 13 Musculoskeletal SBA

September 2021

The Royal College of

Emergency Medicine

MRCEM INTERMEDIATE SBA

SEPTEMBER 2021

13 Musculoskeletal
SBA

Collected by Dr. Haitham Khalil September 2021

 Musculoskeletal  QUESTION 1

A 40 year old man attends the Emergency Department with a 2 week history of low back pain and shooting pains
radiating down his left leg to the foot. On examination you note altered sensation over the lateral left foot and mild
weakness of left ankle plantarflexion. You suspect his symptoms are due to disc herniation. Given his symptoms, at
what level is the herniation?

L1/L2 3%

x L2/L3 2%

L3/L4 9%

L4/L5 22%

✓ L5/S1 64%

ANSWER
An L5/S1 disc prolapse will tend to cause pressure on the S1 nerve root which will give this clinical picture.
 Musculoskeletal  QUESTION 2

A 61 year old man presents to the Emergency Department feeling unwell, with a
hot, red, grossly swollen, painful right knee which has developed over the last 24
hours. He has very limited range of movement due to pain and a large joint
effusion on examination. He denies any history of trauma. No other joints are
involved. His observations are recorded as:
Heart rate: 98 beats per minute
Blood pressure: 128/85 mmHg
Respiratory rate: 16 breaths per minute
Saturations: 95% on air
Temperature: 38.5°C
What is the diagnosis?

Gout 2%

x Bursitis 3%

✓ Septic arthritis 90%

Reactive arthritis 2%

Haemarthrosis 3%

ANSWER
Septic arthritis:

Pain and swelling are the most common symptoms. The commonest reported site of isolated
septic arthritis is the knee.
Septic joints will be held in a position of maximum joint volume: fully extended knee; hip
abducted, flexed, and externally rotated.
Positively identify an intra-articular effusion (not just surrounding soft-tissue swelling).
Localised swelling external to the joint suggests bursitis rather than septic arthritis.
Passive and active movement of the joint will be limited and very painful in septic arthritis. In
practice, most patients with septic arthritis of a weight-bearing joint will not be able to walk.
Fever, chills, and rigors may be present in some patients.
 Musculoskeletal  QUESTION 3

A 14 year old boy is brought to the Emergency Department complaining of left knee
pain. He is a keen rugby player and trains three times a week. He explains that over the
last month he has noticed mild knee pain "at the front of the knee" when playing rugby
but over the last 2 days this has become more severe and constant. He cannot recall
any history of trauma. On examination you note a slight antalgic gait. He has a full,
unrestricted range of movement of the knee. He is tender over the tibial tuberosity,
with pain on extension against resistance. What is the diagnosis?

Perthes' disease 3%

✓ Osgood-Schlatter disease 77%

x Sever's disease 7%

Osteochondritis dissecans 8%

Chondromalacia patellae 6%

ANSWER

Osgood-Schlatter disease
An overuse injury with multiple small avulsion fractures within the ossification centre
(apophysis) of the tibial tuberosity at the inferior attachment of the patellar ligament caused by
forceful contractions of the quadriceps muscles.
It is a usually self-limiting disorder causing anterior knee pain during adolescence, particularly
in children active in sport. Symptoms typically settle over weeks or months but occasionally
may persist for 1–2 years, before resolving completely in 90% of people.
Knee pain is typically unilateral (but may be bilateral in up to 30% of people), gradual in onset
(initially mild and intermittent progressing to severe and continuous), relieved by rest and made
worse by kneeling and activity. On examination there may be tenderness over the tibial
tuberosity and firm or bony enlargement of the tibial tuberosity.
X-ray is not required routinely but if undertaken, knee X-ray may be normal or may demonstrate
anterior soft tissue swelling, fragmentation of the tibial tubercle, or rarely a persistent bony
ossicle may be visible after fusion of the tibial epiphysis.

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 Musculoskeletal  QUESTION 4

A 69 year old woman, with known rheumatoid arthritis, presents to the Emergency Department with
worsening pain in both her hands. What is most obvious abnormality seen?

Boutonniere’s deformity 15%

Heberden's nodes 1%

✓ Swan-neck deformity 80%

Z deformity of the thumb 1%

Bouchard's nodes 3%

ANSWER
Hand signs of rheumatoid arthritis:

Joint swelling, redness and heat – particularly MCPJs, PIPJs

Subluxation and ulnar deviation at MCPJs
Boutonniere’s deformity (PIPJ hyperflexion and DIPJ hyperextension)
Swan-neck deformity (PIPJ hyperextension and DIPJ flexion)
Z deformity of the thumb (IPJ hyperextension and MCPJ fixed flexion and subluxation)
Bowstring sign (tendons appear prominent and stretched across a shrunken carpus)
Inability to make a fist or flex fingers
Positive metacarpophalangeal squeeze test - pain on squeezing the metacarpophalangeal or metatarsophalangeal
joints together
 Musculoskeletal  QUESTION 5

A 27 year old man presents to the ED with a 4 month history of progressively

worsening low back pain. He tells you a few years ago he was investigated for some
episodes of back pain, but was lost to follow-up. He is complaining of lower back pain
which wakes him at night, and is particularly bad in the morning. He also describes
stiffness in the morning lasting for about 1 hour. What is the most likely diagnosis?

Osteoarthritis 4%

Spinal stenosis 3%

x Polymyalgia rheumatica 11%

✓ Ankylosing spondylitis 77%

Intervertebral disc prolapse 4%

ANSWER
Suspect ankylosing spondylitis in anyone with chronic or recurrent low back pain, fatigue, and
stiffness, especially if:

The person is 45 years of age or younger.

The back pain has been present for more than 3 months.
Back pain and stiffness is inflammatory (rather than mechanical) and worse in the morning (lasting
for more than 30 minutes), improving with movement.
They have current or previous:
Buttock pain — sometimes on one side and sometimes on the other.
Pain in the thoracic or cervical spine.
Arthritis, predominantly asymmetric and peripheral.
Enthesitis.
Anterior uveitis — this presents as an acutely painful red eye with photophobia or blurred
vision.
Psoriasis or inflammatory bowel disease, or genitourinary infection.
Symptoms wake them in the night (particularly during the second half).
Symptoms respond to a course of nonsteroidal anti-inflammatory drugs (NSAIDs) within 48 hours.
There is a family history of ankylosing spondylitis or spondyloarthritis.
Other conditions with similar presentations have been excluded.
 Musculoskeletal  QUESTION 6

A 49 year old woman who works as a receptionist presents to the

Emergency Department with a 2 month history of pain in her right hand and
thumb weakness. She describes "shooting pains" in her thumb, index and
middle finger which have increased in frequency. She has noticed weakness
of the thumb for the last 3 weeks and on occasion the first three fingers
feeling "numb". On examination you note wasting of the thenar eminence
and weakness of thumb abduction. Which nerve or nerve root is affected?

C6 8%

C8 3%

✓ Median nerve 83%

x Radial nerve 3%

Ulnar nerve 3%

ANSWER
Carpal tunnel syndrome (CTS) is a collection of symptoms and signs caused by compression of
the median nerve in the carpal tunnel at the wrist. The carpal tunnel is an anatomical
compartment bounded on three sides by carpal bones and on the palmar side by the transverse
carpal ligament. It contains the median nerve and the flexor tendons. Reduction in the
dimensions of the carpal tunnel or increase in the volume of its contents produce an
intermittent or sustained high pressure in the tunnel which causes ischaemia of the median
nerve and impairs nerve conduction leading to paraesthesia, pain and decreased function of
the nerve. If pressure on the nerve is continued this can lead to segmental demyelination with
more constant and severe symptoms which are in some cases associated with muscle
weakness and wasting. Nerve dysfunction may become irreversible if axonal injury secondary
to prolonged ischaemia occurs.
 Musculoskeletal  QUESTION 7

A 10 year old boy is brought to the Emergency Department by his mother. She has noticed an increasingly
severe limp over the last 2 months. The child complains of pain in the left hip region. On examination you
note a limp. He is systemically well with normal observations. A pelvic x-ray is performed. What is the
diagnosis?

