i 

EVALUATION OF MEDICAL INTERNS’ 
KNOWLEDGE AND CONFIDENCE IN 

ORTHOPAEDIC SURGERY AT THE UNIVERSITY 
OF THE WITWATERSRAND’S ACADEMIC 

HOSPITAL COMPLEX IN JOHANNESBURG, 
SOUTH AFRICA 

 

 

 

 

 

 

Dr Michael Harland Terreblanche  

 

 

A research report submitted to the Faculty of Health Sciences, University of the 

Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the 

degree of Master of Medicine in Orthopaedic Surgery 

Johannesburg, 2023



i 

 

Declaration 

 

I, Michael Harland Terreblanche, declare that this Research Report is my own, unaided work.  

 

It is being submitted for the Degree of Master of Medicine in Orthopaedic Surgery at the 

University of the Witwatersrand, Johannesburg.  

 

It has not been submitted before for any degree or examination at any other University.  

 

_______________________________________ 

(Signature of candidate)  

 

16th day of April 2023 in Johannesburg, South Africa 

 

 

 

 

 

 

 

 



 
ii 

Dedication 

This research report is dedicated to my family: my mother, Di; my late father, Chris, and my 

brothers, Peter and John; without whose unwavering support and encouragement I would never 

have reached this point in my career. 

To my beloved mother, Di, thank you for helping to steer my ship at a time in my life when I 

was rudderless. After losing my father at a young age, you stepped in, took charge so 

decisively, and did everything in your power to help me get into medical school so that I could 

pursue my dream of becoming a doctor. You have been my biggest and most loyal supporter 

during my career as a training doctor and later as a training surgeon. I could not have come this 

far without your enduring love and care. You have been the perfect role model to me, and I 

hope one day to impart the values and principles which you so gracefully lived your life by 

onto my own children, as a tribute to the wonderful mother you have been to me. 

To my brother, Pete, thank you for always being there for me; for the hours of telephone 

conversations we would have which allowed me to air my frustrations and offered me great 

insight and perspective, and a tremendous amount of solace too. Those conversations would 

always calm me down when I felt overwhelmed and panic-stricken by the amount of studying 

I always felt needed to be done. Your gutsiness, hunger and desire to succeed, dedication and 

perseverance both on the rugby field at school and on the famous Umsundusi river inspired me 

to want to develop those qualities in myself. Thank you for inspiring those qualities in me, 

Pete, as I believe they were completely necessary for me to be able to complete my medical 

journey. 

To my brother, John, thank you for always being in my corner. You had your own personal 

challenges to deal with during my training, but you made sure to never leave me feeling short 

of your support, love and care. There are so many qualities of yours that I admire but for the 

purposes of this dedication, I have chosen one that stands out amongst the others. I have always 

admired your ability to explain some of the most complex matters to me in such simple, 

understandable terms. It is a quality of yours which has inspired me to want to do the same for 

the patients who have been under my care during my medical career. It is often difficult to 

explain medical terminology, diagnostic tests and medical procedures to a lay person in simple, 

understandable terms but you inspired me to want to do this for my patients. I believe it is such 

an important skill for a medical professional to be equipped with, and something I have always 



 
iii 

endeavoured to do, so I am incredibly thankful to you for instilling that in me, so that I could 

try to be a better doctor to my patients. 

To my late father, Chris, thank you for inspiring me to want to become a doctor. I fondly 

remember asking you all sorts of questions about medicine and biology and the human body 

as an inquisitive teenager, and you always patiently explained things to me and appeased my 

thirst for knowledge. It breaks my heart that you did not live long enough to witness me 

graduating from medical school and subsequently going on to become an orthopaedic surgeon, 

as I’m sure this would have made you incredibly proud, being such a highly regarded 

orthopaedic surgeon yourself. How great it would be for us to discuss all things orthopaedics 

today. For me to learn from you the tips and tricks you had learnt over your career, and for me 

to share with you my experiences as a training doctor and training orthopaedic surgeon. What 

I would give to be able to have these conversations with you today. But far above being a 

doctor and an orthopaedic surgeon, you were my Dad, and the greatest Dad myself, Pete and 

John could have ever asked for. You taught me how to laugh, how to be humble and how to be 

generous. I will forever be grateful for the immense impact you had on my life.   

To all of you, a few words over one or two pages will never, ever do justice to the gratitude I 

feel for all the support, love and care you have always shown me. However, I do hope it goes 

some way to showing how much I truly appreciate each one of you and the unique role you 

have played in shaping me into the doctor and person I am today.  

 

 

 

 

 

 

 

 



 
iv 

Abstract  

Background 

Junior doctors’ knowledge and confidence in the assessment and treatment of musculoskeletal 

disorders and injuries has previously been shown to be limited, both locally and internationally. 

This has far-reaching consequences, not least of which is sub-optimal patient care. The aim of 

this study was to evaluate the effectiveness of current undergraduate orthopaedic training in 

South Africa. 

Materials and methods 

Medical interns rotating through the orthopaedic departments of three academic hospitals in 

Johannesburg, South Africa were surveyed, using a validated questionnaire consisting of 

twenty-five questions, to assess their knowledge of orthopaedic surgery. Furthermore, they 

were asked to rate their self-perceived confidence levels relating to various aspects of the care 

of individuals with musculoskeletal problems using a 5-point Likert scale. The future career 

interest of the interns was also recorded. 

Results 

Seventy-eight completed questionnaires were included in this study for analysis. Ninety six 

percent (96%) of the medical interns in this study failed to achieve basic cognitive competency 

concerning knowledge of orthopaedic surgery. Three out of seventy-eight medical interns in 

this study achieved basic theoretical competency in orthopaedic surgery. The interns’ mean 

score in the 25-question examination was 40.7% (SD 13.4%) with a range of 17 – 69%. Ninety 

two percent (92.3%) of participants reported that they were either confident or highly confident 

in orthopaedic surgery. Future career choice had no influence on the knowledge of orthopaedic 

surgery.   

Conclusion 

The effectiveness of South African undergraduate training of orthopaedic surgery is deficient. 

Recent South African medical graduates’ knowledge of orthopaedic surgery is inadequate, with 

a mean score of 40.7% in the Freedman and Bernstein questionnaire, and only 3.8% of interns 

achieving theoretical competency. The graduates demonstrated inappropriate confidence in 

orthopaedic surgery with only 7.7% acknowledging a lack of confidence. Interns’ future career 



 
v 

interest was not found to have a significant association with knowledge of orthopaedic surgery. 

This study suggests that, in South Africa, orthopaedic undergraduate training needs reform.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 
vi 

Acknowledgements 

I would like to thank Dr. B. Milner and Dr. M. Jingo for their contributions to this research 

report; for their advice, input, suggestions and editing of this research report. 

I would like to thank my supervisor, Dr. S. Khan, for supervising this research report and for 

encouraging me and guiding me both as a training orthopaedic surgeon and in the completion 

of this research report. 

I would like to thank Prof. A. Robertson for his huge contribution to this report. The completion 

of this report would not have been possible without your input and advice. 

I would like to thank Mr. O. Fadahun for his assistance with the statistical analysis in this 

report. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 
vii 

Table of Contents 

 

Declaration……………………………………………………………………………….....i 

Dedication…………………………………………………………………………………..ii 

Abstract……………………………………………………………………………………..iv 

Acknowledgements…………………………………………………………………………vi 

Nomenclature……………………………………………………………………………….x 

List of Figures……………………………………………………………………………….xi 

List of Tables………………………………………………………………………………..xii 

Chapter 1: Introduction and Literature Review…………..……………………………..1 

1.1 Background……………………………………………………………………………...1 

1.1.1 Epidemiology and impact of musculoskeletal disorders………………………………1 

1.1.2 High burden of musculoskeletal pathology and orthopaedic trauma in SA…………...1 

1.1.3 Inappropriate referrals to orthopaedic surgery departments in SA…………………….1 

1.2 Literature review………………………………………………………………………....2 

1.2.1 Knowledge and confidence in orthopaedic surgery amongst medical practitioners.…..2 

1.2.2 Inadequate knowledge of orthopaedic surgery and its impact on patient care………...2 

1.2.3 Freedman and Bernstein questionnaire………………………………………………...3 

1.2.3.1 Strengths and limitations of the Freedman and Bernstein questionnaire…………….4 

1.2.4 International experience of musculoskeletal education and assessment……………….4 

1.2.5 South African experience of musculoskeletal education and assessment……………...5 

1.2.6 Relationship of future career interest and knowledge of orthopaedic surgery…………6 



 
viii 

1.3 Motivation for the current study…………………………………………………………6 

1.4 Aims and objectives……………………………………………………………………...6 

Chapter 2: Methodology…………………………………………………………………...8 

2.1 Research question………………………………………………………………………..8 

2.2 Study design……………………………………………………………………………..8 

2.3 Materials and methods…………………………………………………………………..8 

2.4 Study sites……………………………………………………………………………….9 

2.5 Study sample…………………………………………………………………………….9 

2.6 Data collection…………………………………………………………………………..9 

2.7 Data analysis…………………………………………………………………………….10 

Chapter 3: Results…………………………………………………………………….........11 

3.1 Study participant demographics…………………………………………………………11 

3.2 Interns’ knowledge of orthopaedic surgery……………………………………………...13 

3.2.1 Sub-analysis of interns’ knowledge…………………………………………………....23 

3.3 Interns’ self-perceived confidence levels in orthopaedic surgery………………………..23 

3.4 Interns’ future career interest…………………………………………………………….26 

3.5 Relationship of interns’ future career interest and knowledge of orthopaedic surgery….28 

Chapter 4: Discussion………………………………………………………………………31 

4.1 Demographic profile of the interns……………………………………………………....31 

4.2 Knowledge of orthopaedic surgery amongst South African medical interns…………....31 

4.2.1 Local comparisons……………………………………………………………………..31 

4.2.2 International comparisons.…………………………………………………………….32 

4.3 Self-perceived confidence levels in orthopaedic surgery amongst medical interns…….33 



 
ix 

4.4 Future career interest of medical interns………………………………………………..34 

4.5 Limitations of the study………………………………………………………………...34 

4.6 Recommendations………………………………………………………………………34 

Chapter 5: Conclusion…………………………………………………………………….36 

References…………………………………………………………………………………..37 

Appendix A: Informed consent document ……………………………..…………………..41 

Appendix B: Study questionnaire ………………………………………………………….45 

Appendix C: Human Research Ethics Committee (Medical) Certificate ………………….56 

Appendix D: Hospital CEO permission letters……………………………………………..57 

  



 
x 

Nomenclature 

AIDS   Acquired Immunodeficiency Syndrome 

BOA  British Orthopaedic Association 

CEO  Chief Executive Officer 

CHBAH Chris Hani Baragwanath Academic Hospital 

CI  Confidence Interval 

CMJAH Charlotte Maxeke Johannesburg Academic Hospital 

ENT   Ear, Nose and Throat  

GP  General Practice 

HEQF  Higher Education Qualifications Framework 

HIV   Human Immunodeficiency Virus 

HOD  Head of Department 

HJH  Helen Joseph Hospital 

HPCSA Health Professions Council of South Africa 

HREC  Human Research Ethics Committee 

IQR  Interquartile range 

SA  South Africa 

SD  Standard Deviation 

UK  United Kingdom 

USA  United States of America 

 

