Surgery

Match the following pediatric orthopedic conditions with their most characteristic clinical presentation and diagnostic findings.

A 13-year-old boy is brought to the clinic by his parents due to a 4-week history of dull, aching pain in his right anterior thigh and knee. He has no history of recent trauma, and he has been afebrile. His body mass index (BMI) is 34 kg/m². He walks with a noticeable limp, keeping his right foot externally rotated. On physical examination, internal rotation of the right hip is significantly limited and elicits pain. When the physician passively flexes the patient's right hip, the thigh obligatorily rotates outward. Radiographs of the pelvis demonstrate widening of the right proximal femoral physis with posterior and inferior displacement of the epiphysis relative to the femoral neck. Which of the following is the most appropriate next step in management?

An otherwise healthy 65-year-old woman arrives at the emergency department with severe right wrist pain and visible deformity following a slip and fall onto her outstretched hand. She is alert, and her vital signs are within normal limits. Physical examination reveals a characteristic 'dinner-fork' deformity of the right wrist with moderate swelling. There are no open wounds. Radiographs demonstrate a dorsally displaced, extra-articular fracture of the distal radius. The treating physician decides to manage the fracture non-operatively. Arrange the following steps for the acute management of this patient's fracture in the correct chronological order.

Match each acute orthopedic injury with its most classic associated neurovascular complication or physical examination finding.

A 29-year-old male is transported to the emergency department following a high-speed motorcycle collision where he was thrown from the vehicle. Upon arrival, the patient is confused and diaphoretic. Vital signs show a temperature of 36.5°C (97.7°F), heart rate of 138/min, blood pressure of 78/40 mmHg, and respiratory rate of 26/min. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is soft, non-distended, and non-tender to palpation. Bedside focused assessment with sonography for trauma (FAST) reveals no free fluid in the intraperitoneal space or pericardium. Pelvic examination demonstrates a significant scrotal hematoma and mechanical instability with gentle anterior-posterior compression. Neurologic examination shows intact motor function in both lower extremities, and dorsalis pedis pulses are palpable but faint bilaterally. Which of the following is the most appropriate next step in management?

A 35-year-old woman is brought to the emergency department after a high-velocity motor vehicle collision. Her primary trauma survey is intact, and she is hemodynamically stable. She complains of severe right hip pain. On physical examination, her right lower extremity is shortened, internally rotated, and adducted. Arrange the following steps in the optimal chronological order for the acute orthopedic management of this patient's condition.

A 22-year-old man is evaluated in the hospital for escalating right lower extremity pain. Eight hours ago, he sustained a closed diaphyseal fracture of the right tibia and fibula during a rugby match. The fracture was initially managed in the emergency department with closed reduction and application of a long-leg cast. The patient now describes his pain as a severe, burning ache that is "much worse than when the bone broke." He has received two doses of intravenous morphine over the past hour with no significant relief.

Vital signs are temperature 37.1°C (98.8°F), pulse 105/min, and blood pressure 135/85 mmHg.

On physical examination, the patient is visibly distressed. The visible toes of the right foot are pink, and capillary refill time is less than 2 seconds. Passive plantar flexion of the ankle and toes elicits excruciating pain in the anterior lower leg. The dorsalis pedis and posterior tibial pulses are palpable.

Which of the following is the most appropriate next step in management?

A $27$-year-old male construction worker is brought to the trauma bay after falling approximately $20\text{ feet}$ from scaffolding. On arrival, he is confused and profusely diaphoretic. His temperature is $36.2^\circ\text{C}$, heart rate is $128\text{ /min}$, blood pressure is $82/50\text{ mm Hg}$, and respiratory rate is $26\text{ /min}$. A rigid cervical collar is in place. The airway is patent, and breath sounds are vesicular and equal bilaterally. The trachea is midline. Heart sounds are rapid but regular without murmurs. The abdomen is flat, soft, and non-distended. Anteroposterior compression of the anterior superior iliac spines reveals abnormal mobility and elicits crepitus. A focused assessment with sonography for trauma (FAST) exam demonstrates no intraperitoneal free fluid and no pericardial effusion. Two large-bore intravenous lines are established, and $1\text{ L}$ of warmed crystalloid is rapidly infusing. Which of the following is the most appropriate next step in management?