Pathological fracture of proximal femur 3%

✓ Perthes' disease 69%

x Slipped upper femoral epiphysis (SUFE) 22%

Osteomyelitis 3%

Osteomalacia 3%

ANSWER

Perthes' disease (also called Legg-Calve-Perthes' disease)

An idiopathic avascular necrosis of the developing femoral head. It is more common in boys than in girls.
Onset is usually over weeks, and the child will typically present with limitation of hip rotation and a subacute limp
sometimes with referred pain to the groin, thigh, or knee. It is typically unilateral, though bilateral involvement is present in
10% of cases. The child is systemically well with no other joint involvement and no evidence of joint inflammation.
X-ray changes are progressive; early imaging may show widening of the joint space (the best view is frog-leg lateral). Later
there is a decrease in size of the femoral head with patchy density and and later still, there may be collapse and deformity
of the femoral head with new bone formation.
Most children with Perthes' disease have good outcomes, but long-term complications may include chronic pain and
osteoarthritis.
 Musculoskeletal  QUESTION 8

A 46 year old carpet fitter presents to the Emergency Department complaining of a large swelling
over his left knee, he is finding it difficult to kneel at work. He has no past medical history and is
otherwise well. On examination you note a large, erythematous swelling over the left knee . He is
able to fully flex his knee and it is relatively pain-free. What is the most likely diagnosis?

Septic arthritis 7%

Cellulitis 1%

x Ruptured Baker's cyst 13%

✓ Prepatellar bursitis 77%

Ligamentous injury 2%

ANSWER
Also known as ‘housemaid’s knee’ this condition tends to affect people who kneel down whilst they work. The patient is
able to flex his knee and may still be relatively pain-free, which makes septic arthritis less likely. The photograph shows a
tense extra-articular swelling superficial to the patella with some overlying erythema. This is an inflammatory bursitis – the
WCC is likely to be normal and it is treated with anti-inflammatories, elevation and avoidance of the activity which
precipitates it (i.e. kneeling). A bursitis may be infected, especially after breaks in the skin and may need antibiotics and
surgical drainage.
 Musculoskeletal  QUESTION 9

A 72 year old man presents to the Emergency Department with leg

weakness and urinary retention. He complains of intermittent lumbar back
pain over the past 2 years but associated this with his previous employment
as a builder. In the last 24 hours the back pain has become severe. He has a
past medical history of prostate cancer. You catheterise him and record a
residual volume of over 1000 mL. Which of the following is the most useful
initial investigation?

Computed tomography (CT) of the abdomen/pelvis 6%

Lumbar X-rays 7%

✓ Magnetic resonance imaging (MRI) of the lumbar spine 80%

x Serum calcium 4%

Ultrasound scan (USS) of the renal tract 4%

ANSWER
This man is presenting with advanced signs of spinal cord compression. Initially this may
present with sensory deficit and weakness, and progress to bladder and bowel disturbance.
Spinal cord compression needs to be considered in any patient presenting with acute back
pain, but a higher index of suspicion is required in patients with known malignancy as
metastases to the spine may be a cause. Spinal cord compression is an emergency that
requires prompt diagnosis to prevent lasting deficit and therefore an urgent MRI is appropriate
to visualise the lesion and extent of compression. MRI is a better medium than CT scan as it
allows better visualisation of the soft tissues of the spinal cord. Treatment will depend on the
cause but may include urgent referral for neurosurgery.

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 Musculoskeletal  QUESTION 10

A 34 year old man presents to the Emergency Department with a two week
history of pain in the right foot. He denies any trauma and is otherwise well.
He describes the pain as being over the medial aspect of the heel, worse on
weight-bearing and particularly bad in the morning. What is the most likely
diagnosis?

Compartment syndrome 2%

Foot sprain 4%

x Osteoarthritis of the ankle 11%

Achilles tendonitis 12%

✓ Plantar fasciitis 72%

ANSWER

Plantar fasciitis can occur spontaneously or as a chronic overuse injury. Inflammation

develops in the plantar fascia, typically at its calcaneal insertion.
This results in gradually increasing burning pain in the sole of the foot and heel, which is
worse on weight-bearing. The pain is often worst when you take your first steps on
getting up in the morning, or after long periods of rest where no weight is placed on your
foot.
Examine for localised tenderness over the calcaneal insertion of the plantar fascia and
heel pad.
X- ray may reveal a calcaneal spur, but this is not a useful diagnostic feature.
Advise NSAID, rest, and elevation for 1– 2 days, with GP follow-up. A padded shoe insole
or sorbothane heel pad may help. Severe, persistent cases are occasionally treated with
local steroid injection or even surgical division of the plantar fascia.

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Musculoskeletal  QUESTION 11 >

A 45 year old woman presents to the Emergency Department with a 2 week

history of increasing back pain on the background of several years of lower
back pain. Whilst assessing the patient you are considering whether the
patient has features of cauda equina syndrome. Which of the following is
NOT a typical feature of cauda equina syndrome?

Distended bladder 13%

Reduced anal tone 2%

Reduced reflexes in the ankles 17%

x Saddle anaesthesia 2%

✓ Upgoing plantars 66%

ANSWER
The spinal cord ends with the conus medullaris around L2–L3, below which the dural sac
simply contains the cauda equina, nerve roots that will exit at the lower lumbar and sacral
spine. Saddle anaesthesia is due to compression of the sensory fibres leaving the spine at S3–
S5. The bladder may be distended as detrusor motor paralysis and sensory loss leads to urinary
retention. The lower motor neuron nature of the weakness reduces the anal tone, and may lead
to reduced or absent ankle reflexes. The plantars would be expected to be downgoing,
however. Plantars may be upgoing if there was compression higher up the spine, however there
would not be the constellation of other signs mentioned here.

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 Musculoskeletal  QUESTION 12

A 29 year old man presents to the Emergency Department with a fever and a red, hot, swollen, painful knee. You
suspect septic arthritis. What is the most likely causative pathogen?

Streptococcus pyogenes 5%

Staphylococcus epidermidis 2%

✓ Staphylococcus aureus 73%

x Neisseria meningitidis 2%

Neisseria gonorrhoea 18%

ANSWER
Staphylococcus aureus infection is the most common cause of septic arthritis.

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 Musculoskeletal  QUESTION 13

A 60 year old man attends the Emergency Department with a painful left knee. He denies any trauma. He tells you it is
painful to walk on and becomes stiff after sitting for a period. An x-ray is performed at triage. You are considering the
diagnosis of osteoarthritis. Which of the following is a NOT a typical feature of osteoarthritis on x-ray?