 

 

 

 

 

  



 
xi 

List of Figures 

Figure 3.1: Gender of the medical interns 11 

Figure 3.2: Racial profile of the medical interns 12 

Figure 3.3: University representation amongst the medical interns  12 

Figure 3.4: Future career interest of the medical interns  27 

Figure 3.5: Future career interest of the medical interns grouped into career 

choices considered related or unrelated to orthopaedic surgery 

28 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 
xii 

  List of Tables 

Table 3.1: Freedman and Bernstein questionnaire with the medical interns’ scores 

for each question 

13 

Table 3.2: Medical interns’ self-perceived confidence levels in history taking and 

physical examination of an individual with a chronic shoulder complaint and an 

individual with a chronic knee complaint  

23 

Table 3.3: Medical interns’ self-perceived confidence levels in diagnostic and 

therapeutic procedures related to individuals with musculoskeletal disorders 

25 

Table 3.4: Medical interns’ overall self-perceived confidence levels in orthopaedic 

surgery 

26 

Table 3.5: Relationship of the medical interns’ future career interest, when 

grouped into career choices considered related to orthopaedic surgery and career 

choices considered unrelated to orthopaedic surgery, and their knowledge of 

orthopaedic surgery  

28 

Table 3.6: Relationship of the medical interns’ future career interest, when 

grouped into orthopaedic surgery, surgical specialties, non-surgical specialties and 

general practice, and their knowledge of orthopaedic surgery 

29 

 



1 

 

Chapter 1: Introduction and literature review 

1.1 Background  

 

1.1.1 Epidemiology and impact of musculoskeletal disorders  

Musculoskeletal disorders are common. Disorders of the musculoskeletal system comprise 

approximately 20 – 30% of visits to primary health care facilities and emergency departments 

and up to 50% of visits in individuals 75 years of age and older. 1 – 4 In South Africa (SA), the 

prevalence of musculoskeletal disorders at primary health care facilities has been shown to be 

more than 30%. 5 Furthermore, musculoskeletal disorders represent the most common cause of 

severe chronic pain and physical disability. 6 In the United Kingdom (UK), up to 25% of all 

surgical procedures are trauma and orthopaedic related. 4 Musculoskeletal disorders and 

orthopaedic injuries incur significant costs on the financial resources of healthcare facilities 

and on societies and economies through loss of productivity. 1, 4, 7 – 9  In summary, 

musculoskeletal disorders are highly prevalent, they cause considerable pain and disability, and 

they are a significant strain on human and financial resources. 

1.1.2 High burden of musculoskeletal pathology and orthopaedic trauma in SA 

There is a high burden of trauma in SA, resulting in large volumes of musculoskeletal injuries. 
10, 11 Coupled with the high trauma burden, there is a high burden of human immunodeficiency 

virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), and lifestyle diseases 

such as obesity and diabetes in SA. 12, 13 The impact of these conditions on orthopaedic 

departments at healthcare facilities around SA is large. 

1.1.3 Inappropriate referrals to orthopaedic surgery departments in SA 

To add to the high burden of appropriately referred individuals to orthopaedic departments, 

orthopaedic departments in SA are often faced with many inappropriate referrals. 14 The 

benefits of appropriate referral of individuals, with timeous surgical care and subsequent 

timeous discharge from hospital and earlier return to work and saving hospital costs have been 

elucidated in the literature. 15 Inappropriate referrals are likely the result of inadequate 

musculoskeletal education. In addition, poor or limited musculoskeletal education has also 



 
2 

been found to result in the unnecessary use of diagnostic tests, inappropriate prescriptions and 

a lack of diagnostic suspicion of uncommon but limb and/or life-threatening conditions. 16 In 

SA, where resources are often extremely limited, ineffective use of these valuable resources 

needs to be curtailed. 

1.2 Literature review 

1.2.1  Knowledge and confidence in orthopaedic surgery amongst medical practitioners 

Locally and internationally, junior doctors’ knowledge of orthopaedic surgery has been shown 

to be poor. 17 – 31 Junior doctors’ confidence levels in musculoskeletal medicine has been shown 

to be low. 21, 23, 24, 32, 33 Knowledge and confidence in the assessment and treatment of 

musculoskeletal disorders amongst experienced primary care practitioners has also been 

proven to be low. 34 The self-perceived confidence in musculoskeletal medicine amongst junior 

doctors in SA has been highlighted as an area of future research. 20 In spite of low levels of 

confidence and knowledge of musculoskeletal medicine amongst medical graduates, 

universities around the world continue to allocate insufficient time and resources towards the 

teaching and training of orthopaedic surgery at undergraduate and postgraduate levels. 18, 25, 35, 

36  

Certain diagnostic and therapeutic skills, such as how to inject or aspirate the knee and shoulder 

joints, have been listed as core skills which the South African family practitioner should be 

able to perform. 37, 38 Furthermore, it has been shown that primary care physicians demonstrated 

low levels of confidence in the performance of knee joint aspirations and shoulder joint 

injections. 34 

1.2.2  Inadequate knowledge of orthopaedic surgery and its impact on patient care 

In addition to a large percentage of qualified medical doctors’ knowledge of musculoskeletal 

medicine and orthopaedic surgery being limited, some of their practices have been shown to 

be detrimental to patient outcomes too. 14, 16, 39, 40 In one study, initial misdiagnosis was the 

only factor associated with a time delay to arthrotomy in children with septic arthritis of the 

hip joint, a condition which requires emergent surgical care, without which a poor outcome is 

almost certain. 40, 41 Incorrect or missed diagnoses not only have unfavourable consequences 

for individuals (patients), but they have also been shown to have a negative impact on the 

financial resources of healthcare facilities by contributing to medical negligence claims. 42 



 
3 

1.2.3 Freedman and Bernstein questionnaire 

In 1998, Freedman and Bernstein designed a basic competency examination in musculoskeletal 

medicine. 43 It consists of twenty-five questions which cover a range of topics relevant to 

orthopaedic surgery (including the assessment and management of certain orthopaedic 

emergencies, questions pertaining to musculoskeletal anatomy and other general 

musculoskeletal topics). An open response format is provided for the answers to these 

questions, to eliminate guesswork from skewing the results of the answers. The recommended 

answers were provided by the investigators who designed the questionnaire. The examination 

was reviewed by 124 chairpersons of orthopaedic residency programs in the USA. The 

chairpersons were asked to rate the importance of each question and suggest a pass mark. The 

mean pass mark (and standard deviation) they recommended was 73.1 ± 6.8%. The mean 

importance score of the 25 questions was 7.0 out of 10. The examination was given to eighty-

five residents in their first postgraduate year at the University of Pennsylvania in the USA. The 

authors showed that 82% of eighty-five residents failed this validated musculoskeletal 

competency examination, highlighting the deficiencies of musculoskeletal education in USA 

medical schools. 43 Based on the findings of their study, the authors believed that course content 

was too narrow with a focus on inpatient care of patients, and that course content needed to be 

broadened to include more contact hours of students and to allow students greater exposure to 

common outpatient orthopaedic problem; or that other residency programs should compensate 

for any reduced exposure to musculoskeletal training at undergraduate level. 

In a later study by the same authors, in response to criticism that orthopaedic surgeons may 

over-emphasise the importance of topics with surgical relevance, this same questionnaire was 

given to a large sample of directors of internal medicine residency programs. 44 The 

questionnaire was completed by 240 directors of these internal medicine residency programs. 

The pass mark recommended by the 240 internal medicine directors was 70.0 ± 9.9% and the 

mean importance score for all 25 questions as rated by the 240 directors was 7.4 out of 10. 44 

This questionnaire has thus been validated by orthopaedic surgeons, as well as internal 

medicine specialists, and as such has been used by many investigators as the instrument of 

choice in studying the adequacy or inadequacy of musculoskeletal teaching around the world. 

 

 



 
4 

1.2.3.1 Strengths and limitations of the Freedman and Bernstein questionnaire  

Although the Freedman and Bernstein questionnaire has several strengths (namely: it covers a 

range of important and relevant topics relating to musculoskeletal medicine which require 

cognitive competency for patient care to be optimised; the format is open-ended to eliminate 

guessing and it has been validated by multiple program directors of both orthopaedic surgery 

and internal medicine residency programs in the USA); it does have certain weaknesses and 

criticisms too. One of the limitations of the Freedman and Bernstein questionnaire is that it has 

not been validated for relevance in a developing country (although it has been utilised by 

authors who have previously published on this subject matter in South Africa). 17 – 20 Perhaps 

a greater focus on questions pertaining to musculoskeletal problems prevalent in developing 

countries, such as South Africa, (for example: musculoskeletal tuberculosis, hand sepsis, 

cervical spine trauma and/or the assessment and treatment of polytrauma patients both of which 

are frequently seen as a result of high velocity motor vehicle collisions, a common mechanism 

of injury in developing countries) would offer greater insights into the knowledge of 

orthopaedic surgery amongst recent medical graduates in developing countries. 

