AKT – Musculoskeletal presentations (Orthopaedics)

Jason Turner, aged 41, presents with right knee pain following a twisting injury while playing social soccer three days ago. He reports that the knee ‘gave way’ and he heard a ‘pop’ at the time of injury. Since then he has had swelling, difficulty bearing weight and limited knee movement. He denies any prior knee injuries.

There is a moderate knee effusion and limited range of movement. Lachman test is positive, McMurray’s test is negative.

What is the MOST likely diagnosis?

Elizabeth Moore, aged 68, presents with progressive thoracic back pain and height loss over the past 6 months. She denies trauma. She has a history of rheumatoid arthritis, treated with long-term prednisone.

On examination, she has mid-thoracic spinal tenderness and reduced thoracic spine mobility. She has developed a mild kyphosis. X-ray shows reduced vertebral body height at T7 and T8.

What is the MOST likely cause of her symptoms?

Michael Jovanovic, aged 29, presents with lower back pain radiating down his left leg to below the knee for the past 2 weeks. The pain started after lifting a heavy box at work. He reports tingling in his foot and finds prolonged sitting worsens the pain.

On examination, straight leg raise is positive at 40 degrees on the left. There is reduced ankle reflex on the left and diminished sensation over the lateral foot.

What is the MOST appropriate initial management?

Sophie Nguyen, aged 12, presents with right-sided heel pain that worsens with running and jumping. She plays netball five days a week. Her pain has been present for two months and is gradually worsening. There is tenderness over the posterior aspect of the calcaneus. She has no systemic symptoms.

What is the MOST likely diagnosis?

John Wallace, aged 73, presents with right shoulder pain and difficulty raising his arm above shoulder height, which developed after a fall one week ago. He reports a ‘tearing’ sensation at the time and has since had difficulty combing his hair or reaching overhead. There is weakness in abduction and active range is limited, but passive range is preserved.

X-ray of the shoulder is normal.

What is the MOST likely diagnosis?

Chloe Harper, aged 9, presents with a limp that has gradually developed over the last 3 weeks. She denies trauma and reports intermittent right hip and knee pain, worse at the end of the day. She is otherwise well and afebrile. On examination, there is limited internal rotation of the right hip. X-ray of the pelvis shows widening and irregularity of the right femoral epiphysis.

What is the MOST likely diagnosis?

Kevin Daniels, aged 52, presents with pain at the lateral side of his right elbow for 2 months. He works as a carpenter and reports pain when gripping objects or using a screwdriver. Examination reveals tenderness over the lateral epicondyle and pain on resisted wrist extension.

What is the MOST likely diagnosis?

Sarah Taylor, aged 63, presents with bilateral shoulder and hip stiffness lasting over 1 hour in the morning. She also complains of fatigue and recent onset of mild depression. She has difficulty rising from chairs and combing her hair. On examination, there is reduced active movement of both shoulders due to pain but no joint swelling.

What is the MOST appropriate initial investigation?

Peter Zhong, aged 37, presents with sudden onset severe left ankle pain and swelling that started overnight. He denies trauma. He has a history of hypertension and drinks 3–4 standard drinks most nights. On examination, the ankle is warm, erythematous and exquisitely tender. Joint aspiration reveals needle-shaped negatively birefringent crystals.

What is the MOST likely diagnosis?

Emily Waters, aged 17, presents with chronic anterior knee pain that worsens with squatting, stair climbing and prolonged sitting. She is active in netball and running. Examination shows a positive Clarke’s test and mild patellar maltracking.

What is the MOST likely diagnosis?

Mark Benson, aged 60, presents with a 4-week history of right shoulder pain and stiffness. He denies trauma. He finds it difficult to put on his shirt and reach overhead. Examination reveals global reduction in both active and passive range of motion, particularly external rotation. There is no significant tenderness.

What is the MOST likely diagnosis?

Amira Khan, aged 34, presents with pain and swelling in her right wrist for the past 6 weeks. She also has stiffness in the morning lasting over an hour. On examination, there is synovitis of the right wrist and 2nd and 3rd MCP joints bilaterally.

What is the MOST appropriate initial investigation?

Jacob Wilson, aged 45, presents with chronic lower back pain for the past 9 months. He reports morning stiffness lasting over 45 minutes and improvement with activity. His pain is worse at night and improves with a hot shower. Examination shows reduced lumbar flexion and positive Schober’s test.

What is the MOST likely diagnosis?

Alison Rogers, aged 71, presents with progressive bilateral hand stiffness and pain. It predominantly affects the distal interphalangeal joints. She also reports bony enlargements of her fingers. On examination, there are bony swellings over the DIP joints and crepitus on movement.

What is the MOST likely diagnosis?