Subchondral sclerosis 5%

Osteophyte formation 2%

Bony cyst formation 31%

x Loss of joint space 3%

✓ Chondrocalcinosis 59%

ANSWER
Typical radiological features of osteoarthritis include:

Subchondral bone thickening (sclerosis) and/or cysts

Osteophyte formation (new bone formation at joint margins)
Loss or narrowing of the joint space (provides an estimate of the severity of cartilage damage).
Note: structural changes on X-ray may not correlate with reported symptoms and functional impairment.
 Musculoskeletal  QUESTION 14

A 35 year old known intravenous drug user (IVDU), presents to the

Emergency Department complaining of feeling generally unwell with low
back pain which is worse at night and which has been progressively
worsening over the last couple of weeks. On examination he has midline
tenderness to gentle spinal percussion over vertebrae L4/L5. His
observations are recorded as:
Heart rate: 105 beats per minute
Blood pressure: 123/98 mmHg
Respiratory rate: 25 breaths per minute
Temperature: 39.1°C
What is the most likely diagnosis?

✓ Spinal epidural abscess 88%

Spinal fracture 3%

Spinal malignancy 2%

x Ankylosing spondylitis 5%

Paget’s disease 3%

ANSWER
Most cases of epidural abscess arise from haematogenous seeding of the epidural space from
a distant source of infection. A few cases are the result of direct extension of infection from
the spine or paraspinal tissues. A spinal epidural abscess threatens the spinal cord or cauda
equina by compression and also by vascular compromise. If untreated, an expanding
suppurative infection in the spinal epidural space impinges on the spinal cord, producing
sensory symptoms and signs, motor dysfunction, and, ultimately, paralysis and death.
 Musculoskeletal  QUESTION 15

A 56 year old man presents to the Emergency Department with an acutely painful right great toe. He denies trauma
and is otherwise well. He has a past medical history of insulin dependant diabetes and severe heart failure secondary
to a previous myocardial infarction. On examination you find the area over the right metatarsophalangeal joint is
warm and erythematous. How should this patient be managed?

Oral allopurinol 3%

Oral paracetamol 5%

Oral corticosteroids 5%

x Oral NSAIDs 28%

✓ Oral colchicine 58%

ANSWER
NSAIDs are contraindicated in this patient due to his severe heart failure. Colchicine is a useful alternative in patients in whom NSAIDs are
contraindicated, not tolerated or ineffective. Although its use is limited by toxicity at higher doses, it is useful in patients with heart failure or
those taking anticoagulants.
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Musculoskeletal  QUESTION 16 >

A 74 year old man presents to the Emergency Department complaining of pain in his neck
that has been ongoing over the past week. He denies trauma. He has a past medical history
of hypertension and prostate cancer. On examination you find he has weakness of elbow
extension and loss of sensation over his middle finger. You suspect cervical radiculopathy.
Which nerve root is most likely affected?

C4 0%

C5 6%

x C6 17%

✓ C7 72%

C8 5%

ANSWER

Nerve Muscle Weakness Reflex Sensory Changes

Root Changes
C5 Shoulder abduction and flexion, Biceps Lateral arm
Elbow flexion
C6 Elbow flexion, Wrist extension Biceps, Lateral forearm, Thumb, Index finger
Supinator
C7 Elbow extension, Wrist flexion, Triceps Middle finger
Finger extension
C8 Finger flexion None Medial side lower forearm, Ring and
little fingers
T1 Finger abduction and adduction None Medial side upper forearm, Lower
arm

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Musculoskeletal  QUESTION 17 >

A 5 year old is brought to the Emergency Department by his parents. They

describe him limping yesterday but today refusing to bear weight on his left
leg. There is no history of trauma. He is flushed and febrile and you note the
left leg is in a flexed, abducted and externally rotated position. He is refusing
to let you move the leg. His full blood count shows:
Haemoglobin: 126 g/L
White cell count: 21 x 10⁹/L
What is the most likely diagnosis?

Transient synovitis 9%

✓ Septic arthritis 75%

Perthes' disease 7%

x Slipped upper femoral epiphysis 6%

Osteochondritis dissecans 3%

ANSWER
Septic arthritis is an infection of the synovium and joint space. It can present in any joint but
most commonly affects the lower limbs, and can lead to joint destruction, permanent loss of
joint function, and sepsis. Clinical features include refusal to bear weight and fever. There may
be evidence of joint inflammation.
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Musculoskeletal  QUESTION 18 >

A 37 year old man presents to the Emergency Department with a 1 day

history of back pain. He cannot recall any trauma. Whilst assessing the
patient you are considering whether the patient has features suggestive of
an infective cause. Which of the following features would make you suspect
an infective cause for the patient's symptoms?

Age < 40 years old 5%

✓ History of intravenous drug use 83%

x Sensory loss, or bladder or bowel dysfunction 3%

Pain in the thoracic or cervical spine 3%

Point tenderness over a vertebral body 6%

ANSWER

 Infection:
Fever
Tuberculosis, or recent urinary tract infection
Diabetes
History of intravenous drug use
HIV infection, use of immunosuppressants, or the person is otherwise
immunocompromised

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 Musculoskeletal  QUESTION 19

You have been asked to review a patient by a junior colleague, she thinks he may have gout. Gout most commonly
affects which joint?

Knee 3%

Elbow 1%

✓ Big toe 91%

x Ankle 3%

Wrist 2%

ANSWER
The most commonly affected joint is the big toe. It is also common in the midfoot, ankle, knee, fingers, wrist and elbow joints although can affect
any joint. Gout tends to attack joints in the extremities because temperatures in the feet and hands can be low enough to precipitate urate from
plasma. Thus tophi typically form in the helix of the ear, finger tips, olecranon bursae, and other cool anatomical sites.
 Musculoskeletal  QUESTION 20

A 65 year old man presents to the Emergency Department with a fever and
a 24 hour history of a red, hot, swollen painful knee which he is reluctant to
move due to pain. His blood results show:
Haemoglobin: 134 g/L
White cell count: 16.8 x 109/L
Platelets: 378 x 109/L
C reactive protein: 234 mg/L
A joint aspiration demonstrates the presence of Gram-positive cocci. Which
of the following antibiotics is most appropriate to start in this patient?

Intravenous ceftriaxone 13%

✓ Intravenous flucloxacillin 71%

x Intravenous co-amoxiclav 10%

Intravenous metronidazole 2%

Intravenous gentamicin 4%

ANSWER
The most common cause of septic arthritis is Staphylococcus aureus, which is consistent with
a finding of Gram-positive cocci. The first line treatment of septic arthritis with likely typical
organisms is with intravenous flucloxacillin. If gonococcal arthritis or Gram-negative infection
suspected, cefotaxime or ceftriaxone would be indicated.

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Musculoskeletal  QUESTION 21 >

A 57 year old man presents to the Emergency Department with a 4 day

history of back pain. He cannot recall any trauma. Whilst assessing the
patient you are considering whether the patient has features suggestive of
an inflammatory cause. Which of the following features would make you
suspect an inflammatory cause for the patient's symptoms?

Person ≥ 50 years of age 6%

Sudden onset severe central spinal pain which is relieved by lying down 8%

Structural deformity of the spine 5%

✓ Stiffness in the morning that is relieved with movement/exercise 73%

Pain aggravated by straining 8%

ANSWER

Inflammatory disease:
Age < 40 years old
Pain at night that is not relieved when the person is supine
Stiffness in the morning that is relieved with movement/exercise
Gradual onset of symptoms
Symptoms that have lasted for more than three months

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 Musculoskeletal  QUESTION 22

You have been asked to give a teaching session to junior colleagues on atraumatic joint pain. You are discussing
septic arthritis. What is the most common site of isolated septic arthritis?

Hip 6%

Shoulder 0%

Ankle 5%

✓ Knee 87%

Elbow 2%

ANSWER
The commonest reported site of isolated septic arthritis is the knee. The hip, shoulder, ankle, elbow, and wrist are also common sites of joint
infection.