1.2.4 International experience of musculoskeletal education and assessment  

Numerous authors have utilized the Freedman and Bernstein questionnaire to assess the 

knowledge of musculoskeletal medicine amongst newly qualified medical practitioners. 17 – 31 

A study in the UK, showed that only 21% of newly qualified medical doctors passed the 

cognitive competency questionnaire created by Freedman and Bernstein. 21 The authors 

recommended appropriate steps be taken to improve the quantity and quality of training in 

musculoskeletal medicine in the United Kingdom. Ninety-four percent (94%) of Nepalese 

medical interns failed to achieve theoretical competency in the same examination 

(questionnaire) and the authors of this study similarly recommended improvements be made in 

the medical school curriculum as well as in teaching methods. 30 Fifty percent (50%) of final 

year medical students in an Indian study achieved theoretical competence in the Freedman and 

Bernstein questionnaire and similar recommendations of greater exposure to orthopaedics in 

the medical school curriculum was recommended by these authors. 26 An Australian study 

revealed theoretical competency of 39.4% amongst medical interns at Flinders University, 

South Australia. 29 

 



 
5 

1.2.5 South African experience of musculoskeletal education and assessment  

In South Africa, similarly low levels of cognitive competency have been reported. Dachs et al., 

in a study performed in Cape Town, found that 91% of medical interns did not achieve a mark 

higher than the pass mark suggested by Freedman and Bernstein and thus failed to achieve 

theoretical competency. 17 A follow up to this study, to determine if two months of post-

graduate training in orthopaedics had any impact on the knowledge of orthopaedics amongst 

medical interns, demonstrated that 85.7% of interns still failed to show theoretical competency 

in the Freedman and Bernstein questionnaire despite receiving two months of post-graduate 

exposure to orthopaedic surgery. 18 Several changes to the way orthopaedics is taught at the 

authors’ institution were implemented based on the findings of their two studies. These 

included, but are not limited to, rostering medical students to shadow the on-call orthopaedic 

surgery registrar on duty, upgrading the online resources accessible to medical students, and 

ensuring that teaching by consultant and training orthopaedic surgeons is monitored by having 

regular and formal feedback from students in the form of evaluations of their teachers. Coetzee 

et al., showed similarly low scores on the Freedman and Bernstein questionnaire amongst 

medical interns with a 94% failure rate. 20 They also sought to determine if there was a 

difference in cognitive competency between graduates from the various health sciences 

faculties in South Africa and found that the top two performing universities had longer pre-

clinical rotations in musculoskeletal medicine and that the top performing university ensured 

revision of course work through more frequent examinations. They suggested that perhaps such 

educational methods should be incorporated at other health science faculties in SA. 

Undergraduate teaching of orthopaedic surgery is not standardised at medical schools in SA. 
18, 20 Time allocated to teaching orthopaedic surgery to medical undergraduates in SA varies 

amongst medical schools and averages between four and six weeks, during the entire five to 

six years of undergraduate teaching at medical schools in SA. 18 Some of the medical schools 

in SA combine teaching of orthopaedic surgery with teaching of other specialties, effectively 

reducing exposure to orthopaedics even further. Some medical schools in SA do not require 

their medical students to perform after-hours duties. 17, 18 

Postgraduate training of orthopaedic surgery in SA is not standardised either. However the 

duration of training for medical interns is standardised to a period of two months, at an 

accredited health care facility, as set out by the Health Professions Council of South Africa 

(HPCSA). 45 



 
6 

1.2.6 Relationship of future career interest and knowledge of orthopaedic surgery 

Several studies have demonstrated that future career interest has correlated with 

musculoskeletal knowledge (scores in the Freedman and Bernstein theoretical examination). 
21, 23  

In order to reduce the burden that orthopaedic departments in SA experience, it is imperative 

that junior medical doctors and non-orthopaedic specialists become proficient in the diagnosis 

and management of common and important orthopaedic conditions, regardless of their future 

career choices. Junior medical doctors’ proficiency in managing orthopaedic conditions would 

minimise the morbidity associated with sub-optimal treatment of individuals with orthopaedic 

conditions or injuries and would also free up learning and training opportunities for training 

orthopaedic specialists working in teaching hospitals. 46 – 48 

For this to be realised, undergraduate and postgraduate (internship) teaching and training of 

orthopaedic surgery should become standardised, and more time and resources should be 

allocated to the teaching and training of orthopaedic surgery to medical students and medical 

interns (hereafter referred to as interns) in SA. 

1.3 Motivation for the current study 

Medical school curricula are fluid and constantly evolving. The outcomes of the changes to 

these curricula need to be regularly re-assessed. Therefore, the reason for this study is to re-

evaluate undergraduate training of orthopaedic surgery and musculoskeletal medicine in South 

Africa. Furthermore, as far as the primary investigator of this study is aware, self-reported 

confidence levels in orthopaedic surgery amongst newly qualified medical graduates have 

never been formally evaluated in the South African setting. 

The findings of this study could provide co-ordinators and administrators with an opportunity 

to improve undergraduate and/or postgraduate orthopaedic training in SA. 

1.4 Aims and objectives of the study 

This study aims to assess the effectiveness of undergraduate training of orthopaedic surgery in 

South Africa, by evaluating the knowledge of orthopaedic surgery and self-perceived 

confidence in orthopaedic surgery amongst recently qualified medical graduates at three 

academic hospitals.  



 
7 

This will serve as a measure of undergraduate teaching of orthopaedic surgery in South Africa.  

The objectives of the study are:  

1. To document the demographic profile of the study participants  

 

2. To determine the interns’ level of knowledge of orthopaedic surgery utilising the 

Freedman and Bernstein questionnaire 

 
3. To determine the interns’ self-perceived confidence levels in orthopaedic surgery, 

using a five point Likert scale 

 

4. To determine if a future career interest in musculoskeletal medicine has an influence 

on the interns’ overall knowledge of orthopaedic surgery  

 

 

 

 

 

 

 

 

 

 

  



 
8 

Chapter 2: Methodology 

2.1 Research question 

What is the current state of orthopaedic undergraduate training in South Africa? 

2.2 Study design 

This study was a prospective questionnaire-based study. 

2.3 Materials and methods 

The interns at the study sites were invited to participate in the study on the first day of their 

orthopaedic rotation during their internship. Participation in the study was completely 

voluntary and the interns were asked to sign an informed consent document (see Appendix A) 

indicating their willingness to participate in the study.  

The interns were asked to answer the Freedman and Bernstein questionnaire and a five point 

Likert scale (see appendix B) after a printed copy of the questionnaire (see appendix B) was 

distributed to each intern. 

An invigilator was present when the interns completed the questionnaire to prevent the interns 

from copying one another or cheating. The interns were not allowed to make use of the internet, 

any textbooks or other study material while completing the questionnaire. No time limit was 

set for the interns to complete the questionnaire. 

A five-point Likert scale was utilised for the questions pertaining to the interns’ self-perceived 

confidence levels. Scores of 1 and 2 were considered ‘not confident’, scores of 3 were 

considered ‘confident’ while scores of 4 and 5 were considered ‘highly confident’.  

The interns’ answers to the Freedman and Bernstein questionnaire were marked by the primary 

investigator of this study according to the answer memorandum provided in the original study 

published by Freedman and Bernstein. 43 A maximum score of one point was possible for each 

answer. 43 Partial marks were awarded to questions which had multiple answers, as per the 

memorandum in the Freedman and Bernstein study. 43 A pass mark of 73.1 ± 6.8% was selected 

as this was the pass mark that was determined in the original study by Freedman and Bernstein. 
43 Each intern’s overall individual score in the Freedman and Bernstein questionnaire (out of a 

maximum of 25) was multiplied by four to obtain a percentage. To determine the overall intern 



 
9 

score for each question, the individual intern scores for each question were summed and then 

multiplied by four to obtain a percentage. 

2.4 Study sites 

The study was conducted on a sample of South African-trained medical interns who rotated 

through the orthopaedic surgery departments at Chris Hani Baragwanath Academic Hospital 

(CHBAH), Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Helen Joseph 

Hospital (HJH) during the course of the year 2019.  

2.5 Study sample 

The study was conducted from 1 January 2019 until 1 July 2019. 

Inclusion criteria (criterion):  

1. South African-trained medical interns  

 

2. Interns rotating through orthopaedic surgery for the first time 

Exclusion criteria:  

1. Interns who had obtained prior orthopaedic experience (e.g. if he/she had done any 

extra-curricular elective rotation in orthopaedic surgery at undergraduate level; or if 

he/she had any previous experience as a healthcare provider – specifically as a nurse, 

occupational therapist or physiotherapist) 

 

2. Any intern who had previous exposure to the study questionnaire  

 
3. Interns who submitted questionnaires that were incomplete or illegible 

2.6 Data collection 

Approval from the Human Research Ethics Committee (Medical) of the University of the 

Witwatersrand (ethics clearance number: M190667) and from each participating hospital’s 

Chief Executive Officer (CEO) or hospital manager to conduct the study was obtained (see 

Appendices C and D). All data was collected by the primary investigator, Dr M Terreblanche. 

Data was captured on a Microsoft Excel spreadsheet. The study participants were anonymised. 