Tommy Wallace, aged 4, presents with a limp for the past week. He has no fever and has been otherwise well. He had a mild upper respiratory infection two weeks ago. Examination reveals a well-appearing child with mild limitation of hip internal rotation on the left but no significant tenderness. X-ray is normal.

What is the MOST likely diagnosis?

Julie Renwick, aged 57, presents with pain in the base of her right thumb that has been progressively worsening over the last 6 months. She reports difficulty opening jars and turning keys. Examination reveals tenderness at the 1st carpometacarpal joint and a positive grind test.

What is the MOST likely diagnosis?

Nathan Wells, aged 25, presents after falling from his skateboard and landing on his outstretched right hand. He reports wrist pain and tenderness in the anatomical snuffbox. X-ray appears normal.

What is the MOST appropriate next step?

Linda Thomas, aged 49, presents with pain and swelling at the posterior aspect of her heel. She has recently started a new exercise program involving running and step aerobics. On examination, there is tenderness and swelling at the Achilles tendon insertion and a palpable thickening of the tendon.

What is the MOST likely diagnosis?

James O’Malley, aged 36, presents with neck pain and stiffness following a rear-end motor vehicle accident 2 days ago. He denies loss of consciousness, neurological symptoms or head injury. Examination shows midline cervical tenderness but normal neurological exam and no focal deficits.

According to the Canadian C-Spine Rule, what is the MOST appropriate next step?

Emily Dawson, aged 32, presents with pain over the lateral aspect of her hip, worse when lying on that side or climbing stairs. She has no low back pain. On examination, there is tenderness over the greater trochanter and pain reproduced with resisted hip abduction.

What is the MOST likely diagnosis?

Angela Rees, aged 50, presents with pain and numbness in the right hand that wakes her at night. She reports dropping objects and tingling in the thumb, index and middle fingers. Tinel’s and Phalen’s tests are positive.

What is the MOST likely diagnosis?

Tom Gregson, aged 67, presents with acute onset of right shoulder pain after lifting a heavy bag. He has limited active abduction and weakness, but passive movement is preserved. There is no history of prior shoulder issues. Ultrasound confirms a full-thickness supraspinatus tear.

What is the MOST appropriate initial management?

Harriet Young, aged 79, presents following a fall at home. She reports left hip pain and inability to bear weight. Examination shows shortened and externally rotated left leg. X-ray confirms a displaced intracapsular femoral neck fracture.

What is the MOST appropriate next step in management?

Nina Dawson, aged 14, presents with anterior knee pain that worsens with running and jumping. She has prominent tibial tuberosities bilaterally and tenderness over the tibial tubercle. She plays school basketball and soccer.

What is the MOST likely diagnosis?

Douglas Yee, aged 58, presents with chronic mid-back pain. He describes the pain as dull and aching, worse at night, and not relieved by rest. He has a history of prostate cancer. Examination reveals localised tenderness at T9 without neurological signs.

What is the MOST appropriate next investigation?

Leah Monaghan, aged 44, presents with left lateral elbow pain that started after increasing her gym training. Pain is aggravated by lifting weights and opening jars. Examination reveals tenderness 2 cm distal to the lateral epicondyle and pain on resisted supination.

What is the MOST likely diagnosis?

Benjamin Reilly, aged 62, presents with right knee pain and swelling after a minor twisting injury. He reports episodes of locking and catching. On examination, joint line tenderness is noted and McMurray’s test is positive.

What is the MOST likely diagnosis?

Julia Carr, aged 39, presents with a 3-month history of right heel pain that is worst with the first steps in the morning and after prolonged standing. Examination reveals point tenderness at the medial calcaneal tuberosity.

What is the MOST likely diagnosis?

Carlos Jimenez, aged 48, presents with sudden pain and swelling in the left great toe overnight. He had a few beers the previous evening. On examination, the toe is red, hot and tender. Joint aspiration shows needle-shaped negatively birefringent crystals.

What is the MOST appropriate acute management?

Olivia Bennett, aged 33, presents with bilateral wrist pain and morning stiffness for 6 weeks. She has swelling of the MCP and PIP joints bilaterally. She has no rash or systemic features. ESR and CRP are elevated, and anti-CCP antibodies are positive.

What is the MOST likely diagnosis?

Liam Shore, aged 8, presents with right arm pain after falling off a playground slide. Examination reveals swelling and tenderness over the mid-humerus. X-ray shows a spiral fracture of the humeral shaft.

What additional finding should be assessed MOST carefully?

Steven Doyle, aged 70, presents with bilateral foot pain and deformity. He has a long history of poorly controlled type 2 diabetes. Examination shows midfoot collapse, warmth, swelling, and loss of arch in the right foot. X-ray reveals joint destruction and subluxation at the tarsometatarsal joints.

What is the MOST likely diagnosis?