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 Musculoskeletal  QUESTION 23

A 54 year old man presents to the Emergency Department after developing back pain whilst on holiday in Turkey. He
underwent a private MRI of the lumbar spine whilst abroad and it has shown disc herniation with involvement of the
L5 nerve root. Which of the following features would you expect with this finding?

Decreased or absent ankle jerk 15%

Decreased patellar reflex 8%

x Diminished sensation of the lateral small toe 18%

Impaired plantar flexion 15%

✓ Weakness of extension of the great toe 44%

ANSWER
Involvement of the L5 nerve root presents with weakness of extension of the great toe, decreased sensation in the first web space, and normal
reflexes. An S1 radiculopathy is characterised by diminished sensation of the lateral small toe, impaired plantar flexion, and decreased or absent
ankle jerk.
 Musculoskeletal  QUESTION 24

A 12 year old boy is brought to the Emergency Department complaining of knee pain and
limping. He has no past medical history and denies trauma. On examination you note an
antalgic gait of the right leg and the right knee is warm and swollen. His mother has noticed a
rash on his arm. What is the diagnosis?

Septic arthritis 5%

x Juvenile idiopathic arthritis 9%

✓ Lyme arthritis 80%

Osteochondritis dissecans 2%

Osgood-Schlatter disease 4%

ANSWER
Lyme arthritis is the second most common symptom to the classic rash associated with Lyme disease. In cases
where the erythema migrans rash (commonly called the bull’s eye rash) does not appear or goes unnoticed, Lyme
arthritis may be the first clinical sign. It typically presents without a fever. The child will bear partial weight and
present with a limp.
 Musculoskeletal  QUESTION 25

A 6 year old boy is brought to the Emergency Department by his parents. They tell you
he has been complaining of left hip pain and walking with a limp. He had been
diagnosed with transient synovitis by his GP but the pain has been progressively
worsening over the past 3 weeks. On examination his left hip is stiff and all
movements are limited. He is otherwise well and all other joints examine normally.
What is the most likely diagnosis?

Juvenile arthritis 16%

✓ Perthes' disease 49%

x Slipped upper femoral epiphysis (SUFE) 24%

Septic arthritis 9%

Osteomalacia 2%

ANSWER

Perthes' disease (also called Legg-Calve-Perthes' disease)

An idiopathic avascular necrosis of the developing femoral head. It is more common in boys
than in girls.
Onset is usually over weeks, and the child will typically present with limitation of hip rotation
and a subacute limp sometimes with referred pain to the groin, thigh, or knee. It is typically
unilateral, though bilateral involvement is present in 10% of cases. The child is systemically well
with no other joint involvement and no evidence of joint inflammation.
X-ray changes are progressive; early imaging may show widening of the joint space (the best
view is frog-leg lateral). Later there is a decrease in size of the femoral head with patchy
density and and later still, there may be collapse and deformity of the femoral head with new
bone formation.
Most children with Perthes' disease have good outcomes, but long-term complications may
include chronic pain and osteoarthritis.

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Musculoskeletal  QUESTION 26 >

A 74 year old man presents to the Emergency Department complaining of pain in his neck
that has been ongoing over the past couple of weeks. He denies trauma. He has a past
medical history of hypertension and prostate cancer. On examination you find he has
weakness of wrist extension and loss of sensation over his thumb. You suspect cervical
radiculopathy. Which nerve root is most likely affected?

C4 4%

C5 13%

✓ C6 63%

C7 14%

C8 7%

ANSWER

Nerve Muscle Weakness Reflex Sensory Changes

Root Changes
C5 Shoulder abduction and flexion, Biceps Lateral arm
Elbow flexion
C6 Elbow flexion, Wrist extension Biceps, Lateral forearm, Thumb, Index finger
Supinator
C7 Elbow extension, Wrist flexion, Triceps Middle finger
Finger extension
C8 Finger flexion None Medial side lower forearm, Ring and
little fingers
T1 Finger abduction and adduction None Medial side upper forearm, Lower
arm

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 Musculoskeletal  QUESTION 27

A 23 year old man presents to the Emergency Department with a 3 month

history of low back pain and stiffness. Which of the following would make you
consider ankylosing spondylitis as the diagnosis?

HLA-DR4 genotype 19%

Asymmetrical tenderness on palpation over the lumbosacral spine 12%

✓ Pain present on waking in the early morning 58%

x Scoliosis present on examination 8%

Pain worse after heavy lifting 3%

ANSWER
Suspect ankylosing spondylitis in anyone with chronic or recurrent low back pain, fatigue, and
stiffness, especially if:

The person is 45 years of age or younger.

The back pain has been present for more than 3 months.
Back pain and stiffness is inflammatory (rather than mechanical) and worse in the morning
(lasting for more than 30 minutes), improving with movement.
They have current or previous:
Buttock pain — sometimes on one side and sometimes on the other.
Pain in the thoracic or cervical spine.
Arthritis, predominantly asymmetric and peripheral.
Enthesitis.
Anterior uveitis — this presents as an acutely painful red eye with photophobia or
blurred vision.
Psoriasis or inflammatory bowel disease, or genitourinary infection.
Symptoms wake them in the night (particularly during the second half).
Symptoms respond to a course of nonsteroidal anti-inflammatory drugs (NSAIDs) within 48
hours.
There is a family history of ankylosing spondylitis or spondyloarthritis.
Other conditions with similar presentations have been excluded.
 Musculoskeletal  QUESTION 28

A 45 year old man presents to clinic with worsening lower back pain. The pain is worse in the
morning and improves throughout the day with exercise. The pain spreads to his buttocks and
is associated with stiffness. He recalls having this pain since he was in his early twenties, and
it has never resolved. What is the diagnosis?

Spinal stenosis 5%

Vertebral osteomyelitis 3%

✓ Ankylosing spondylitis 91%

Osteosarcoma 0%

Reiter’s syndrome 1%

ANSWER
Ankylosing spondylitis is suggested by X-ray changes of the sacroiliac joints and spine, including sacroiliitis, sclerosis
(thickening of bone), erosions, and partial or total ankylosis (fusion of joints). Bamboo spine is a pathognomonic
radiographic feature seen in ankylosing spondylitis that occurs as a result of vertebral body fusion by marginal
syndesmophytes. It is often accompanied by fusion of the posterior vertebral elements as well.
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Musculoskeletal  QUESTION 29 >

A 67 year old woman presents to the Emergency Department with a 2 day

history of back pain. She cannot recall any trauma. Whilst assessing the
patient you are considering whether the patient has features of a spinal
fracture. Which of the following features would make you suspect spinal
fracture?

Severe or progressive bilateral neurological deficit of the legs 21%

✓ Sudden onset severe central spinal pain which is relieved by lying down 62%

Aching night pain that prevents or disturbs sleep 10%

x Stiffness in the morning that is relieved with movement/exercise 3%

History of intravenous drug use 4%

ANSWER

Spinal fracture:
Sudden onset severe central spinal pain which is relieved by lying down
Major trauma such as RTA or fall from a height
Minor trauma, or even just strenuous lifting, in people with osteoporosis or those
on corticosteroids
Structural deformity of the spine
Point tenderness over a vertebral body

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Musculoskeletal  QUESTION 30 >

A 50 year old woman presents to the Emergency Department complaining

of worsening intermittent pain and tingling in her right thumb which is
waking her up at night. The symptoms are worse when driving. She has also
noted that her right thumb and index finger feel weak and she has difficulty
doing up buttons. What is the most likely diagnosis?