 
10 

Basic demographic information (age, gender, race) of the respondents was collected. Other 

information that related to the intern’s undergraduate experience, the field of medicine the 

intern may wish to specialise in once their internship is completed, and how the intern 

perceived a personal level of confidence in diagnosing and managing a range of orthopaedic 

conditions and in performing certain orthopaedic diagnostic or therapeutic procedures was also 

captured on the questionnaire (see appendix B). The names of the universities the interns 

attended as undergraduates were captured. These were coded, numerically.  

2.7 Data analysis 

STATA version 14.0 statistical package was used for data analysis. Descriptive statistics were 

used to analyse the demographic profile of the study participants; these are reported as 

frequency and percentages for categorical variables. The mean and standard deviation (SD) or 

median and interquartile range (IQR) are reported for continuous variables as appropriate.  

For inferential statistics: 

1. A one-way analysis of variance (ANOVA) test was employed to test the correlation 

between the medical interns’ knowledge with the amount of exposure to orthopaedic 

surgery the interns received at undergraduate level. An ANOVA test was also employed 

to determine if medical interns with a future career interest in disciplines which may 

involve the care of orthopaedic patients performed better than those with a future career 

interest in disciplines which have no role in the care of orthopaedic patients. 

2. Regression analysis was used to assess the relationship of the medical interns’ self-

perceived confidence in orthopaedic surgery and their scores in the Freedman and 

Bernstein cognitive examination. 

3. A students t-test was applied to determine if medical interns who obtained a previous 

undergraduate bachelor’s degree performed better in the Freedman and Bernstein test 

or not. 

P-values < 0.05, with a confidence interval (CI) of 95%, were considered statistically 

significant. 

 

 



 
11 

Chapter 3: Results 

A total of 83 questionnaires were collected. Of these, 78 were suitable for inclusion in this 

study. 

3.1 Study participant demographics  

Study participants (medical interns) were recruited from the three academic hospitals in 

Johannesburg, SA, namely CHBAH, CMJAH and HJH during the course of the year 2019. 

There were 57 female respondents (73.1%), 20 male respondents (25.6%) and 1 respondent 

identified as ‘other’ (1.3%). The median age of the respondents was 26 years (IQR: 2). The 

racial profile of the study participants was as follows: 41% black (African), 37.2% white 

(Caucasian), 14.1% Indian, 7.7% mixed race (coloured) and 1.3% Asian. All the interns in this 

study had obtained their medical qualification from a South African university. There were 

three (3.9%) respondents from university 1, eight (10.3%) from university 2, seven (9%) from 

university 3, eleven (14.1%) from university 4, nine (11.5%) from university 5, thirty-four 

(43.6%) from university 6, two (2.6%) from university 7 and three (3.9%) from university 8. 

These numbers are reflected in Figures 3.1 – 3.3.  

 

Figure 3.1: Gender of the medical interns 

 

0

10

20

30

40

50

60

Gender

N
um

be
r o

f i
nt

er
ns

Female Male Other



 
12 

 

Figure 3.2: Racial profile of the medical interns 

 

 

Figure 3.3: University representation amongst the medical interns 

 

 

0

5

10

15

20

25

30

35

Race

N
um

be
r o

f i
nt

er
ns

Black White Indian Mixed race Asian

0

5

10

15

20

25

30

35

40

Universities

N
um

be
r o

f i
nt

er
ns

University 1 University 2 University 3 University 4

University 5 University 6 University 7 University 8



 
13 

3.2 Interns’ knowledge of orthopaedic surgery  

The interns’ mean score on the 25-question theoretical competency examination (Freedman 

and Bernstein questionnaire) was 40.7% (SD 13.4%) with a range of 17 – 69%. 

The pass mark recommended by the 124 orthopaedic residency chairpersons in the Freedman 

and Bernstein study was 73.1 ± 6.8%. 43 Using this pass mark, three out of the seventy-eight 

(3.8%) medical interns in this study achieved a mark higher than 73.1 ± 6.8% and thus achieved 

basic cognitive competency in the examination. Ninety-six percent (n = 75/78) of the interns 

thus did not achieve basic cognitive competency in the examination.  

In only seven of the twenty-five questions, did the interns achieve an overall score of more 

than 50%; with the interns scoring highest on question 7 (overall intern score of 87.2%) and 

question 10 (overall score of 83.3%). 

A copy of the Freedman and Bernstein questionnaire is provided below with the weight or 

importance of each question (out of a total of 10, as determined by the 124 chairpersons of 

orthopaedic residency programs in the Freedman and Bernstein study) 43 shown in the column 

to the right of the suggested answer for each question. The overall intern score for each question 

is displayed in the column to the right of the weight or importance of each question. Overall 

scores from one local study (Dachs et al.) 17 and one international study (Al-Nammari et al.) 21 

are provided alongside the overall scores for each question of this study, for comparison. 

Table 3. 1: Freedman and Bernstein questionnaire with the interns’ scores for each question 43 

Questions Answers Importance 

score (out 

of 10) 

Interns’ 

score 

(%) 

Interns’ 

score 

(Dachs 

et al.) 

Interns’ 

score (Al-

Nammari 

et al.)  

1. What common 

problem must all 

Congenital 

dislocation of the 

hip (CDH, 

9.1 53.2% 80.7% 87.6% 



 
14 

newborns be 

examined for? 

dislocation, 

subluxation also 

accepted): 1 point 

2. What is a 

compartment 

syndrome? 

Increased 

pressure in a 

closed fascial 

space: 1 point 

9.0 52.6% 71.8% 60.5% 

3. Acute septic 

arthritis of the knee 

may be 

differentiated from 

inflammatory 

arthritis by which 

laboratory test? 

Any analysis of 

fluid from 

aspiration (cell 

count, Gram 

stain, culture): 1 

point 

8.5 17.9% 21.8% 51.9% 

4. A patient 

dislocates his knee 

in a car accident. 

What structure(s) 

is/are at risk for 

injury and therefore 

must be evaluated? 

Must mention 

popliteal artery: 1 

point 

8.4 62.8% 51.3% 53.8% 



 
15 

5. A patient 

punches his 

companion in the 

face and sustains a 

fracture of the 5th 

metacarpal and a 

3mm break in the 

skin over the 

fracture. What is 

the correct 

treatment and why? 

Irrigation and 

debridement; risk 

of infection: ½ 

point each 

8.4 39.1% 32.7% 13.8% 

6. A patient comes 

to the office 

complaining of low 

back pain that 

wakes him up from 

sleep. What two 

diagnoses are you 

concerned about? 

Tumour and 

infection: ½ point 

each 

8.0 24.4% 28.2% 56.2% 

7. How is 

compartment 

syndrome treated? 

Fasciotomy 

(surgery also 

accepted): 1 point 

7.9 87.2% 92.3% 68.6% 



 
16 

8. A patient lands 

on his hand and is 

tender to palpation 

in the ‘snuff box’ 

(the space between 

the thumb extensor 

and abductor 

tendons). Initial 

radiographs do not 

show a fracture. 

What diagnosis 

must be 

considered?  

Scaphoid fracture 

(carpal bone 

fracture also 

accepted): 1 point 

7.8 43.6% 50.0% 72.9% 

9. A 25 year old 

man is involved in 

a motor vehicle 

accident. His left 

limb is in a 

position of flexion 

at the knee and the 

hip, with internal 

rotation and 

adduction of the 

Hip dislocation: 1 

point  

7.6 48.7% 59.0% 37.6% 



 
17 

hip. What is the 

most likely 

diagnosis? 

10. What nerve is 

compressed in 

carpal tunnel 

syndrome? 

Median nerve: 1 

point 

7.4 83.3% 87.2% 100% 

11. A patient had a 

disc herniation 

pressing on the 5th 

lumbar nerve root. 

How is motor 

function of the 5th 

lumbar nerve root 

tested? 

Dorsiflexion of 

the great toe (toe 

extensors also 

accepted): 1 point 

7.2 1.9% 9.0% 31.4% 

12. How is the 

motor function of 

the median nerve 

tested in the hand? 

Any median 

nerve function 

(metacarpophalan

geal flexion; 

thumb opposition, 

flexion or 

7.0 35.2% 44.2% 60.5% 



 
18 

abduction): 1 

point 

13. A 12 year old 

boy severely twists 

his left ankle. 

Radiographs show 

only soft tissue 

swelling. He is 

tender at the distal 

aspect of the fibula. 

What are two 

possible diagnoses? 

Ligament sprain 

and Salter-Harris 

I fracture (sprain, 

fracture also 

accepted): 1 point 

7.0 26.9% 41.7% 40.9% 

14. A patient 

presents with new-

onset low back 

pain. Under what 

conditions are plain 

radiographs 

indicated? Please 

name five 

(example: history 

of trauma) 

Age > 50 years; 

neurological 

deficit; bowel or 

bladder changes; 

history of cancer; 

pregnancy; drug 

use; or steroid 

use; systemic 

symptoms (night 

pain, fever); 

paediatric 

7.0 40.1% 57.1% 36.7% 



 
19 

population: ¼ 

point for each 

15. A patient has a 

displaced fracture 

near the fibular 

neck. What 

structure is at risk 

for injury? 

Common 

peroneal nerve 

(peroneal nerve 

also accepted): 1 

point 

6.8 39.7% 35.9% 68.6% 

16. A 20 year-old 

injured his knee 

while playing 

football. You see 

him on the same 

day, and he has a 

knee effusion. An 

aspiration shows 

frank blood. What 

are the three most 

common 

diagnoses?  

Ligament tear, 

fracture, 

peripheral 

meniscus tear 

(capsular tear, 

patellar 

dislocation also 

accepted): ½ 

point each, full 

credit for two 

correct responses 

6.8 35.9% 37.2% 55.2% 

17. What are the 

five most common 

Breast, prostate, 

lung, kidney, 

6.7 63.5% 63.3% 79.0% 



 
20 

sources of cancer 

metastases to 

bone? 

thyroid: ¼ point 

for each, full 

credit for four 

correct responses 

18. Name two 

differences 

between 

rheumatoid arthritis 

and osteo-arthritis? 

