriate next steps, and provide management advice on recovery and return to work.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Thompson
Age: 32 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No history of fractures or significant musculoskeletal injuries

Social History

Works as a construction labourer, requiring heavy lifting and use of power tools
Plays soccer recreationally
Non-smoker, drinks alcohol socially

Family History

No history of osteoporosis or bone disorders

Smoking & Alcohol

Non-smoker
Drinks occasionally (1-2 standard drinks per week)

Vaccination and Preventive Activities

Up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I think I might have broken my wrist. I fell on it during soccer, and now it’s really swollen and painful.”

General Information

Your name is Daniel Thompson, and you are a 32-year-old construction worker. You have been playing soccer recreationally for about five years. Yesterday, while playing, you were running towards the ball and tripped, falling forward and landing on your outstretched right hand. You felt a sharp, immediate pain in your wrist, followed by swelling within 30 minutes. You could still move your fingers, but certain movements—especially lifting or twisting your wrist—were extremely painful.

You finished the game but avoided using your right hand too much. When you got home, you put some ice on it and took paracetamol, which helped slightly. This morning, the wrist is still swollen, and the pain has worsened. You are now struggling to grip objects, and even simple tasks like brushing your teeth or opening a door are painful. You are worried that it might be broken and want to know if you need an X-ray and whether you can still work.

Your job as a construction worker involves heavy lifting, using power tools, and working with your hands all day. If you can’t use your wrist properly, you will struggle to perform your duties. You are concerned about needing time off work and whether this could affect your income.

Specific Information (Only Provide if Asked Relevant Questions)

Symptoms and Functional Impact

The pain is sharp when moving the wrist, especially when lifting, twisting, or putting pressure on it.
The pain is constant, but there is a dull ache even at rest.
You have significant swelling around the wrist but no obvious bruising.
You can move your fingers normally, but gripping objects is weak and painful.
There is no numbness or tingling in your fingers.
You haven’t noticed any deformity, but you’re worried about an internal fracture.

Work Situation

You work in construction, where heavy lifting and using tools are a daily requirement.
You don’t think you can do your job properly with this wrist injury.
You are worried about needing time off work and how this might affect your finances.
Your job has workers’ compensation, but you are unsure if this situation qualifies.

Concerns and Expectations

You want to know if it’s broken and whether you need an X-ray.
You want proper pain relief so you can function better.
You need advice on returning to work, whether you can continue working with a brace, or if you need complete rest.
You hope it’s just a sprain and that you won’t need a cast or surgery.

Emotional Cues and Behaviour

At first, you are calm but slightly anxious, as you don’t want this injury to disrupt your work and lifestyle.
If the doctor suggests it could be a fracture, you become more concerned and may say:
- “That’s going to be a big problem if I need a cast. How long would I be out for?”
If the doctor hesitates about whether an X-ray is needed, you might push for it, saying:
- “I’d rather get it checked properly now than wait and make it worse.”
If the doctor mentions time off work, you become frustrated and might say:
- “I can’t afford to be off work for weeks. Is there a way I can still do light duties?”
If the doctor suggests a referral to a specialist, you nod but seem worried, asking:
- “How long does that usually take? I don’t want to wait forever to get this sorted.”
If the doctor provides reassurance and a clear plan, you relax slightly and feel more confident in their advice.

Questions for the Candidate

You should naturally ask these questions during the consultation:

“Do you think it’s broken? Do I need an X-ray?”
“How long will it take to heal? Will I need a cast?”
“Can I still work with this, or will I need time off?”
“What can I do to stop this from happening again?”
“Do I need to see a specialist, or can this be managed here?”
“If it’s just a sprain, do I still need a brace or anything?”

Possible Responses to the Doctor’s Suggestions

If the Doctor Recommends an X-ray:

You nod in agreement and say:
- “Yeah, that makes sense. I’d rather know for sure.”
You feel relieved that they are taking it seriously.

If the Doctor Says It’s Likely Just a Sprain:

You look slightly unsure and say:
- “But what if it is broken and we don’t check? Won’t that make it worse?”
If they explain why imaging isn’t needed, you listen but remain cautious.

If the Doctor Recommends a Cast or Splint:

You sigh and shake your head, saying:
- “That’s going to make work really hard. Is there a way I can manage without it?”
If they explain the necessity, you reluctantly agree.

If the Doctor Recommends Time Off Work:

You seem frustrated, responding:
- “I really can’t afford to be off for weeks. Is there any way I can still do some light duties?”
If they suggest a medical certificate, you ask about workers’ compensation options.

If the Doctor Suggests a Referral to a Specialist:

You nod but look worried, asking:
- “How long will that take? I don’t want to be waiting forever.”
If they offer reassurance about follow-up care, you feel more at ease.

Final Behaviour and Conclusion

If the doctor explains things clearly and gives a solid plan, you feel reassured and say:
- “Alright, that sounds reasonable. I just want to make sure it heals properly.”
If they fail to provide clear answers, you might express doubt and push for more information.
You leave with a better understanding of your injury and what steps to take next.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history regarding the mechanism of injury, symptoms, and impact on function.