Raynaud’s phenomenon 3%

Multiple sclerosis 2%

✓ Carpal tunnel syndrome 85%

Osteoarthritis 4%

Ulnar nerve entrapment 7%

ANSWER
Typical symptoms of carpal tunnel syndrome include intermittent tingling, numbness or altered
sensation and burning or pain in the distribution of the median nerve (the thumb, index finger,
middle finger, and radial half of the ring finger). Symptoms are often worse at night and can
disrupt sleep. Symptoms may affect one or both hands. Pain in the hand may radiate up the
arm into the wrist or as far as the shoulder. The person may complain of loss of grip strength,
clumsiness and reduced manual dexterity for example when doing up buttons.

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 Musculoskeletal  QUESTION 31

A 14 year old boy is brought to the Emergency Department with a limp. He complains
of left hip and knee pain which has been increasing over the last 2 weeks. On
examination you note he is overweight and has an antalgic gait. You note the left leg is
held in external rotation, is shorter than the right leg and there is limited painful
passive internal rotation. What is the most likely diagnosis?

Perthes' disease 12%

Transient synovitis 4%

✓ Slipped upper femoral epiphysis (SUFE) 77%

x Septic arthritis 3%

Juvenile idiopathic arthritis 4%

ANSWER

Slipped upper femoral epiphysis (SUFE)

A displacement of the proximal femoral epiphysis from the metaphysis.
SUFE is slightly more common in boys than girls and in children who are overweight. It is
sometimes associated with endocrine abnormalities, such as hypothyroidism, and in children
being treated for growth hormone deficiency or with a history of radiotherapy treatment.
When there is sudden displacement of the epiphysis, the child presents with sudden onset of
severe hip pain with the leg held in external rotation. Gradual displacement of the epiphysis
may cause only mild discomfort of the hip or only referred knee pain. The child may walk with an
antalgic gait out-toeing, with shortening of the affected limb.
Anteroposterior and frog-leg lateral X-rays show widening of epiphyseal line or displacement of
the femoral head. The lateral x-ray is the best way to identify a subtle slip. Trethowan’s sign
seen on the AP view (and shown below) describes where a line (the line of Klein) drawn along
the superior border of the femoral neck passes above the femoral head, instead of intersecting
the femoral epiphysis as in the normal hip.
Prompt diagnosis and management is crucial to avoiding further displacement and the
development of avascular necrosis.

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 Musculoskeletal  QUESTION 32

A 42 year old man presents to the Emergency Department complaining of a severely painful big toe
which he woke up with this morning. On examination there is redness and swelling over the first
metatarsophalangeal joint. You note firm swellings in his pinna. He has a history of similar episodes of
joint pains. What is the diagnosis?

Septic arthritis 1%

Psoriatic arthritis 4%

x Reactive arthritis 5%

✓ Gout 82%

Pseudogout 8%

ANSWER

Arthritis
Swelling, redness, warmth, and pain on passive movement, typically of the first metatarsophalangeal joint, although
any joint can be affected.
Tophi
Firm, white nodules under translucent skin, usually occurring over extensor joint aspects such as the elbow or knee,
or achilles tendon. They can occur in other areas such as the helix of the ears or dorsum of hands or feet.
It usually takes at least 10 years after the first attack of acute gout for tophi to develop.
They are usually pain-free but can become inflamed, infected or ulcerated, or discharge white material.
 Musculoskeletal  QUESTION 33

A 53 year old lady is admitted to the acute medical unit with a painful knee. It is hot and
swollen. Her observations on admission include oxygen saturations of 96%, blood pressure
99/68 mmHg, temperature 38.1 degrees and heart rate 101 bpm. On examination there is
reduced movement on flexion and extension of the joint due to pain. She looks flushed and is
concerned because she has rheumatoid arthritis and is worried this is another flare. Which of
the following investigations would provide a definitive diagnosis for the above presentation?

Knee x-ray 2%

Blood uric acid levels 5%

x Blood cultures 4%

✓ Joint aspiration 78%

Erythrocyte sedimentation rate 12%

ANSWER

The patient most likely has septic arthritis.

Diagnostic joint aspiration & synovial fluid evaluation
Take a synovial fluid sample, bloods, and any other relevant culture samples before starting antibiotics,
unless this would cause undue delay.
Refer patients with a prosthetic joint or inaccessible joint to orthopaedics.
Only a specialist should manage suspected septic arthritis in a prosthetic joint, as the diagnostic
approach and management is significantly different to native joint infection, and may or may not
require surgery.
If the hip is involved, refer to orthopaedics immediately for ultrasound-guided joint aspiration and
possible surgical debridement.
Aspirate the joint through a closed-needle approach using sterile technique if it is safe and you have had
appropriate training and experience of this procedure.
Assess the colour, viscosity, and clarity of the joint aspirate to support/weaken your presumptive
diagnosis.
Aspirate to dryness. Repeat aspiration to dryness as often as is required: for pain relief, removing source
of sepsis and for diagnosis.
Send joint aspirate to the microbiology laboratory for urgent processing. Order:
Gram stain, microscopy, and white cell count
Polarising microscopy for crystals
Culture and sensitivities
White cell count is the first result available and is the most useful in differentiating between septic
arthritis and other diagnoses.
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Musculoskeletal  QUESTION 34 >

A 3 year old boy is brought to the Emergency Department with a 2 day history of limp.
He has no past medical history but did suffer with a viral upper respiratory tract
infection the previous week. You suspect a transient synovitis. Which of the following
is NOT part of Kocher's criteria suggesting an increased likelihood of a diagnosis of
septic arthritis instead?

Presence of fever > 38.5°C 5%

Child not weight-bearing on the affected side 11%

ESR > 40 mm/h 15%

x WCC > 12 x 10⁹/L 7%

✓ CRP > 50 mg/L 63%

ANSWER

Transient synovitis in children with hip pain

The Kocher criteria is a tool useful in the differentiation of septic arthritis from transient
synovitis in the child with a painful hip. A point is given for each of the four following criteria:
Kocher’s criteria:
History or presence of fever > 38.5°C
Child not weight-bearing on the affected side
ESR > 40 mm/h
WCC > 12 x 109/L
Score interpretation:
Score 1 - 3% likelihood of septic arthritis
Score 2 - 40% likelihood of septic arthritis
Score 3 - 93% likelihood of septic arthritis
Score 4 - 99% likelihood of septic arthritis
 Musculoskeletal  QUESTION 35

A 65 year old woman presents to the Emergency Department with painful swollen stiff fingers. Her fingers are
chronically painful, but have become worse over the past few days. She is currently only taking paracetamol for the
pain. What abnormality is seen?

Rheumatoid nodules 21%

Boutonniere’s deformity 8%

x Swan-neck deformity 8%

✓ Heberden’s nodes 62%

Z deformity 2%

ANSWER
Osteoarthritis clinical features:

Symptoms
Activity-related joint pain — typically only one or a few joints are affected at any one time, and pain develops over months or years, and
No morning joint-related stiffness, or morning stiffness lasting no longer than 30 minutes.
Signs
Bony swellings and joint deformities
Bouchard’s nodes (bony nodules on proximal interphalangeal joints)
Heberden’s nodes (bony nodules on distal interphalangeal joints)
Joint effusions
Joint warmth and/or tenderness
Muscle wasting and weakness
Restricted and painful range of joint movement
Joint crepitus
Joint instability
Antalgic gait
 Musculoskeletal  QUESTION 36

A 56 year old man presents to the Emergency Department with an acutely painful
right great toe. He denies trauma and is otherwise well. He has a past medical
history of hypertension and hypercholesterolaemia. On examination you find the
area over the right metatarsophalangeal joint is warm and erythematous. How
should this patient be managed?