Any two correct 

statements (i.e 

inflammatory vs 

degenerative, 

proximal 

interphalangeal 

joint vs distal 

interphalangeal 

joint, etc): ½ 

point for each 

6.6 72.4% 46.8% 48.1% 

19. Which 

malignancy may be 

present in bone yet 

typically is not 

detected with a 

bone scan? 

Myeloma (full 

credit for 

haematological 

malignancies – 

leukaemia, 

lymphoma): 1 

point 

6.4 29.5% 38.5% 16.7% 



 
21 

20. What is the 

function of the 

normal anterior 

cruciate ligament 

of the knee? 

To prevent 

anterior 

displacement of 

the tibia on the 

femur: 1 point 

6.2 20.5% 24.4% 48.6% 

21. What is the 

difference between 

osteoporosis and 

osteomalacia? 

Osteoporosis: 

decreased bone 

density; 

osteomalacia: 

decreased bone 

mineralisation 

(any true 

statement about 

epidemiology, 

pathophysiology, 

e.g. oestrogen vs 

Vitamin D also 

accepted): 1 point 

5.7 28.8% 27.8% 60.5% 

22. In elderly 

patients, displaced 

fractures of the 

femoral neck are 

typically treated 

Blood supply to 

the femoral head 

(avascular 

necrosis, non-

5.2 39.1% 67.9% 75.2% 



 
22 

with joint 

replacement, 

whereas fractures 

near the trochanter 

are treated with 

plates and screws, 

why? 

union also 

accepted): 1 point 

23. What muscle(s) 

is/are involved in 

lateral epicondylitis 

(tennis elbow)?  

Wrist extensors 

(full credit for any 

wrist extensor – 

extensor carpi 

radialis brevis, 

extensor carpi 

radialis longus, 

extensor 

digitorum 

communis): 1 

point 

5.1 3.8% 17.9% 62.4% 

24. Rupture of the 

biceps at the elbow 

results in weakness 

of both elbow 

flexion and … ? 

Supination: 1 

point 

5.1 28.2% 28.2% 70.9% 



 
23 

 

3.2.1 Sub-analysis of the interns’ knowledge  

Interns’ overall scores for the orthopaedic emergencies (‘red flag’) questions 

These were questions 2, 4, 5, 6, 7 and 9 (see Table 3.1). The mean score of the interns for these 

questions was 52.4%.  

Interns’ overall scores for the anatomy-related questions 

These were questions 8, 10, 11, 12, 15, 20, 22, 23, 24 and 25 (see Table 3.1). The mean score 

for these questions was 33.2%. 

3.3 Interns’ self-perceived confidence levels in orthopaedic surgery  

The interns’ self-perceived levels of confidence in history taking and examination of an 

individual with a chronic shoulder and chronic knee complaint are displayed in Table 3.2. 

Table 3.2: Medical interns’ self-perceived confidence levels in history taking and physical 

examination of an individual with a chronic shoulder complaint and an individual with a 

chronic knee complaint  

  Number of interns 

(n) 

Percentage of total 

interns (%) 

Confidence in history taking  

(shoulder complaint)                  

  

Not confident 30 38.4% 

25. What muscle(s) 

control(s) external 

rotation of the 

humerus with the 

arm at the side? 

Infraspinatus or 

teres minor (full 

credit for rotator 

cuff): 1 point 

4.6 37.2% 14.1% 54.3% 



 
24 

Confident 40 51.3% 

Highly confident 8 10.3% 

Confidence in history taking  

(knee complaint)                   

    

Not confident 16 20.5% 

Confident 35 44.9% 

Highly confident 27 34.6% 

Confidence in examination (shoulder)     

Not confident 26 33.3% 

Confident 41 52.6% 

Highly confident 11 14.1% 

Confidence in examination (knee)     

Not confident 22 28.2% 

Confident 35 44.8% 

Highly confident 21 26.9% 

 

The interns’ self-perceived levels of confidence in performing various diagnostic and 

therapeutic procedures pertaining to individuals with musculoskeletal problems are displayed 

in Table 3.3. The overall self-reported levels of confidence amongst the interns are displayed 

in Table 3.4. 

 

 

 



 
25 

Table 3.3: Medical interns’ self-perceived confidence levels in diagnostic and therapeutic 

procedures related to individuals with musculoskeletal disorders 

  Number of interns 

(n) 

Percentage of total 

interns (%) 

Confidence in performance of 

application of plaster of Paris cast                

    

Not confident 12 15.4% 

Confident 42 53.9% 

Highly confident 24 30.7% 

Confidence in performance of knee 

joint aspiration         

    

Not confident 43 55.1% 

Confident 23 29.5% 

Highly confident 12 15.4% 

Confidence in performance of 

shoulder steroid injection  

    

Not confident 62 79.5% 

Confident 13 16.7% 

Highly confident 3 3.8% 

 

 

 

 

 



 
26 

Table 3.4: Medical interns’ overall self-perceived confidence levels in orthopaedic surgery 

Overall level of confidence Number of interns 

(n) 

Percentage of total 
interns (%) 

Not confident 6 7.7% 

Confident 53 67.9% 

Highly confident 19 24.4% 

 

The interns’ overall confidence in orthopaedic surgery (musculoskeletal medicine) was 

calculated by a summation of the Likert-scale scores the interns selected for the seven questions 

pertaining to their confidence levels. Considering that a score of 5 was the maximum score an 

intern could select amongst the self-perceived confidence questions, the maximum obtainable 

score when ranking the interns’ overall confidence in orthopaedic surgery for the seven 

questions was 35. Since Likert-scale scores of 1 or 2 were considered ‘not confident’, scores 

of 3 were considered ‘confident’ and scores of 4 or 5 were considered ‘highly confident’; and 

since there were seven questions pertaining to the interns’ self-perceived confidence levels, 

overall intern scores of 14 or less were considered ‘not confident’, overall intern scores of 15 

– 21 were considered ‘confident’ and scores of 22 – 35 were considered ‘highly confident’.  

3.4 Interns’ future career interest 

Future speciality interest was recorded, in order of descending frequency, as: anaesthesia in 

20.5% (n = 16/78), paediatrics in 12.8% (n = 10/78), internal medicine in 10.3% (n = 8/78), 

orthopaedic surgery in 7.7% (n = 6/78), psychiatry in 6.4% (n = 5/78), emergency medicine in 

5.1% (n = 4), neuro-surgery in 5.1% (n = 4/78), general practice (GP) in 3.8% (n = 3/78), 

radiology in 3.8% (n = 3/78), trauma surgery in 3.8% (n = 3/78), ophthalmology in 2.6% (n = 

2/78), general surgery in 2.6% (n = 2/78), pathology in 2.6% (n = 2/78), sports medicine (n = 

2) and plastic surgery in 2.6% (n = 2/78). These numbers are reflected in Figure 3.5. A wide 

range of other speciality interests was recorded in smaller numbers. These choices included: 

Ear, Nose and Throat (ENT); obstetrics and gynaecology; aviation medicine; public health; 

chemical pathology; and occupational health. Only one intern selected each of these 

specialities. These specialty choices have been grouped together under ‘other’ in Figure 3.4.  



 
27 

 

 

Figure 3.4: Future career interest of the medical interns 

Those specialities which have overlap with the assessment and/or care of individuals with 

musculoskeletal disorders or complaints were grouped as ‘related’, as in related to the care of 

orthopaedic patients or ‘unrelated’, as in specialities which are unrelated to the care of 

orthopaedic patients or are considered to have very little overlap with the assessment and/or 

care of individuals with musculoskeletal disorders or complaints. 

The ‘related’ group consisted of career choices such as orthopaedic surgery, anaesthesia, 

paediatrics, internal medicine, radiology, pathology, trauma surgery, emergency medicine, 

general practice and sports medicine.  

The ‘unrelated’ group consisted of career choices such as ophthalmology, ENT, obstetrics and 

gynaecology and psychiatry. 

Eighty-four percent (n = 66/78) of the interns indicated a future career interest in one of the 

specialities deemed to be ‘related’ to orthopaedic surgery or musculoskeletal medicine. Sixteen 

percent (n = 12/78) of the interns selected a future career which was deemed unrelated to 

orthopaedic surgery. This is illustrated in Figure 3.5. 

 

0

2

4

6

8

10

12

14

16

18

N
um

be
r o

f i
nt

er
ns

Future career interest

Anaesthesia Paediatrics Internal medicine Orthopaedic surgery

Other Psychiatry Emergency medicine Neuro-surgery

Trauma surgery Radiology GP General surgery

Pathology Plastic surgery Opthalmology Sports medicine



 
28 

 

Figure 3.5: Future career interest of the medical interns grouped into career choices considered 

related or unrelated to orthopaedic surgery  

 

3.5 Relationship of interns’ future career interest and knowledge of orthopaedic surgery  

Table 3.5 demonstrates the interns’ mean scores in the Freedman and Bernstein examination 

when interns’ future career interest was grouped into those specialities considered related to 

orthopaedic surgery and those considered unrelated to orthopaedic surgery.  

Table 3.5: Relationship of the medical interns’ future career interest, when grouped into career 

choices considered related to orthopaedic surgery and career choices considered unrelated to 

orthopaedic surgery, and their knowledge of orthopaedic surgery  

Group Number 

of interns 

(n) 

Mean 

Freedman 

& 

Bernstein 

score 

SD CI (95%)  P-value 

Career interest unrelated 

to orthopaedic surgery 

12 40.8% 11.9% 33.2 – 48.3 0.7457 

0

10

20

30

40

50

60

70
N

um
be

r o
f i

nt
er

ns

Future career interest

Related Unrelated



 
29 

Career interest related to 

orthopaedic surgery 

66 42.2% 13.5% 38.8 – 45.5   

Combined 78 41.9% 13.2% 39.0 – 44.9   

 

No statistically significant difference in the interns’ Freedman and Bernstein examination 

scores was detected when medical interns with a future career interest in specialities which are 

unrelated to orthopaedic surgery were compared to those with a future career interest in 

specialities which are related to orthopaedic surgery (p = 0.7457). 

