Orthopedic Surgery

Match each specific orthopedic injury with the most likely corresponding acute neurovascular physical exam finding.

A $5$-year-old boy is brought to the emergency department by his parents because he has been refusing to walk since this morning. The parents report that he had a subjective fever at home yesterday but otherwise has been healthy. His immunizations are up to date. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is $100/60\text{ mmHg}$, pulse is $115/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a distressed child who cries when the right leg is touched. The right hip is held in a position of flexion, abduction, and external rotation. Any attempted passive range of motion of the right hip elicits severe pain. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ and an erythrocyte sedimentation rate (ESR) of $55\text{ mm/hr}$. Radiographs of the pelvis and bilateral hips demonstrate no fractures or structural abnormalities. Which of the following is the most appropriate next step in management?

Match each of the following orthopedic physical examination maneuvers with the underlying structural injury it is most specifically designed to evaluate.

A 28-year-old man is evaluated on postoperative day 1 after undergoing intramedullary nailing for a closed right tibial shaft fracture. Over the past 4 hours, he has developed severe, unrelenting pain in his right lower leg that is not relieved by intravenous morphine. His temperature is 37.8°C (100°F), blood pressure is 130/80 mmHg, and pulse is 108/min. On physical examination, the right leg is tense, visibly swollen, and firm to palpation. Passive plantar flexion of the toes elicits excruciating pain in the anterior leg. The pedal pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?

A 24-year-old man is evaluated in the hospital 12 hours after sustaining a closed, comminuted midshaft fracture of the right tibia. The fracture was stabilized with a well-molded, long-leg fiberglass cast in the emergency department. He now reports severe, unrelenting right leg pain that is poorly localized and unresponsive to intravenous opioid analgesia. Physical examination reveals a tense, swollen right calf and severe pain exacerbated by passive dorsiflexion of the right toes. Dorsalis pedis and posterior tibial pulses are easily palpable. Arrange the following management steps in the most appropriate chronological order.

Emergency medical services transport a logging worker via helicopter to a regional trauma center after a heavy falling tree branch crushed his right lower extremity. The patient remains hemodynamically stable throughout transport. Upon initial trauma evaluation, the right knee exhibits a gross multi-ligamentous dislocation with severe instability. Vascular assessment reveals a pale, cold right foot with no palpable or Doppler-identifiable pulses in the dorsalis pedis or posterior tibial arteries. Because of the remote location of the accident, the estimated total warm ischemia time has already exceeded 5.5 hours. An urgent bedside closed reduction is performed, but subsequent Doppler re-evaluation confirms persistent absence of arterial flow. The surgical team immediately mobilizes to the operating suite for a limb salvage procedure. Arrange the following intraoperative interventions in the correct sequential order required to optimize limb preservation.

Match each of the following upper extremity orthopedic injuries with the peripheral nerve most commonly at risk for damage.

A 26-year-old professional rugby player is transported to the trauma bay after sustaining a direct, high-velocity blow to his right knee during a match. He complains of excruciating leg pain. On physical examination, the right knee is visibly deformed. His right foot is pale and cool to the touch. He is hemodynamically stable and has no other systemic injuries. Arrange the following steps in the acute management of this patient's limb in the most appropriate chronological sequence.

A 19-year-old college student presents to the urgent care clinic with right wrist pain after falling on an outstretched hand while skateboarding yesterday. Vital signs are within normal limits (temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 78/min, respirations 14/min). On physical examination, there is mild swelling over the radial aspect of the wrist and exquisite tenderness to palpation in the anatomical snuffbox. Sensation to pinprick is intact in all digits, and radial and ulnar pulses are 2+ and symmetric. Capillary refill is less than 2 seconds. Radiographs of the right wrist reveal no evidence of fracture or dislocation. What is the most appropriate next step in management?

A 13-year-old boy is brought to the emergency department by his parents due to severe right-sided leg pain. For the past month, he has complained of a dull, intermittent ache in his right anterior thigh and knee, which he attributed to playing basketball. This morning, while walking down the stairs, he felt a sudden "pop" and experienced exquisite pain. He is now completely unable to bear weight on the right leg. His body mass index is $33 \text{ kg/m}^2$. Vital signs are within normal limits, and he is afebrile. Physical examination reveals a well-appearing boy in moderate discomfort. Inspection of the right knee shows no swelling, erythema, or localized tenderness. When the examiner attempts to passively flex the right hip to $90^\circ$, the thigh obligately rotates externally. There is significantly limited internal rotation of the right hip compared to the left. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the hospital for right knee pain and swelling that has progressively worsened over the past 3 months. He underwent a right total knee arthroplasty 2 years ago for severe osteoarthritis. His medical history includes hypertension and diet-controlled type 2 diabetes mellitus. His temperature is 37.2°C (99.0°F), blood pressure is 132/82 mmHg, and pulse is 78/min. Physical examination of the right knee reveals a moderate effusion, erythema, and warmth over the joint. Range of motion is significantly limited by pain. Radiographs of the right knee demonstrate periprosthetic radiolucency. Joint aspiration is performed, and synovial fluid analysis reveals a leukocyte count of 65,000/mm³ with 85% neutrophils. Synovial fluid culture grows methicillin-susceptible *Staphylococcus aureus* (MSSA). The patient was started on empiric intravenous vancomycin upon admission. Which of the following is the most appropriate definitive management for this patient?