Oral allopurinol 8%

Oral paracetamol 4%

Oral corticosteroids 7%

✓ Oral NSAIDs 79%

Intra-articular corticosteroids 3%

ANSWER

Acute attacks should be treated as early as possible (as soon as an attack occurs).
Pharmacological management
Prescribe either of the following first-line agents, provided that there are no
contraindications:
A nonsteroidal anti-inflammatory drug (NSAIDs) at a maximum dose as early as
possible, and continue the treatment until 1-2 days after the attack has resolved. Co-
prescribe a proton pump inhibitor (PPI) for gastric protection.
Oral colchicine.
Choice of first-line agent depends on patient preference, renal function and comorbidities.
Joint aspiration and intra-articular corticosteroids are an option in people with acute
monoarticular gout and co-morbidity provided the diagnosis is certain, the person (and joint) are
suitable for injecting and the expertise to inject the joint is available.
A short course of oral corticosteroids or a single intramuscular corticosteroid injection can be
considered in people who cannot tolerate NSAIDs or colchicine, and if intra-articular injection is
not possible or in oligo-/polyarticular gout.
Consider paracetamol as an adjunct for pain relief, in addition to other drug treatment, although
this is not generally recommended as a primary treatment.
Do not stop allopurinol or febuxostat during an acute attack of gout if the person is already
established on these drugs.
 Musculoskeletal  QUESTION 37

A 27 year old student presents to the Emergency Department. He is complaining of neck pain that was present on
waking. He denies any trauma. On examination he is holding his neck in 20 degrees of rightward rotation. Any
attempted movement of the neck is painful. You cannot find any abnormal upper limb neurology. How should this
patient be managed?

Urgent cervical spine CT 5%

Cervical spine x-rays 6%

x Apply cervical collar 5%

✓ Prescribe oral analgesia 66%

Prescribe IM procyclidine 18%

ANSWER
Acute torticollis is diagnosed clinically — in typical cases which present within 1–2 days of onset of symptoms investigations are not usually required.
Offer people with acute torticollis oral analgesics (for example, ibuprofen, paracetamol or codeine) — the choice depends on the severity of pain,
personal preferences, tolerability, and risk of adverse effects. Consider prescribing muscle relaxants. Explain that acute torticollis usually resolves
within 24–48 hours. Occasionally, symptoms may take up to a week to resolve.
 Musculoskeletal  QUESTION 38

An 11 year old boy is brought to the Emergency Department by his parents complaining of pain in both his heels that is
causing him to limp. He is very active and plays hockey three times a week. His parents have noticed the pain is worse after
exercise and is relieved by resting. On examination there is tenderness on palpation of the heel and pain on dorsiflexion of
the ankle. What is the diagnosis?

Plantar fasciitis 22%

✓ Sever's disease 36%

x Achilles tendonitis 29%

Retrocalcaneal bursitis 5%

Heel spur 9%

ANSWER

Sever's disease
An overuse injury thought to be caused by repetitive microtrauma from the pull of the Achilles tendon on the unossified apophysis.
It is most common in boys aged 10–12 years who are active in sports, such as running and football, and produces heel pain as a result of
inflammation of the calcaneal apophysis.
It often resolves within 2 weeks to 2 months, but a child may have recurrent symptoms until skeletal maturity.
 Musculoskeletal  QUESTION 39

You are given a teaching session to medical students on the topic of atraumatic limb
pain in children. You are discussing the radiological findings seen on hip x-rays. What
diagnosis is shown in this x-ray?

Transient synovitis 1%

Osteopenic femoral head fracture 3%

✓ Slipped upper femoral epiphysis 87%

Perthes disease 6%

Juvenile idiopathic arthritis of the hip 3%

ANSWER
The red line demonstrates Trethowan's sign, when a line along the superior edge of the neck of the femur
passes above the femoral head. This strongly suggests a diagnosis of slipped upper femoral epiphysis.
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Musculoskeletal  QUESTION 40 >

A 45 year old woman presents to the Emergency Department with a 2 week

history of increasing back pain on the background of several years of lower
back pain. Whilst assessing the patient you are considering whether the
patient has features of cauda equina syndrome. Which of the following
would make you suspect cauda equina?

✓ Laxity of anal sphincter on examination 88%

Point tenderness over a vertebral body 2%

Severe unremitting or progressive lumbar pain that remains when the person is 4%
x supine

Pain at night that is not relieved when the person is supine 4%

Gradual onset of symptoms 3%

ANSWER

Cauda equina syndrome:

Severe or progressive bilateral neurological deficit of the legs, such as major motor
weakness with knee extension, ankle eversion, or foot dorsiflexion
Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
Recent onset bladder dysfunction (urinary retention or overflow incontinence)
Recent onset faecal incontinence (due to loss of sensation of rectal fullness)
Laxity of anal sphincter on examination
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Musculoskeletal  QUESTION 41 >

A 36 year old woman presents to the Emergency Department complaining of neck pain that
was present on waking this morning. The pain radiates to the right shoulder. She does not
recall any pain or concern the previous day. She denies any history of trauma and has no
significant past medical history. She is prescribed the combined oral contraceptive pill. On
examination you find she has rotated her neck to the right and finds rotation to the midline
painful. Her neck movements are restricted and painful in all directions. What is the most
likely diagnosis?

Acute dystonic reaction 8%

✓ Acute torticollis 68%

Cervical radiculopathy 16%

x Arthritis of cervical spine 7%

Acromioclavicular joint dislocation 2%

ANSWER

Clinical features of acute torticollis:

Sudden onset of severe unilateral pain that may be referred to the head or shoulder, with deviation of
the neck to one side.
Restricted and painful neck movements.
Diffuse tenderness on the affected side with palpable spasm, possibly with tender points of muscle
spasm (trigger points).
No history of trauma preceding the onset of pain, but there may be a history of exposure to cold,
prolonged or unusual positioning of the neck.

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 Musculoskeletal  QUESTION 42

A 56 year old woman presents to the Emergency Department with pain and
weakness in her right hand. You are considering the diagnosis of carpal
tunnel syndrome. Which of the following is NOT a feature of carpal tunnel
syndrome?

Atrophy of the thenar muscles 5%

Reduced strength of thumb abduction 19%

Positive Phalen’s test 12%

x Positive Tinel’s sign 5%

✓ Reduced strength of thumb adduction 60%

ANSWER

Signs of Carpal Tunnel Syndrome include:

Sensory loss in median nerve distribution
Weakness or atrophy of thenar muscles
Reduced strength of thumb abduction
Dry skin of the thumb, index, and middle fingers
Positive Phalen’s test (flexing the wrist for 60 seconds causes pain or paraesthesia
in the median nerve distribution)
Positive Tinel’s sign (tapping lightly over the median nerve at the wrist causes pain
or paraesthesia in the median nerve distribution)
Positive carpal tunnel compression test (pressure over the proximal edge of the
carpal ligament (proximal wrist crease) with thumbs cause paraesthesia to develop
or increase in the median nerve distribution)

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 Musculoskeletal  QUESTION 43

A 5 year old boy is brought to the Emergency Department by his worried parents who
are concerned that he has developed a limp over the last 24 hours. There is no history
of trauma. They tell you he has only just recovered from a nasty cold that was going
round at school but now he seems to be otherwise well. You note that he is playing
happily and does not appear to be in pain whilst sat on the floor in the waiting room,
he is afebrile with normal observations. On examination, passive movement of the
right hip is painful and limited at the extreme range of movement. What is the most
likely diagnosis?