When future career interest of the interns was grouped into orthopaedic surgery, surgical 

disciplines, non-surgical disciplines, and general practice (GP), the mean score of the interns 

in the orthopaedic surgery group was 43.6% (SD 16.2%), the mean score in the surgical group 

was 39% (SD 12.7%), the mean score of the interns in the non-surgical group was 41.8% (SD 

13.5%) while for the GP group the mean score of the interns was 35.6% (SD 15.0%), as 

illustrated in Table 3.6. 

Table 3.6: Relationship of the medical interns’ future career interest, when grouped into 

orthopaedic surgery, surgical specialties, non-surgical specialties and general practice, and 

their knowledge of orthopaedic surgery 

Future career choice Number of 
interns (n) 

Mean Freedman & 
Bernstein score 

SD P-value 

Orthopaedic surgery 6 43.6% 16.2% 0.4099 

Surgical specialities  15 38.8% 10.8%  

Non-surgical specialities 54 43.1% 13.4%  

General practice 3 32.4% 16.6%  

 

No statistically significant difference in the interns’ Freedman and Bernstein examination 

scores was detected comparing interns with a future career interest in surgical disciplines to 

those with a future career interest in non-surgical disciplines or general practice (p = 0.4099).  



 
30 

The future career interests of the three interns who passed the Freedman and Bernstein 

questionnaire were: plastic surgery (n = 1) and anaesthesia (n = 2). None of the interns who 

chose orthopaedic surgery as their future speciality passed the Freedman and Bernstein 

questionnaire in this study. Similarly, none of the interns who selected GP or family practice 

as their future career choice passed the examination. 

 

 

 

 

 

 

 

 

  



 
31 

Chapter 4: Discussion 

The results of this study provide insight into the knowledge and self-perceived confidence in 

orthopaedic surgery and musculoskeletal medicine that South African medical interns retain 

from their undergraduate curriculum. Essentially the findings of this study provide the reader 

with an understanding of how South African health sciences faculties prepare their newly 

qualified medical doctors to diagnose and treat disorders of the musculoskeletal system. 

4.1 Demographic profile of the interns 

The demographics of this cohort reflect a diverse group of recent medical graduates, from all 

universities in South Africa (see Figures 3.1 – 3.3). 

4.2 Knowledge of orthopaedic surgery amongst South African medical interns 

The primary aim of this study was to determine the knowledge and self-reported confidence 

levels in orthopaedic surgery amongst South African medical interns. The findings of this study 

are in keeping with the findings of previous studies on this topic conducted in SA; and with 

studies conducted internationally. 17 – 31 This study confirms that South African junior doctors’ 

knowledge of musculoskeletal medicine is inadequate, with 96.1% (n = 75/78) of the interns 

in this study failing the basic competency examination in musculoskeletal medicine designed 

by Freedman and Bernstein, and the interns achieving a mean score of 40.6%. 

Importantly, this study demonstrates that there has not been an improvement in basic 

musculoskeletal knowledge of junior doctors a decade after the first studies conducted on 

medical interns’ musculoskeletal competence was performed in SA. 17 – 19 On the contrary, this 

study demonstrated that South African medical interns’ knowledge has in fact worsened since 

the initial studies on intern knowledge and competence in orthopaedic surgery in SA were 

performed; a finding confirmed by Coetzee et al. in a recently published study on the same 

subject matter. 20 

4.2.1 Local comparisons  

With specific reference to local research on this subject matter, Dachs et al. 17 showed that 91% 

of interns that they surveyed at the start of their orthopaedic rotation in the Western Cape 

province of SA failed the basic cognitive competency examination, with an average score of 

45.3%. They suggested greater time be devoted to orthopaedic training, the content of the 



 
32 

curriculum be revised and more time be devoted to the teaching of anatomy in particular, since 

interns scored lowest on the anatomy-based questions. Robertson and Lukhele, in 2010, 

demonstrated an 89% failure rate amongst interns who completed the same questionnaire, with 

an average score of 51%. 19 More recently, in the study conducted by Coetzee et al., the largest 

study of interns’ competence in orthopaedic surgery in SA, showed that the interns they studied 

with the Freedman and Bernstein questionnaire had a 94% failure rate, with a mean cognitive 

score of 46%. 20  

4.2.2 International comparisons and recommendations 

Internationally, the original study by Freedman and Bernstein, published in 1998, showed a 

failure rate of 82% amongst first year residents in the USA, with an average score of 59.6%. 43 

Skelley et al. showed mean scores of 59% amongst medical students who were given the 

Freedman and Bernstein examination at the end of their fourth and final academic year. 23 Day 

et al., using the Freedman and Bernstein questionnaire as their assessment tool, showed a 

failure rate of 74% amongst final year medical students in the USA. 24 Similarly low cognitive 

competency amongst final year medical students or medical interns have been shown in the 

West Indies, Nepal, Australia, India and Hawaii. 25 – 30 In an Australian study, the failure rate 

amongst 66 interns was 60.6% and the mean score was 69.4%. 29 More recently, Al-Nammari 

et al. found that 79% of the newly qualified doctors in the UK they studied failed the Freedman 

and Bernstein cognitive examination with an average score of 56.5%. 21  

This demonstrates that the overall scores in the Freedman and Bernstein questionnaire amongst 

international junior doctors or final year medical students are higher than newly qualified South 

African doctors; and that their failure rates are lower.  

These studies all called for greater quantity but also improved quality of musculoskeletal 

education at undergraduate level; similarly they recommended nationally commissioned 

investigations into the deficiency in knowledge pertaining to musculoskeletal medicine. One 

study advocated for inter-disciplinary teaching of musculoskeletal medicine since the care of 

musculoskeletal disorders is provided for by doctors working in different disciplines, and this 

would not only serve to reinforce knowledge already gained previously, but would provide 

unique insights into care of musculoskeletal disorders from the various disciplines. 

 

 



 
33 

4.3 Self-perceived confidence levels in orthopaedic surgery amongst medical interns 

In contrast to other studies, this study found that interns have mixed levels of self-perceived 

confidence in their abilities to diagnose, investigate and treat common musculoskeletal 

disorders. 21, 23, 24 

The overall self-reported confidence levels amongst the interns in this study were high, with 

24.3% (n = 19/78) feeling ‘highly confident’; 67.9% (n = 53/78) of the interns feeling 

‘confident’ in musculoskeletal medicine, and only 7.7% (n = 6/78) rating themselves as ‘not 

confident’. 

The majority of interns in this study felt confident or highly confident with regards to history 

taking and physical examination (as illustrated in Table 3.2). 

The results of the interns’ knowledge of basic anatomy of the knee and shoulder joint conflict 

with these high levels of self-perceived confidence. Only 20.5% (n = 16/78) of the interns had 

knowledge of the function of the anterior cruciate ligament and only 37.2% (n = 29/78) of the 

interns had knowledge of which muscles are responsible for external rotation of the shoulder.  

The findings of this study contrast with the international literature. Skelley et al. found low 

scores of self-reported confidence levels in assessing musculoskeletal disorders, amongst USA 

medical students. 23 Day et al. similarly demonstrated that medical students in their final year 

of study at Harvard medical school had low self-rated confidence levels in the examination of 

the musculoskeletal system, compared to their confidence in examination of the respiratory 

system. 24 Al-Nammari et al. 21, in the UK, reported that only 40% (n = 83/210) of their study 

cohort felt confident in musculoskeletal medicine. These authors recommended greater 

exposure to musculoskeletal medicine at undergraduate level to improve confidence levels. 

In contrast to their high confidence scores related to history taking and physical examination, 

the interns in this study showed lower scores of self-reported confidence in performing basic 

diagnostic and therapeutic procedures. Although the majority of the interns felt confident at 

being able to apply a plaster of Paris cast for a fracture, the majority of them lacked confidence 

in the performance of aspiration of the knee joint and the performance of a steroid injection of 

the shoulder (as shown in Table 3.3). Skills teaching could thus be a potential area to target in 

the future training of medical graduates in South Africa.  

 



 
34 

4.4 Future career interest of medical interns 

This study demonstrated that South African graduates’ career ambitions have no significant 

bearing on their knowledge of orthopaedic surgery, as illustrated in Tables 3.5 and 3.6.  

This contrasts to other studies which showed a significantly greater knowledge of orthopaedic 

surgery amongst those who wished to enter into a career in musculoskeletal medicine than 

interns who selected other career choices. Skelley et al. showed that medical students who 

wished to enter into disciplines related to musculoskeletal medicine performed better, with an 

average score of 67.5%, than students who wished to enter into careers unrelated to 

musculoskeletal medicine, with an average score of 43.9%. 23 Similarly, Al-Nammari et al. 

found that 52% of their cohort who had a future interest in musculoskeletal specialities passed 

the Freedman and Bernstein examination while only 38% of those with an interest in surgical 

disciplines passed the examination. 21 In contrast, they found that only 9% of those with an 

interest in internal medicine passed the examination and none of the respondents with an 

interest in general practice passed. 21  

None of the interns in the current study who selected general practice or family practice as their 

future speciality of choice passed the Freedman and Bernstein questionnaire. This is 

concerning as a substantial proportion of a general practitioner’s workload will be individuals 

with musculoskeletal complaints or injuries. 

4.5 Limitations of the study 

The findings of this study may be limited by the validity of the Freedman and Bernstein 

questionnaire in the South African context. Furthermore, the Likert scale in this study has not 

been validated. There may have been a selection bias introduced due to medical interns being 

recruited from only three hospitals in one province. This resulted in an overwhelming 

representation from one university. Lastly, it could be argued that the subjects did not take the 

examination seriously as there was no consequence to underperformance.  

