A 19-year-old motorcyclist had just bought a 1000 cc super motorcycle. While negotiating a corner, it appears that he lost control and the bike skidded into the path of an oncoming 4 × 4. The rider’s body hit the vertical front of the vehicle obliquely bouncing across into the ditch. The car driver was uninjured and used a mobile phone to summon assistance. A paramedic was on site within 10 minutes. The helmet was removed and the rider was put onto a spineboard and brought in blue and unresponsive arriving 25 minutes after the 999 call.

As soon as the leathers and clothing were cut away, it became clear that the left femur was sticking out through the skin of the mid-thigh.

A 28-year-old woman is referred to the clinic with painful hands. Her symptoms began several months ago and now all of her metacarpophalangeals are affected. Her fingers are stiff for several hours each morning and swollen for most of the day.

The patient is diagnosed with rheumatoid arthritis and commenced on methotrexate as first-line disease-modifying therapy.

Several months later she presents as an emergency with increasing shortness of breath.

After several years of DMARD (disease-modifying antirheumatic drug) therapy her disease remains uncontrolled. Examination reveals classic bony deformities and muscle wasting in her hands.

The patient has read about TNF (tumour necrosis factor) blockade on the internet and is keen to try it.

A 4-year-old child is brought in by her mother. For 2 days she has been off colour, and is now toxic and generally unwell. The child is crying, wants to be picked up by her mother but screams when her mother tries. There appears to be extreme pain in the left leg and she will not take any weight through that leg. It is difficult to localise the source of the pain – it could be the knee, the hip or even referred from the back.