Septic arthritis 4%

Perthes disease 15%

x Toddler's fracture 5%

✓ Transient synovitis 67%

Slipped upper femoral epiphysis 9%

ANSWER

Transient synovitis
A self-limiting inflammatory disorder of the hip. It is more common in boys than in girls and is
rare in children aged younger than 3 years.
It presents acutely with mild to moderate hip pain and limp, and there is no (or only mild)
restriction of hip movements, especially abduction and internal rotation. Children are otherwise
well and afebrile. There is usually a history of viral illness, but the absence of a viral illness does
not rule out the possibility of synovitis.
The diagnosis of transient synovitis is one of exclusion, after other causes of hip pain and limp
have been ruled out. Four independent predictors (Kocher's criteria) have been proposed and
validated to aid in the differentiation of transient synovitis and septic arthritis: history of fever
(> 38.5°C), non-weight-bearing on the affected side, erythrocyte sedimentation rate (ESR)
greater than 40 mm/h, and serum white blood cell count of more than 12,000 cells/mm3.
Septic arthritis is more likely if these features are present.

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 Musculoskeletal  QUESTION 44

A 60 year old man attends the Emergency Department with a painful left knee which has been
increasing in severity over the past week. He tells you it is painful to walk on and becomes stiff
after sitting for a period. An x-ray is performed at triage. What is the diagnosis?

Rheumatoid arthritis 3%

✓ Osteoarthritis 87%

x Prepatellar bursitis 4%

Gout 1%

Osteonecrosis of the knee 6%

ANSWER
Typical radiological features of osteoarthritis include:

Subchondral bone thickening (sclerosis) and/or cysts

Osteophyte formation (new bone formation at joint margins)
Loss or narrowing of the joint space (provides an estimate of the severity of cartilage damage).
Note: structural changes on X-ray may not correlate with reported symptoms and functional impairment.
 Musculoskeletal  QUESTION 45

A 34 year old factory worker presents to the Emergency Department with a one
week history of left elbow pain. He describes pain radiating down the extensor
aspect of his forearm. He has noticed the pain is much worse after working on
his assembly line. On examination you elicit pain on resisted wrist extension.
What is the diagnosis?

Elbow osteoarthritis 5%

Osteochondritis dissecans of the capitellum 5%

x Radial tunnel syndrome 16%

Intra-articular loose bodies 2%

✓ Lateral epicondylitis 72%

ANSWER
Lateral epicondylitis:

This is commonly called ‘tennis elbow’. It follows repetitive or excessive stress to the origin of
the forearm and hand extensor muscles at the lateral epicondyle. It can occur spontaneously
but usually follows repetitive lifting, pulling, or sports (e.g. as a result of an incorrect backhand
technique in tennis).
Inflammation, oedema, and microtears occur within the extensor insertion.
Look for localised swelling, warmth, or tenderness over the lateral epicondyle and immediately
distal to it.
Examine movements— dorsiflexion of the pronated wrist against resistance will reproduce
symptoms.
X- ray if the problem follows an acute injury. Refer to the orthopaedic surgeon if there is an
avulsion fracture.
Treat with analgesia (preferably an NSAID) and ice application. Support the arm in a broad arm
sling and advise rest, followed by progressive exercise and avoidance of aggravating
movements. If symptoms are recurrent or prolonged, refer as steroid injection, forearm clasp,
physiotherapy, and occasionally surgery may help. Current evidence suggests that
corticosteroid injection may provide short- term relief, but long- term benefit remains
unproven.
 Musculoskeletal  QUESTION 46

A 79 year old woman presents to the Emergency Department complaining of pain in the neck that is radiating into the right arm.
She denies trauma and has no significant past medical history. On examination you find weakness of elbow extension and loss of
sensation over the middle finger. What is the most likely diagnosis?

Acute torticollis 0%

✓ Cervical radiculopathy 88%

Arthritis of cervical spine 5%

x Parsonage-Turner syndrome 4%

Rotator cuff tendinosis 3%

ANSWER

Symptoms of cervical radiculopathy include:

Pain in the neck, shoulder and/or arm that approximates to that of a dermatome. It is usually unilateral, but may be bilateral. The pain may be severe
enough to wake the person at night.
Sensory symptoms, such as absent or altered sensation (for example, shooting pains, numbness, and hyperaesthesia). Sensory symptoms are more
common than motor symptoms.
Motor symptoms, such as muscle weakness. Gradual onset, although it may be abrupt. The most common nerve root affected is C7, followed by C6.
 Musculoskeletal  QUESTION 47

A 13 year old boy presents to the Emergency Department complaining of pain in his right knee. He cannot recall
any trauma. He has no significant past medical history. He notices the pain increases when playing football. What
is the diagnosis?

Perthes' disease 5%

✓ Osgood-Schlatter disease 81%

Sever's disease 3%

Osteochondritis dissecans 5%

Chondromalacia patellae 6%

ANSWER

The lateral radiograph of the knee demonstrates fragmentation of the tibial tubercle with overlying soft tissue swelling, as seen in
Osgood-Schlatter disease.
Osgood-Schlatter disease
An overuse injury with multiple small avulsion fractures within the ossification centre (apophysis) of the tibial tuberosity at the
inferior attachment of the patellar ligament caused by forceful contractions of the quadriceps muscles.
It is a usually self-limiting disorder causing anterior knee pain during adolescence, particularly in children active in sport.
Symptoms typically settle over weeks or months but occasionally may persist for 1–2 years, before resolving completely in 90% of
people.
Knee pain is typically unilateral (but may be bilateral in up to 30% of people), gradual in onset (initially mild and intermittent
progressing to severe and continuous), relieved by rest and made worse by kneeling and activity. On examination there may be
tenderness over the tibial tuberosity and firm or bony enlargement of the tibial tuberosity.
X-ray is not required routinely but if undertaken, knee X-ray may be normal or may demonstrate anterior soft tissue swelling,
fragmentation of the tibial tubercle, or rarely a persistent bony ossicle may be visible after fusion of the tibial epiphysis.
 Musculoskeletal  QUESTION 48

An 81 year old man presents to the Emergency Department complaining of an acutely

painful left big toe. The toe is grossly swollen, red, painful and extremely tender to touch,
and an x-ray is performed to exclude fracture. What is the diagnosis?

Osteomyelitis 14%

✓ Gout 73%

x Septic arthritis 3%

Rheumatoid arthritis 2%

Osteoarthritis 7%

ANSWER
The x-ray shows periarticular soft tissue swelling and punched-out lytic bone lesions with overhanging
margins. This is seen in chronic gout.
 Musculoskeletal  QUESTION 49

A 47 year old woman presents to the Emergency Department complaining of several

months of fatigue and joint pains. She gives a three month history of general fatigue,
morning stiffness, and bilateral hand, foot, and elbow stiffness that improves over the
day. Her full blood count shows:
Haemoglobin: 109 g/L
White cell count: 11.3 x 109/L
Platelets: 399 x 109/L
MCV: 85 fl
Her main complaint is of pain to the metacarpophalangeal joints of both hands. What
is the diagnosis?