4.6 Recommendations 

The current study has highlighted a deficiency in undergraduate teaching of orthopaedic 

surgery in South Africa. This has resulted in poor knowledge and inappropriate levels of 

confidence in orthopaedics amongst recent medical graduates. Therefore, this study highlights 

a need for curricula to be revised again and for the duration of time spent in orthopaedic training 



 
35 

to be reconsidered. Methods of teaching should be reviewed, and teaching objectives in the 

South African context more clearly defined. An appropriate assessment tool to evaluate 

knowledge of orthopaedic surgery, validated for the South African setting, needs to be 

developed. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 
36 

Chapter 5: Conclusion 

This study has shown that the effectiveness of South African undergraduate training of 

orthopaedic surgery is deficient. Recent medical graduates’ knowledge of orthopaedic surgery, 

using the Freedman and Bernstein questionnaire, is inadequate, with a mean score of 40.7% 

and only 3.8% of interns passing the examination. This is similar to other local and international 

literature. The recent medical graduates in this study demonstrated inappropriate confidence in 

orthopaedic surgery with only 7.7% acknowledging a lack of confidence. The interns lacked 

confidence in the performance of various skills related to musculoskeletal pathologies, skills 

that all general practitioners should be well versed in. Interns’ future career interest was not 

found to have a significant association with orthopaedic knowledge. This is in contrast to 

international literature. Graduates with a career choice related to orthopaedic surgery achieved 

an overall score of 42.2% in the Freedman and Bernstein examination versus an overall score 

of 40.8% in those who chose a career unrelated to orthopaedic surgery. This study suggests 

that in South Africa orthopaedic undergraduate training needs improvement.  

 

 

 

 

 

 

 

 



 
37 

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23. Skelley NW, Tanaka MJ, Skelley LM, LaPorte DM. Medical student musculoskeletal 

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24. Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: An 

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26. Abhinav B, Mayur V, Vanamali S. Inadequacy of Musculoskeletal Knowledge Among 

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the university of West Indies, Barbados. West Indian Med J. 2001;50:66-68  

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musculoskeletal medicine. J Bone Joint Surg [Am]. 2005;87(2):310-314  

29. Broadhurst N. Measuring cognitive and clinical competency in orthopaedics. J Bone 

Joint Surg [Am]. 2002;84(4):683-684  

30. Tamrakar R, Basnyat S, Gyawali B, et al. Adequacy of undergraduate orthopedic 

training at a Nepalese Medical Academy. Med J Shree Birendra Hosp. 2017;15(2):13-

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31. Atrey A, Hunter J, Gibb PA, Gupte C. Assessing and improving the knowledge of 

orthopaedic foundation-year doctors. Clin Teach. 2010;7(1):41-46 

32. Nkabinde TC, Ross A, Reid S, Nkwanyana NM. Internship training adequately 

prepares South African medical graduates for community service – with exceptions. S 

Afr Med J. 2013;103(12):930-934 

33. Ghani et al. Undergraduate and foundation training in trauma and orthopaedics: junior 

doctors have their say. Br J Hosp Med (Lond). 2015;76(7):415-419 

34. Lynch JR, Schmale GA, Schaad DC, Leopold SS. Important demographic variables 

impact the musculoskeletal knowledge and confidence of academic primary care 

physicians. J Bone Joint Surg [Am]. 2006;88-A:1589-1595 

35. Di Giovanni BF, Sunden LT, Southgate RD, Lambert DR. Musculoskeletal medicine 

is underrepresented in the American medical school clinical curriculum. Clin Orthop 

Relat Res. 2016;474(4):901-907 

36. Pinney SJ, Regan WD. Educating medical school students about musculoskeletal 

problem: are community needs reflected in the curricula of Canadian medical schools? 

J Bone Joint Surg [Am]. 2001;83(9):1317–1320  



 
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37. Namane M. How to examine for and inject a painful shoulder. In: Mash B, Blitz J, 

editors. South African Family Practice Manual, 2nd ed. Pretoria, South Africa: Van 

Schaik Publishers; 2006. pp. 47-49  

38. Namane M. How to examine, aspirate and inject an inflamed knee. In: Mash B, Blitz J, 

editors. South African Family Practice Manual. 2nd ed. Pretoria, South Africa: Van 

Schaik Publishers; 2006. p. 59 

39. Hosseinzadeh et al. Delay in the Diagnosis of Stable Slipped Capital Femoral 

Epiphysis; J Pediatr Orthop. 2017;37(1):e19-e22 

40. Nunn TR, Cheung WY, Rollinson PD. A prospective study of pyogenic sepsis of the 

hip in childhood. J Bone Joint Surg [Br]. 2007;89(1):100-106 

41. Hoffman EB, Knudsen CJ, Paterson MP. Acute osteomyelitis and septic arthritis in 

children: a spectrum of disease. Pediatr Surg Int. 1990;5:382-386  

42. Molefe R. Limpopo’s health department faces medical negligence claims in excess of 

R14 billion. News24. 16 February 2022 (Date accessed: 16 February 2022) 

43. Freedman KB, Bernstein J. The adequacy of medical school education in 

musculoskeletal medicine. J Bone Joint Surg [Am]. 1998;80(10):1421-1427 

44. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J 

Bone Joint Surg [Am]. 2002;84(4):604-608 

45. Health Professions Council of South Africa (Medical and Dental Professions Board). 

Handbook on internship training: guidelines for interns, accredited facilities and health 

authorities. Pretoria 2021  

46. Govender S. Musculoskeletal trauma – are we winning? SA Orthop J. 2011;10(3):8 

47. van der Jagt D, Golele R, Govender S, Lukhele M, Shipley JA, Vlok GJ, Walters J. 

Orthopaedic injuries in state hospitals compromised. S Afr Med J. 2008;98(8):601-602 

48. Marais LC, Dunn R. Teaching and training in orthopaedics. SA Orthop J. 

2017;16(4):15-19 

 

 

 

 

 



 
41 

Appendices 

Appendix A: Informed consent document 

 

Informed consent 

Study Title: Evaluation of medical interns’ knowledge and confidence in orthopaedic 

surgery at the University of the Witwatersrand’s academic hospital complex in 

Johannesburg, South Africa 

Good day, 

My name is Dr Michael Terreblanche and I am a registrar working in the department of 

orthopaedic surgery at the University of the Witwatersrand. I am conducting research in the 

form of a survey/questionnaire to understand the level of knowledge and confidence in 

orthopaedic surgery of medical interns working and training at hospitals affiliated to the 

University of the Witwatersrand. This research will contribute towards my Masters degree in 

medicine, which is a requirement for one to become a specialist orthopaedic surgeon in South 

Africa. 

I would like to invite you to consider participating in the study I am conducting entitled: 

“Evaluation of medical interns’ knowledge and confidence in orthopaedic surgery at the 

University of the Witwatersrand’s academic hospital complex in Johannesburg, South Africa” 

Before agreeing to participate, it is important that you read and understand the following 

explanation of the purpose of the study, the study procedures, benefits, and your right to 

withdraw from the study at any time. 



 
42 

The information provided in this consent form is to help you to decide if you would like to 

participate.  

Local and international research has shown that medical undergraduates do not receive 

sufficient exposure to and training within orthopaedic surgery. Furthermore, studies have 

shown that, globally, junior doctors’ knowledge of orthopaedic surgery is low. This is 

concerning because musculoskeletal conditions are common and patients with musculoskeletal 

problems present frequently to both emergency centres and to general/family practitioners. 

Musculoskeletal conditions and disorders can have a significant impact on individuals in terms 

of disability and chronic pain, especially if managed sub-optimally; and also on society (time 

away from work, loss of productivity, permanent disability etc.). The treatment of 

musculoskeletal injuries and disorders consumes a large portion of health care budgets, and 

even more so if treatment or management is delayed or sub-optimal when extensive and/or 

expensive reconstructive surgical procedures are often required to treat problems as a result of 

inadequate initial care of the individual.  

There is a shortage of orthopaedic surgeons working in state health care facilities in South 

Africa, so it is becoming necessary for non-orthopaedic specialists to become proficient in 

managing orthopaedic conditions. The low level of knowledge of orthopaedic surgery among 

junior doctors is particularly alarming in South Africa where relatively inexperienced doctors 

undertaking their mandatory year of community service often have to manage orthopaedic 

conditions in rural hospitals without the direct supervision of an orthopaedic specialist. Some 

of the other knock on effects of inadequate knowledge and confidence in orthopaedic surgery 

among junior doctors are that it impacts on registrar training of orthopaedics as more and more 

trauma cases are referred to academic/university hospitals where more elective (non-trauma) 

orthopaedic surgical procedures should be carried out. This has the added consequence of 

orthopaedic consultants becoming demotivated and uninspired to remain working in state 



 
43 

health care facilities (where registrar training takes place) as they do not get the opportunities 

to develop their surgical skill in elective (non-trauma) orthopaedic procedures, as most of their 

time is spent operating on trauma cases. Registrar training is thus further impacted as more and 

more consultants leave state health care facilities to pursue career development in the private 

health care sector.  

In the context of the information presented above, the purpose of this research is to determine 

the knowledge and confidence in orthopaedic surgery of South African junior doctors (medical 

interns) and if it is found that South African junior doctors are inadequately prepared to care 

for individuals with musculoskeletal injuries or disorders, this might provide co-ordinators 

with an opportunity to improve undergraduate and/or postgraduate orthopaedic training in 

South Africa. 

In this questionnaire, you will be asked to provide basic demographic details such as your age, 

gender and race; and you will be asked questions relating to your potential choice of future 

career interest. You will be asked questions pertaining to the orthopaedic teaching/training you 

received at undergraduate level. You will be asked questions relating to how confident you feel 

you are at managing and diagnosing certain orthopaedic conditions. You will also be asked a 

set of questions to assess your knowledge of orthopaedic surgery.  