A 59-year-old woman is evaluated on postoperative day 7 following an open hysterectomy and lysis of adhesions. She had been tolerating a liquid diet and passing flatus until 24 hours ago, when she developed progressive, crampy abdominal pain and obstipation. Over the past 4 hours, the pain has become severe and constant. Her temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), pulse is $126/\text{min}$, respirations are $26/\text{min}$, and blood pressure is $86/52\text{ mmHg}$. Physical examination reveals a markedly distended abdomen with diffuse rigidity, rebound tenderness, and involuntary guarding. Laboratory studies show a leukocyte count of $21,000/\text{mm}^3$ and a serum lactate level of $5.1\text{ mmol/L}$. An abdominal radiograph demonstrates multiple dilated loops of small bowel with air-fluid levels and a lack of gas in the colon. Which of the following are the most appropriate next steps in this patient's management? (Select two)

A 54-year-old male is evaluated on postoperative day 5 following a robotic-assisted partial nephrectomy for a localized renal mass. His past medical history is significant for obesity, hypertension, and type 2 diabetes mellitus. The patient complains of a new-onset dull ache and swelling in his left leg that started this morning. He also reports feeling warm. His temperature is 38.4°C (101.1°F), blood pressure is 142/88 mmHg, pulse is 102/min, and respirations are 18/min. Oxygen saturation is 98% on ambient air. Physical examination reveals pitting edema and erythema of the left calf, which is exquisitely tender to palpation. The surgical incisions are well-approximated, clean, and dry, with no surrounding induration or discharge. The abdomen is soft and non-distended with normal active bowel sounds. Which of the following is the most appropriate next step in management?

A 45-year-old woman is evaluated in the post-anesthesia care unit 2 hours after undergoing an uncomplicated total thyroidectomy for a multinodular goiter. The nurse urgently requests an evaluation because the patient has become extremely agitated and is complaining of difficulty breathing. Her blood pressure is 142/88 mmHg, pulse is 115/min, and oxygen saturation is 86% on room air. Physical examination reveals audible inspiratory stridor and a tense, rapidly expanding swelling beneath the cervical incision. Arrange the following management steps in the most appropriate chronological order.

During morning rounds, the surgical team evaluates a 67-year-old man who is recovering from an elective open abdominal aortic aneurysm repair performed 48 hours ago. The overnight nurse reported a single temperature spike. The patient states he feels generally well, though he has mild pain at the surgical site when coughing. His past medical history is significant for chronic obstructive pulmonary disease and hypertension. Current vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 138/86 mm Hg, heart rate of 94/min, and respiratory rate of 18/min. Oxygen saturation is 94% on room air. Auscultation of the chest reveals decreased breath sounds at both lung bases and faint end-expiratory wheezes. The abdomen is soft, and the midline laparotomy incision demonstrates healthy granulation without fluctuance, excessive erythema, or purulence. The indwelling urinary catheter was discontinued yesterday, and the patient reports normal, painless urination. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated on postoperative day 6 following an elective laparoscopic sigmoid colectomy with primary anastomosis for recurrent diverticulitis. He had been recovering well, tolerating a soft diet, and passing flatus. Over the past 12 hours, he has developed severe, diffuse abdominal pain, nausea, and confusion. Vital signs show a temperature of 39.2°C (102.6°F), heart rate of 128/min, blood pressure of 82/50 mmHg, and respiratory rate of 26/min. Pulse oximetry is 94% on room air. Physical examination reveals a distended, rigidly tense abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. A surgical drain left in the pelvis during the initial procedure now shows 100 mL of new purulent, feculent output. Two large-bore peripheral intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

A 62-year-old man is evaluated on postoperative day 5 after undergoing an elective open cholecystectomy and common bile duct exploration. Over the past 24 hours, he has developed a fever and increasing pain at the surgical site. His temperature is 38.7°C (101.6°F), blood pressure is 128/82 mm Hg, and pulse is 98/min. Examination of the abdomen reveals a 15-cm subcostal incision that is notably erythematous, indurated, and warm to the touch. Palpation elicits significant tenderness, and a moderate amount of thick, whitish-yellow fluid is easily expressed from between the surgical staples. His lungs are clear to auscultation, and bowel sounds are normoactive. Which of the following are the most appropriate next steps in the management of this patient's current condition? (Select all that apply)

A 68-year-old male is evaluated by the surgical team on postoperative day 3 following an open partial gastrectomy for a gastric mass. The patient has a 40-pack-year smoking history and known chronic obstructive pulmonary disease. He now complains of progressive shortness of breath and chest tightness that began earlier this morning. His temperature is 37.8°C (100.0°F), blood pressure is 145/88 mmHg, pulse is 108/min, and respirations are 24/min. Pulse oximetry shows 89% on room air. Physical examination reveals an anxious patient sitting upright. Jugular venous pressure is estimated at 6 cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezing and a prolonged expiratory phase; there are no crackles. The surgical incision is intact without drainage. Cardiac examination reveals tachycardia with a regular rhythm and no murmurs or gallops. There is no lower extremity edema. Which of the following is the most appropriate next step in management?

