PLAB 2 Orthopaedics: Mastering Common OSCE Scenarios

As an examiner and long-time educator in medical exams like PLAB 2, I've seen countless candidates demonstrate their clinical acumen. Orthopaedic scenarios are a frequent and crucial component of the PLAB 2 OSCE, testing not just your knowledge but your practical skills, communication, and patient management. This isn't about becoming an orthopaedic surgeon overnight; it's about demonstrating safe, effective, and empathetic initial management of common musculoskeletal presentations.

Why Orthopaedics is Key in PLAB 2

Musculoskeletal complaints are incredibly common in primary and secondary care. You will encounter patients with joint pain, fractures, back pain, and various soft tissue injuries daily. PLAB 2 assesses your ability to:

• Elicit a focused history: Pinpointing the nature of the problem, red flags, and impact on the patient's life.

• Perform a relevant examination: Knowing which tests to perform and how to interpret findings.

• Formulate a differential diagnosis: Considering common and serious conditions.

• Manage appropriately: Offering immediate advice, safety netting, prescribing, and knowing when to refer.

• Communicate effectively: Explaining complex concepts clearly, empathising, and involving the patient in decision-making.

High-Yield Orthopaedic Scenarios for PLAB 2

Let's break down some common orthopaedic presentations and the essential approach for each:

1. Acute Fracture Management (e.g., Colles' Fracture, Ankle Fracture)

The Scenario: A patient presents to A&E with a suspected fracture after a fall.

Your Approach:

• History: Mechanism of injury, pain level, neurovascular symptoms (numbness, tingling, pallor), previous injuries, comorbidities (osteoporosis, anticoagulants).

• Examination (if required): Inspect for deformity, swelling, bruising. Palpate gently for tenderness. Assess neurovascular status distal to the injury (sensation, motor function, pulses, capillary refill time). Always compare to the uninjured side if possible.

• Communication & Management:

  • Reassure the patient: Acknowledge their pain and anxiety.

  • Pain management: Advise simple analgesia (paracetamol, ibuprofen, or stronger if appropriate).

  • Immobilisation: Explain the need for temporary immobilisation (e.g., splint, sling) to reduce pain and prevent further injury.

  • Referral: Clearly explain the need for an X-ray to confirm diagnosis and subsequent orthopaedic review (e.g., for reduction, casting, or surgery).

  • Safety netting: Advise them to return immediately if pain worsens significantly, new numbness/tingling, or changes in limb colour. Explain potential complications like compartment syndrome (if applicable to the area).

2. Back Pain: Red Flags and Initial Management

The Scenario: A patient presents with acute or chronic back pain.

Your Approach:

• History: Onset, duration, character of pain, radiation (sciatica), aggravating/relieving factors. Crucially, ask about red flags:

  • Cauda Equina Syndrome: Bilateral leg weakness, saddle anaesthesia, bowel/bladder dysfunction (incontinence, retention).

  • Malignancy: Unexplained weight loss, night sweats, persistent pain unrelieved by rest, history of cancer.

  • Infection (e.g., discitis, osteomyelitis): Fever, recent infection, IV drug use, immunosuppression.

  • Fracture: Trauma, osteoporosis.

• Examination: Observe gait, posture. Palpate spine. Basic neurological exam of lower limbs (power, sensation, reflexes). Straight leg raise.

• Communication & Management:

  • Differentiate: Explain if it's likely mechanical back pain or if red flags necessitate urgent investigation.

  • Advice for mechanical pain: Stay active (avoid bed rest), simple analgesia, heat/cold packs, physiotherapy referral, weight management, ergonomic advice.

  • Urgent Referral: If any red flags are present, explain the need for urgent hospital admission/senior review to investigate (e.g., MRI for Cauda Equina).

  • Safety netting: Emphasise to return if new red flag symptoms develop.

3. Joint Pain/Arthritis (e.g., Osteoarthritis, Gout)

The Scenario: A patient complains of chronic knee pain or an acutely swollen, red joint.

Your Approach:

• History: Onset (sudden/gradual), pattern (monoarticular/polyarticular), morning stiffness, swelling, redness, functional impact. Systemic symptoms (fever, rash, fatigue). Past medical history (e.g., family history of arthritis, previous gout attacks).

• Examination: Look (swelling, erythema, deformity), Feel (warmth, tenderness, effusion), Move (range of motion - active and passive, crepitus), Special tests if appropriate.

• Communication & Management:

  • Explain Diagnosis: Clearly explain the likely diagnosis (e.g., osteoarthritis is wear and tear, gout is crystal deposition).

  • Management (Osteoarthritis): Lifestyle modifications (weight loss, exercise), pain relief (paracetamol, NSAIDs), physiotherapy, occupational therapy, assistive devices, discuss surgical options (joint replacement) if severe and refractory.

  • Management (Gout): Acute attack: NSAIDs, colchicine, steroids. Prophylaxis: allopurinol/febuxostat. Lifestyle advice (diet, alcohol).

  • Safety netting: Advise on when to return (e.g., worsening pain, new joint involvement).

4. Soft Tissue Injuries & Upper Limb Issues (e.g., Carpal Tunnel Syndrome, Shoulder Impingement)

The Scenario: A patient presents with wrist pain and numbness/tingling, or shoulder pain.

Your Approach:

• History: Onset, aggravating/relieving factors, radiation, previous similar episodes, occupational factors, impact on daily life. For CTS: nocturnal symptoms, hand dominance. For shoulder: specific movements causing pain, pain at night.

• Examination: Relevant special tests (e.g., Tinel's sign/Phalen's test for CTS; impingement tests for shoulder).

• Communication & Management:

  • Explain: Describe the condition clearly.

  • Conservative: Rest, ice/heat, NSAIDs, splinting (for CTS, especially at night), physiotherapy, ergonomic advice.

  • Further Steps: Discuss steroid injections or surgical referral if conservative measures fail.

  • Safety netting: Advise to return if symptoms worsen or new symptoms appear.

General OSCE Tips for Orthopaedics

• Be Patient-Centred: Listen actively, empathise, and address their concerns. "How is this affecting your day-to-day life?"

• Structured Approach: Even under pressure, follow a logical history, examination, and management plan. This makes you look organised and competent.

• Safety Netting is Crucial: Always tell the patient when to seek further help. This shows you're thinking about patient safety beyond the consultation.

• Explain Clearly: Avoid medical jargon. Use analogies if helpful. Check for understanding.

• Time Management: Be efficient. You won't have time for a full head-to-toe exam. Focus on what's relevant to the scenario.

• Practice, Practice, Practice: Practice examining joints, discussing management plans, and explaining conditions to laypeople. Role-play with colleagues.

Orthopaedics in PLAB 2 is less about niche knowledge and more about demonstrating core clinical skills in common presentations. Master these principles, and you'll navigate orthopaedic OSCE scenarios with confidence and competence. Good luck!