Your participation in this research is completely voluntary and your responses to the questions 

in the questionnaire will be completely anonymous. Your participation in, or decision not to 

participate in this research and your answers to the questions in this survey will not influence 

your assessment at the end of your orthopaedic rotation in any way.  

If you are willing to take part in this research, kindly tick the check box next to where it says 

“voluntarily agree to participate” at the bottom of this page. If you would not like to participate 



 
44 

in this research, kindly tick the check box at the bottom of this page next to where it says 

“voluntarily disagree to participate”. 

I have been informed of the content of, and the purpose of this research questionnaire and I: 

Voluntarily agree to participate in this research questionnaire    ☐ 

Voluntarily disagree to participate in this research questionnaire ☐ 

Thank you for your time. 

Dr M Terreblanche 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 
45 

Appendix B: Study questionnaire 

 

Undergraduate experience 

 

Where did you obtain your medical degree? 

South Africa   ☐ 

Outside of South Africa  ☐ 

 

Did you undertake an elective in orthopaedic surgery as a medical student (whether part of 

your curriculum or on your own accord) or receive any additional teaching or training in 

orthopaedic surgery outside of the official teaching set aside for orthopaedic surgery as a 

medical student?  ___________________________________ 

 

If you answered ‘yes’ to the question above, or if you have ever seen or completed the 

Freedman and Bernstein questionnaire you do not need to complete the remainder of this 

questionnaire. 

 

If you answered ‘no’ to the question above, and if you wish to participate in this study/research, 

kindly complete the remainder of the questionnaire. 

 



 
46 

What was the duration of your orthopaedic training at undergraduate level (in weeks)? 

______________________________ 

 

Were you required to partake in after-hours duties (e.g. “calls”) in orthopaedic surgery as a 

medical student? 

Yes  ☐ 

No  ☐ 

 

If you answered yes to the above question, what did your after-hours duties consist of? 

Limited “calls” (e.g. until 22h00 or similar)  ☐ 

24 hour “calls”     ☐ 

 

Did you achieve an undergraduate bachelor’s degree prior to achieving your medical degree 

(MBChB, MBBCh or equivalent)?  

Yes  ☐ 

No  ☐ 

 

 



 
47 

Demographic information 

Please indicate your: 

Age (years)  ____________  

Gender  

 Male  ☐ 

 Female  ☐ 

Other  ☐ 

Race  

 African (black)    ☐ 

 Asian (Indian)     ☐ 

 Asian (Oriental ancestry)   ☐ 

Caucasian (white)    ☐ 

Mixed race (coloured)    ☐ 

Other      ☐ 

 

 

 



 
48 

Future career interest: 

 

Please select one of the following options: 

General practice/family practice   ☐ 

Internal medicine     ☐ 

Anaesthesia/pain management    ☐ 

Sports medicine     ☐ 

Emergency medicine      ☐ 

Orthopaedic surgery     ☐ 

Paediatrics      ☐ 

Occupational health     ☐ 

Trauma surgery     ☐ 

General surgery     ☐ 

Rheumatology      ☐ 

Other       ☐ 

Please specify       _______________________________ 

 



 
49 

Rating your confidence in orthopaedic surgery 

 

On a scale of 1 – 5 (1 = none, 2 = low, 3 = adequate, 4 = high, 5 = complete), how would you 

rate your confidence in taking a history to help you to formulate a differential diagnosis (e.g. 

coming up with five diagnostic possibilities) for: 

 

A patient with a shoulder complaint (e.g. chronic shoulder pain)   

1 ☐  2 ☐  3 ☐ 4 ☐ 5 ☐ 

 

A patient with a knee complaint (e.g. chronic knee pain):    

1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 

 

Using the same scale (1 – 5), how would you rate your confidence in:  

 

Performing an examination of the shoulder in order to formulate a differential diagnosis in a 

patient with a shoulder complaint (e.g. chronic shoulder pain): 

1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 

 



 
50 

Performing an examination of the knee in order to formulate a differential diagnosis in a patient 

with a knee complaint (e.g. chronic knee pain): 

1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 

 

Using the same scale (1 – 5), how would you rate your confidence in: 

 

Applying a plaster of Paris cast for a fracture: 

1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 

 

Performing a diagnostic aspiration (arthrocentesis) of a knee joint in an adult patient with a 

knee effusion of unknown cause: 

1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 

 

Performing a local anaesthetic steroid injection (LASI) for an adult patient with gleno-humeral 

(shoulder) joint osteo-arthritis or supraspinatus tendonitis:  

1 ☐ 2 ☐ 3 ☐ 4 ☐  5 ☐ 

 

 



 
51 

Freedman and Bernstein questionnaire: 

Questions Answers 

1. What common problem must all newborns 

be examined for? 

Congenital dislocation of the hip (CDH, 

dislocation, subluxation also accepted): 1 

point 

2. What is a compartment syndrome? Increased pressure in a closed fascial space: 

1 point 

3. Acute septic arthritis of the knee may be 

differentiated from inflammatory arthritis by 

which laboratory test? 

Any analysis of fluid from aspiration (cell 

count, Gram stain, culture): 1 point 

4. A patient dislocates his knee in a car 

accident. What structure(s) is/are at risk for 

injury and therefore must be evaluated? 

Must mention popliteal artery: 1 point 

5. A patient punches his companion in the 

face and sustains a fracture of the 5th 

metacarpal and a 3mm break in the skin over 

the fracture. What is the correct treatment 

and why? 

Irrigation and debridement; risk of infection: 

½ point each 



 
52 

6. A patient comes to the office complaining 

of low back pain that wakes him up from 

sleep. What two diagnoses are you 

concerned about? 

Tumour and infection: ½ point each 

7. How is compartment syndrome treated? Fasciotomy (surgery also accepted): 1 point 

8. A patient lands on his hand and is tender 

to palpation in the ‘snuff box’ (the space 

between the thumb extensor and abductor 

tendons). Initial radiographs do not show a 

fracture. What diagnosis must be 

considered?  

Scaphoid fracture (carpal bone fracture also 

accepted): 1 point 

9. A 25 year old man is involved in a motor 

vehicle accident. His left limb is in a position 

of flexion at the knee and the hip, with 

internal rotation and adduction of the hip. 

What is the most likely diagnosis? 

Hip dislocation: 1 point  

10. What nerve is compressed in carpal 

tunnel syndrome? 

Median nerve: 1 point 



 
53 

11. A patient had a disc herniation pressing 

on the 5th lumbar nerve root. How is motor 

function of the 5th lumbar nerve root tested? 

Dorsiflexion of the great toe (toe extensors 

also accepted): 1 point 

12. How is the motor function of the median 

nerve tested in the hand? 

Any median nerve function 

(metacarpophalangeal flexion; thumb 

opposition, flexion or abduction): 1 point 

13. A 12 year old boy severely twists his left 

ankle. Radiographs show only soft tissue 

swelling. He is tender at the distal aspect of 

the fibula. What are two possible diagnoses? 

Ligament sprain and Salter-Harris I fracture 

(sprain, fracture also accepted): 1 point 

14. A patient presents with new-onset low 

back pain. Under what conditions are plain 

radiographs indicated? Please name five 

(example: history of trauma) 

Age > 50 years; neurological deficit; bowel 

or bladder changes; history of cancer; 

pregnancy; drug use; or steroid use; systemic 

symptoms (night pain, fever); paediatric 

population: ¼ point for each 

15. A patient has a displaced fracture near the 

fibular neck. What structure is at risk for 

injury? 

Common peroneal nerve (peroneal nerve also 

accepted): 1 point 

16. A 20 year-old injured his knee while 

playing football. You see him on the same 

Ligament tear, fracture, peripheral meniscus 

tear (capsular tear, patellar dislocation also 



 
54 

day, and he has a knee effusion. An 

aspiration shows frank blood. What are the 

three most common diagnoses?  

accepted): ½ point each, full credit for two 

correct responses 

17. What are the five most common sources 

of cancer metastases to bone? 

Breast, prostate, lung, kidney, thyroid: ¼ 

point for each, full credit for four correct 

responses 

18. Name two differences between 

rheumatoid arthritis and osteo-arthritis? 

Any two correct statements (i.e. 

inflammatory vs degenerative, proximal 

interphalangeal joint vs distal 

interphalangeal joint, etc): ½ point for each 

19. Which malignancy may be present in 

bone yet typically is not detected with a bone 

scan? 

Myeloma (full credit for haematological 

malignancies – leukaemia, lymphoma): 1 

point 

20. What is the function of the normal 

anterior cruciate ligament of the knee? 

To prevent anterior displacement of the tibia 

on the femur: 1 point 

21. What is the difference between 

osteoporosis and osteomalacia? 

Osteoporosis: decreased bone density; 

osteomalacia: decreased bone mineralisation 

(any true statement about epidemiology, 

pathophysiology, e.g. oestrogen vs Vitamin 

D also accepted): 1 point 



 
55 

 

 

 

 

 

 

 

22. In elderly patients, displaced fractures of 

the femoral neck are typically treated with 

joint replacement, whereas fractures near the 

trochanter are treated with plates and screws, 

why? 

Blood supply to the femoral head (avascular 

necrosis, non-union also accepted): 1 point 

23. What muscle(s) is/are involved in lateral 

epicondylitis (tennis elbow)?  

Wrist extensors (full credit for any wrist 

extensor – extensor carpi radialis brevis, 

extensor carpi radialis longus, extensor 

digitorum communis): 1 point 

24. Rupture of the biceps at the elbow results 

in weakness of both elbow flexion and … ? 

Supination: 1 point 

25. What muscle(s) control(s) external 

rotation of the humerus with the arm at the 

side? 

Infraspinatus or teres minor (full credit for 

rotator cuff): 1 point 



 
56 

Appendix C: Human Research Ethics Committee (Medical) Certificate  

 

 

 



 
57 

Appendix D: Hospital CEO permission letters 

 

 



 
58 

 

 



 
59