Kate Wallace, aged 26, presents with right knee pain after being struck on the lateral aspect while playing hockey. She reports immediate swelling and inability to bear weight. Lachman and anterior drawer tests are negative, but valgus stress reproduces pain and reveals laxity.

What is the MOST likely diagnosis?

Brian Xu, aged 30, presents with pain in the right forearm and wrist after a fall from a motorbike. On examination, he has a visible deformity at the distal radius, with the hand displaced dorsally and radially. X-ray confirms a displaced distal radius fracture with dorsal angulation.

What is the MOST appropriate initial management?

Alana Tran, aged 35, presents with right lateral foot pain after inverting her ankle while trail running. She is tender over the base of the 5th metatarsal. X-ray confirms an avulsion fracture at the tuberosity of the 5th metatarsal.

What is the MOST likely diagnosis?

Sharon Pike, aged 56, presents with longstanding joint pain affecting the knees and hips. She reports stiffness after inactivity that resolves within 5 minutes. Examination shows reduced range of motion in both hips and crepitus in the knees. X-rays reveal joint space narrowing and osteophyte formation.

What is the MOST likely diagnosis?

Samira Nasri, aged 45, presents with chronic neck and shoulder pain radiating down her right arm. She also reports numbness in the thumb and index finger. Spurling’s test reproduces her symptoms. Reflexes are intact. MRI shows disc herniation at C5/C6.

What is the MOST appropriate initial management?

Daniel Huang, aged 52, presents with pain and swelling in the left knee. He reports a similar episode a year ago in the same joint. Joint aspiration reveals rhomboid-shaped positively birefringent crystals. X-ray shows chondrocalcinosis.

What is the MOST likely diagnosis?

Ellie Martin, aged 27, presents with pain and tingling in her right hand after prolonged cycling. She reports numbness in the 4th and 5th fingers. Tinel’s sign is positive over Guyon’s canal.

What is the MOST likely diagnosis?

Phillip O’Neill, aged 74, presents with persistent lower back pain and weight loss over the past two months. He has a history of multiple myeloma. On examination, there is localised tenderness over the lumbar spine. X-ray shows lytic lesions in the vertebrae.

What is the MOST likely cause of his symptoms?

Claire Hewitt, aged 43, presents with lower back and buttock pain that alternates sides and is worse in the morning. She reports stiffness lasting over 30 minutes and improvement with activity. Examination shows reduced lumbar flexion and positive sacroiliac stress tests. HLA-B27 is positive.

What is the MOST likely diagnosis?

Brandon Young, aged 16, presents with sudden knee pain and swelling after jumping during basketball. He reports feeling a ‘pop’ and now struggles to extend the knee. Examination shows a high-riding patella and palpable gap below the patella.

What is the MOST likely diagnosis?

Gavin Russell, aged 50, presents with left wrist pain and reduced grip strength. He is a long-distance cyclist. Tinel’s sign at the wrist is negative. There is decreased sensation over the dorsal ulnar hand and weakness of interossei muscles.

What is the MOST likely site of nerve compression?

Naomi Fielding, aged 58, presents with gradually worsening right groin pain aggravated by activity. She reports stiffness after rest. Examination reveals pain on internal rotation of the hip and reduced flexion. X-ray shows joint space narrowing and subchondral sclerosis of the hip.

What is the MOST likely diagnosis?

Amelia Haddon, aged 32, presents with sharp right foot pain when pushing off while walking. Examination reveals tenderness between the second and third metatarsal heads. There is no swelling or erythema. Pain is worse in tight shoes.

What is the MOST likely diagnosis?

Lucas Phan, aged 6, presents with left arm pain after falling onto an outstretched hand. There is swelling and tenderness at the distal humerus. X-ray shows a supracondylar fracture. His hand is pale with delayed capillary refill.

What is the MOST urgent complication to assess for?

Ella Sadiq, aged 31, presents with right foot pain after increasing her running distance. The pain is localised over the second metatarsal shaft and worsens with weight-bearing. X-ray is initially normal.

What is the MOST likely diagnosis?

Robert Black, aged 64, presents with sudden pain and weakness in his right upper arm after lifting a heavy object. He reports a snapping sound at the time. Examination reveals a bulge in the mid-upper arm and weakness on supination.

What is the MOST likely diagnosis?

Stephanie Riggs, aged 36, presents with chronic bilateral foot pain and fatigue. She has a history of psoriasis. Examination shows swelling of multiple DIP joints and a sausage-like appearance of the second toe. CRP is elevated.

What is the MOST likely diagnosis?

Marcus Trinh, aged 28, presents with left ankle pain after landing awkwardly while playing soccer. He has swelling and bruising around the lateral malleolus. X-ray shows no fracture. He can bear weight but with discomfort.

What is the MOST appropriate initial management?