A 62-year-old woman is evaluated on postoperative day 6 following an elective open sigmoid colectomy for recurrent diverticulitis. She reports new-onset chills and increasing incisional pain over the past 24 hours. Her temperature is 39.1°C (102.4°F), heart rate is 112/min, and blood pressure is 110/70 mmHg. Examination of the surgical site reveals marked erythema, induration, and purulent drainage seeping from between the surgical staples. The patient is admitted to the progressive care unit for close monitoring.

Arrange the following management steps in the most appropriate chronological sequence for the care of this postoperative complication.

During morning rounds, the surgical team evaluates a 60-year-old man who is 36 hours status post an uncomplicated elective open right inguinal hernia repair. The patient reports mild discomfort at the incision site but otherwise feels well. He has been ambulating in the hallways with minimal assistance and is tolerating a regular diet. The nursing staff requested this evaluation because his latest temperature measurement was 38.4°C (101.1°F). His blood pressure is 130/80 mm Hg, pulse is 82/min, and respiratory rate is 14/min. Pulse oximetry shows 98% on room air. Physical examination reveals clear lungs bilaterally and normal heart sounds. The abdomen is soft and non-distended. The right groin incision is clean, dry, and intact without erythema, fluctuance, or induration. The calves are soft and non-tender bilaterally, with no lower extremity edema. Which of the following is the most appropriate next step in management?

A 61-year-old man is evaluated on postoperative day 2 following an elective open hepatic resection for a solitary colorectal metastasis. He reports moderate pain at the surgical site but denies shortness of breath, chest pain, cough, or dysuria. His medical history is significant for chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $134/82\text{ mmHg}$, pulse is $102/\text{min}$, and respirations are $16/\text{min}$. Pulse oximetry is $96\%$ on room air. Physical examination reveals an intact abdominal incision without erythema, induration, or purulent drainage. Lung auscultation demonstrates fine bibasilar crackles that completely disappear after the patient coughs forcefully. Cardiac examination shows a regular rhythm with no murmurs or gallops. The abdomen is soft, and bowel sounds are hypoactive. There is trace bilateral lower extremity edema that is unchanged from his preoperative baseline. Laboratory studies show a leukocyte count of $11,500/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A 71-year-old man is evaluated on postoperative day 2 following an open radical cystectomy with ileal conduit creation for muscle-invasive bladder cancer. He has a history of hypertension, diet-controlled type 2 diabetes mellitus, and a 40-pack-year smoking history. The patient currently complains of mild shortness of breath and right-sided chest discomfort when taking a deep breath. He reports severe incisional pain, especially when attempting to cough. His temperature is 38.3°C (100.9°F), blood pressure is 142/88 mm Hg, heart rate is 102/min, respiratory rate is 22/min, and SpO2 is 93% on room air. The midline abdominal incision is clean, dry, and intact. The urostomy is pink and producing clear yellow urine. Cardiopulmonary examination reveals decreased breath sounds at the bilateral lung bases. There are no crackles, wheezing, or jugular venous distention. The lower extremities show no edema or calf tenderness. Which of the following are the most appropriate next steps in management? (Select all that apply)

A surgical team evaluates a 74-year-old man on the third day after he underwent an open low anterior resection for a rectal adenocarcinoma. Over the past 24 hours, the patient has required an escalating amount of supplemental oxygen and is now complaining of severe shortness of breath and a cough productive of pink, frothy sputum. He has a medical history significant for chronic obstructive pulmonary disease, hypertension, and a myocardial infarction four years ago. During the surgery, he experienced significant hemorrhage requiring the transfusion of three units of packed red blood cells and the administration of 4 liters of normal saline.

His current temperature is 37.8°C (100.0°F), blood pressure is 165/95 mm Hg, pulse is 114/min, and respiratory rate is 28/min. Pulse oximetry indicates an oxygen saturation of 85% on room air. Physical examination demonstrates distended jugular veins when positioned at 45 degrees. Auscultation of the chest reveals bilateral crackles extending up to the mid-scapular regions, accompanied by scattered expiratory wheezes. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. The abdominal incision is well-approximated with no erythema or drainage.

Which of the following are the most appropriate immediate steps in the management of this patient's condition? (Select 2)