✓ Rheumatoid arthritis 83%

Fibromyalgia 4%

x Osteoarthritis 7%

Polyarticular gout 3%

Sarcoidosis 2%

ANSWER
Suspect rheumatoid arthritis in anyone with persistent synovitis, where no other underlying cause is
obvious (for example, psoriatic arthritis). RA typically causes symmetrical synovitis of the small joints of the
hands and feet, although any synovial joint may be affected. Clinical features include:

Pain, swelling, heat and stiffness in affected joints

Pain — usually this is worse at rest or during periods of inactivity.
Swelling — around the joint (not bone swelling) giving a 'boggy' feel on palpation.
Stiffness — early morning stiffness usually last over 1 hour (a history of prolonged morning
stiffness is more helpful when forming a diagnosis than currently having morning stiffness for
early RA).
Rheumatoid nodules – hard, firm swellings over extensor surfaces
Systemic features e.g. malaise, fever, sweats, weight loss, lymphadenopathy
Extra-articular features
 Musculoskeletal  QUESTION 50

A 72 year old gentleman presents to the Emergency Department with progressively worsening shortness of breath.
He also has digital clubbing, a dry cough and diffuse fine inspiratory crackles on auscultation. Pulmonary nodules are
found on the lungs on chest x-ray. Which of the following rheumatological conditions is most likely to have caused
this pathology?

Osteoarthritis 3%

Psoriatic arthritis 6%

Reactive athritis 10%

✓ Rheumatoid arthritis 61%

Systemic lupus erythematosus 20%

ANSWER
The above presentation is describing fibrosis of the lungs. Of the answers included, rheumatoid arthritis is most commonly associated with lung
involvement. The nodules described are likely benign rheumatoid nodules, specific to rheumatoid arthritis. The other answers are not typically
associated with causing interstitial lung disease. SLE has numerous systemic features, however interstitial lung disease is not one of its
diagnostic criteria.
 Musculoskeletal  QUESTION 51

A 40 year old man attends the Emergency Department with a 1 week history
of low back pain and shooting pains radiating down his left leg to the foot.
He also describes tingling and weakness of his left foot. On examination you
note altered sensation over the lateral left foot and mild weakness of left
ankle plantarflexion. The pain is increased during a straight leg raise test. He
has no urinary/bowel symptoms or saddle anaesthesia. What is the most
likely cause of his symptoms?

Cauda equina syndrome 9%

✓ Herniated intervertebral disc 78%

x Spinal stenosis 7%

Discitis 3%

Vertebral fracture 3%

ANSWER
Sciatica describes symptoms of pain, tingling, and numbness which arise from impingement of
lumbosacral nerve roots as they emerge from the spinal canal, and are felt in the distribution of
the nerve root (dermatome). There may be accompanying motor weakness in a corresponding
myotomal distribution. Symptoms of sciatica typically extend to below the knee from the
buttocks, across the back of the thigh, to the outer calf, and often to the foot and toes. The
compression is caused by a herniated intervertebral disc in about 90% of cases. An L5/S1 disc
prolapse will tend to cause pressure on the S1 nerve root - which would fit with the clinical
picture here.

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 Musculoskeletal  QUESTION 52

A 57 year old woman presents to the Emergency Department with a 2 day

history of back pain. She cannot recall any trauma. Whilst assessing the
patient you are considering whether the patient has features suggestive of
malignancy. Which of the following features would make you suspect
malignancy as a cause for the patient's symptoms?

✓ Pain aggravated by straining 35%

Structural deformity of the spine 30%

x Fever 10%

Stiffness in the morning that is relieved with movement/exercise 5%

Sudden onset severe central spinal pain which is relieved by lying down 21%

ANSWER

Malignancy:
Person ≥ 50 years of age
Gradual onset of symptoms
Severe unremitting or progressive lumbar pain that remains when the person is
supine
Aching night pain that prevents or disturbs sleep
Pain aggravated by straining
Pain in the thoracic or cervical spine
Localised spinal tenderness
No symptomatic improvement after four to six weeks of conservative low back pain
therapy
Unexplained weight loss
Past history of cancer (breast, lung, gastrointestinal, prostate, renal, and thyroid
cancers are more likely to metastasise to the spine)
 Musculoskeletal  QUESTION 53

A 53 year old man presents to the Emergency Department complaining of pain and
swelling in his knee. He is able to weight bear but is uncomfortable. He has no
significant past medical history and denies trauma. On examination you
demonstrate an effusion, and the joint is red, hot and tender. He is able to actively
flex the knee from 0 to 80 degrees with only mild discomfort. You aspirate the
effusion and receive an urgent microscopy result:
Cloudy synovial fluid
Few white cells
Negatively birefringent needle shaped crystals seen
What is the diagnosis?

Septic arthritis 12%

Rheumatoid arthritis 2%

✓ Gout 61%

x Pseudogout 22%

Osteoarthritis 3%

ANSWER
Swollen knees are a very common reason for people to seek medical attention. Septic arthritis needs to
be recognised and excluded as soon as possible. Aspiration involves removing some intra-articular
synovial fluid from the joint via a needle using an aseptic technique. Samples are then sent for
microscopy, culture and crystal analysis. In the absence of significantly raised white cells on
haematology and organisms on microscopy or culture, septic arthritis can usually be excluded. A
diagnosis of gout can be confirmed by the presence of negatively birefringent, needle-shaped
monosodium urate crystals. Weakly positive rhomboid shaped calcium pyrophosphate crystals are
found in pseudogout.

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 Musculoskeletal  QUESTION 54

A 67 year old woman presents to the Emergency Department with a 2 day

history of increased joint pain in both hands. She has a past medical history
of rheumatoid arthritis. Which of the following is NOT a typical feature of
rheumatoid arthritis?

Ulnar deviation at the metacarpophalangeal joints 8%

Positive metacarpophalangeal squeeze test 13%

✓ Bony nodules on proximal interphalangeal joints 30%

Hyperflexion at proximal interphalangeal joint and hyperextension at distal 26%

interphalangeal joint

Hyperextension at proximal interphalangeal joint and hyperflexion at distal 23%

interphalangeal joint

ANSWER
Hand signs of rheumatoid arthritis:

Joint swelling, redness and heat – particularly MCPJs, PIPJs

Subluxation and ulnar deviation at MCPJs
Boutonniere’s deformity (PIPJ hyperflexion and DIPJ hyperextension)
Swan-neck deformity (PIPJ hyperextension and DIPJ flexion)
Z deformity of the thumb (IPJ hyperextension and MCPJ fixed flexion and subluxation)
Bowstring sign (tendons appear prominent and stretched across a shrunken carpus)
Inability to make a fist or flex fingers
Positive metacarpophalangeal squeeze test - pain on squeezing the
metacarpophalangeal or metatarsophalangeal joints together

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
 Musculoskeletal  QUESTION 55

A 45 year old man presents to the Emergency Department with a 2 day history of increasing back pain. He cannot recall
any specific trauma. He had been using over the counter analgesics and has only presented to the Emergency
Department due to a new onset of urinary incontinence. On examination you note saddle anaesthesia. What
investigation should be performed as a priority?

X-ray lumbar spine 4%

FAST scan 1%

x Bladder scan 4%

CT spine 5%

✓ MRI spine 87%

ANSWER
The diagnosis of cauda equina syndrome (CES) is primarily based on a thorough history and clinical examination, assisted by appropriate radiological
investigation. MRI scan is the preferred investigation to confirm the diagnosis and determine the level of the compression and any underlying cause.
Patients should be referred immediately for a neurosurgical consultation. Urgent surgical spinal decompression is indicated for most patients to
prevent permanent neurological damage.
 Musculoskeletal  QUESTION 56

A 32 year old woman presents to the Emergency Department with a 3 day history of fever, back pain and lower limb
weakness. She is 1 week postpartum and received an epidural for anaesthesia during labour. You suspect an epidural
abscess. What is the most likely pathogen?

Mycobacterium tuberculosis 2%

Pseudomonas aeruginosa 2%

✓ Staphylococcus aureus 73%

x Staphylococcus epidermidis 16%

Streptococcus pyogenes 7%

ANSWER
Staphylococcus aureus causes 70% of spinal epidural abscesses.

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