A $52$-year-old man with a history of poorly controlled diabetes mellitus presents to the emergency department with a $24$-hour history of severe right knee pain, swelling, and subjective fevers. His temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, and pulse is $110/\text{min}$. Physical examination reveals a markedly erythematous, warm, and swollen right knee held in slight flexion. Any passive range of motion of the knee elicits excruciating pain. A large joint effusion is palpable.

Arrange the following management steps in the correct chronological order for this patient.

Match each patient presentation of a lower extremity orthopedic injury with the most likely associated neurovascular complication and physical exam finding.

A $32$-year-old man is evaluated in the surgical intensive care unit for severe right lower extremity pain. $12$ hours ago, he underwent closed reduction and intramedullary nailing for a comminuted right tibial shaft fracture sustained in a high-speed skiing accident. He reports that the pain has progressively worsened over the last $3$ hours and is now "unbearable," describing it as a deep, burning ache. The pain is completely unresponsive to multiple doses of intravenous morphine. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $148/92 \text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. On physical examination, the right leg is tensely swollen, shiny, and exceedingly firm to palpation. Passive plantar flexion of the right ankle and toes elicits excruciating pain. Sensation to light touch is markedly decreased over the first dorsal web space of the right foot. The dorsalis pedis and posterior tibial pulses are palpable and symmetric to the contralateral side. Which of the following is the most appropriate next step in management?

An emergency medical team brings a 6-year-old female to the trauma bay after she sustained a fall from a playground structure onto an outstretched left arm. She is crying and refusing to move her left upper extremity. Physical examination reveals a significant "S-shaped" deformity and severe swelling around the left elbow. The left hand is pale and cool to the touch. Capillary refill is 4 seconds. Radial and ulnar pulses are absent on palpation and cannot be detected with a handheld Doppler. She is unable to flex the interphalangeal joint of her thumb. Radiographs confirm a completely displaced, extension-type supracondylar humerus fracture. Arrange the following management steps in the most appropriate chronological order for this patient.

Following a high-speed motorcycle collision, a male patient in his mid-twenties arrives at the trauma resuscitation bay. He is lethargic and responds only to painful stimuli. Vital signs include a blood pressure of $76/40\text{ mmHg}$, heart rate of $135/\text{min}$, respiratory rate of $26/\text{min}$, and temperature of $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$). Physical assessment reveals profound ecchymosis over the suprapubic and perineal areas, accompanied by visible blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability of the pelvic ring. A bedside focused assessment with sonography for trauma (FAST) shows no anechoic fluid in the peritoneal spaces. Massive transfusion protocol is initiated via two large-bore peripheral intravenous catheters. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing a mechanism of injury, physical exam finding, and radiographic pattern with the correct upper extremity orthopedic diagnosis.

A 42-year-old man presents to the orthopedic clinic with a 2-month history of progressive left anterior hip and groin pain. The pain is exacerbated by climbing stairs and prolonged standing, and he frequently experiences aching at night that disrupts his sleep. His medical history is significant for severe persistent asthma, for which he has required multiple bursts of oral corticosteroids over the past 5 years. Vital signs are within normal limits. On physical examination, the patient walks with a noticeable antalgic gait. There is no erythema, warmth, or palpable effusion over the left hip. Passive internal rotation and abduction of the left hip elicit sharp pain, while straight leg raise is negative. Anteroposterior and frog-leg lateral radiographs of the left hip reveal normal joint space without evidence of fracture, subchondral sclerosis, or a crescent sign. Which of the following is the most appropriate next step in management?

A $27$-year-old man is evaluated in the surgical intensive care unit for acute-onset agitation and shortness of breath. Twenty hours ago, he underwent uncomplicated intramedullary nailing of a right mid-shaft femur fracture sustained in a high-speed motor vehicle collision. His temperature is $38.6^{\circ}\text{C}$ ($101.5^{\circ}\text{F}$), blood pressure is $118/76 \text{ mm Hg}$, heart rate is $126/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $86\%$ on room air. Physical examination is notable for a petechial rash distributed over the anterior chest and axillae. The right thigh is moderately swollen but soft to palpation, and the surgical incisions are clean and dry. The right dorsalis pedis and posterior tibial pulses are intact bilaterally. Which of the following is the most appropriate management for this patient's current condition?

A 22-year-old male is brought to the emergency department after a severe collision during a rugby match. On presentation, he is in severe pain. His vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mmHg, heart rate 98/min, and respiratory rate 16/min. Physical examination reveals a grossly deformed left knee with a significant posterolateral prominence. The left foot is cool and pale, and both the dorsalis pedis and posterior tibial pulses are not palpable. Capillary refill is delayed. Assume that after initial interventions, the distal pulses return but remain asymmetric compared to the contralateral limb, and subsequent advanced imaging reveals a popliteal artery intimal flap. Arrange the following steps in the correct chronological order for the acute evaluation and management of this patient.