The competent candidate should:

Use open-ended questions to explore how the injury occurred, including the mechanism of injury (fall on outstretched hand), force of impact, and immediate symptoms.
Clarify the timing of pain, swelling onset, and whether the pain is worsening or improving.
Assess functional limitations, including difficulty gripping, lifting, or moving the wrist.
Ask about previous fractures, musculoskeletal injuries, or risk factors for poor bone health (osteoporosis, steroid use, smoking, alcohol consumption).
Explore work-related concerns, including duties that require wrist function, need for modified work, and compensation concerns.
Assess for red flag symptoms such as numbness, tingling, loss of movement, or severe deformity suggesting a displaced or open fracture.
Summarise key findings and address the patient’s concerns empathetically.

Task 2: Explain your assessment of the injury, including differential diagnoses and the need for imaging.

The competent candidate should:

Explain that a distal radius fracture (e.g., Colles’ fracture) is a primary concern, given the mechanism of injury and symptoms.
Discuss other differentials, including:
- Scaphoid fracture (risk due to fall on outstretched hand, tenderness in anatomical snuffbox).
- Wrist sprain (if no bony tenderness, mild swelling, and full range of motion).
- Ligament injury (e.g., scapholunate ligament injury) if there is pain on wrist extension or weight-bearing.
Explain that an X-ray is needed to confirm a fracture, as clinical assessment alone is insufficient.
Address concerns about whether an X-ray is urgent, advising that delaying imaging could lead to complications such as non-union in scaphoid fractures.
Provide clear, jargon-free explanations to ensure patient understanding.

Task 3: Provide an appropriate management plan, including pain relief, immobilisation, and referral if necessary.

The competent candidate should:

Offer pain relief options, such as paracetamol and ibuprofen, and explain when stronger analgesia (e.g., codeine) may be needed.
Explain the importance of immobilisation and apply a temporary splint (if available) to reduce movement and pain.
Arrange urgent X-ray imaging and ensure results are reviewed promptly.
Discuss the possible need for orthopaedic referral if the fracture is:
- Displaced (may require reduction or surgery).
- Intra-articular (risk of long-term joint dysfunction).
- A scaphoid fracture (may require a cast for 6-12 weeks).
Advise on activity restrictions, including avoiding heavy lifting or manual labour until the injury is assessed.
Provide safety-netting advice, including when to seek urgent care (worsening pain, numbness, increased swelling).

Task 4: Address the patient’s concerns, including return to work, recovery expectations, and injury prevention.

The competent candidate should:

Explain that recovery time depends on the severity of the injury, but a simple wrist fracture may take 4-6 weeks to heal.
Discuss modified duties, including the possibility of light office work or avoiding heavy lifting.
Provide workplace documentation if required, such as a medical certificate or workers’ compensation form.
Educate on preventing future injuries, such as:
- Wrist guards for high-risk activities (e.g., sports, construction work).
- Strength and flexibility exercises after healing.
- Safe work practices (avoiding heavy lifting with one hand, using proper ergonomics at work).
Offer follow-up in one week to review imaging results and reassess pain and function.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive history, assessing mechanism of injury, symptoms, function, and work impact.
Identifies key differentials, explaining the need for X-ray imaging and possible orthopaedic referral.
Provides appropriate pain management and immobilisation, ensuring patient comfort and safety.
Addresses return to work concerns, offering realistic recovery expectations and injury prevention advice.
Uses clear communication and empathy, ensuring patient understanding and engagement.

PITFALLS

Failing to take a detailed history, missing red flags such as numbness, weakness, or deformity.
Not considering a scaphoid fracture, which requires specific examination and may not be visible on initial X-ray.
Inadequate explanation of imaging necessity, leading to patient uncertainty or non-compliance.
Providing inappropriate reassurance, such as suggesting it is ‘just a sprain’ without proper assessment.
Not considering workplace and compensation concerns, leaving the patient without appropriate documentation or advice.
Failure to offer follow-up, risking missed complications or delayed recovery.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

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

1. Communication and Consultation Skills

1.1 Communicates clearly and effectively with the patient regarding injury assessment and management.
1.2 Provides patient-centred education on the injury, prognosis, and recovery expectations.
1.3 Addresses concerns empathetically, ensuring patient understanding of treatment and follow-up.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history, including mechanism of injury, symptoms, and functional impact.
2.2 Interprets clinical findings to determine fracture severity and need for imaging.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between simple and complex fractures and determines appropriate management.
3.2 Identifies red flags that may require urgent referral (e.g., neurovascular compromise, open fracture).

4. Clinical Management and Therapeutic Reasoning

4.1 Provides initial fracture care, including pain management and immobilisation.
4.2 Advises on appropriate follow-up with imaging, orthopaedic referral, or emergency escalation if needed.

5. Preventive and Population Health

5.1 Discusses injury prevention strategies, particularly in occupational or sports settings.

6. Professionalism

6.1 Demonstrates ethical and professional conduct in decision-making and patient interactions.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures proper documentation and compliance with workplace injury or compensation requirements.

8. Procedural Skills

8.1 Provides or arranges appropriate immobilisation (e.g., splinting, buddy taping, or referral for casting).

9. Managing Uncertainty

9.1 Recognises when specialist referral is required and provides appropriate safety-netting advice.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises signs of complications, including infection, compartment syndrome, or non-union.

Competency at Fellowship Level

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