Orthopedic Surgery

A 34-year-old right-handed male presents to the emergency department one hour after an altercation in which he was struck on the right upper arm with a heavy steel pipe. He complains of intense pain and an inability to use his right hand. His vital signs are within normal limits. On physical examination, the right arm reveals significant soft tissue swelling, ecchymosis, and a visible deformity over the mid-humerus. The skin is completely intact. Neurological examination of the right upper extremity reveals an inability to extend the wrist or fingers. Sensation to pinprick is diminished over the dorsal aspect of the first web space. The radial and ulnar pulses are $2+$ and symmetric. Capillary refill is less than $2$ seconds in all digits. Anteroposterior and lateral radiographs of the right humerus demonstrate a displaced transverse fracture of the middle third of the humeral shaft. Which of the following is the most appropriate next step in management?

A 31-year-old male agricultural worker presents to the emergency department with a 3-day history of progressive pain and swelling in his left index finger. He reports sustaining a small puncture wound from a wire fence 5 days prior. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $98/\text{min}$. Physical examination reveals a diffusely swollen, erythematous left index finger that the patient holds in a partially flexed posture. There is pronounced tenderness extending along the volar aspect of the digit down to the proximal palmar crease. Passive extension of the finger elicits excruciating pain. Sensation and capillary refill are intact in the affected digit. Radiographs of the hand show soft tissue swelling but no foreign body, fracture, or bony destruction. Which of the following is the most appropriate next step in management?

A 29-year-old woman is brought to the trauma center after being thrown from her motorcycle in a high-speed collision. The primary trauma survey reveals a patent airway, unlabored breathing, and intact circulation. Her vital signs are within normal limits. The secondary survey is notable for a severe right lower extremity injury. There is an obvious deformity of the midshaft tibia with a 14-cm full-thickness laceration. The underlying muscle is severely crushed, and exposed bone is stripped of its periosteum. The dorsalis pedis and posterior tibial pulses are palpable. Arrange the following steps in the most appropriate chronological sequence for the optimal management of this patient's limb injury.

A 68-year-old man presents to the emergency department with a 2-day history of worsening right knee pain, swelling, and fever. He underwent a primary right total knee arthroplasty 3 weeks ago for severe osteoarthritis. His early postoperative course was uncomplicated, and he had been progressing well with physical therapy until the onset of these symptoms. His temperature is 38.9°C (102.0°F), blood pressure is 125/80 mmHg, pulse is 105/min, and respiratory rate is 18/min. Physical examination reveals a markedly swollen, erythematous, and warm right knee. The surgical incision is well-healed with no active drainage. Range of motion is severely limited by pain. Laboratory studies show a leukocyte count of 14,500/mm³ and an erythrocyte sedimentation rate of 85 mm/hr. Arthrocentesis of the right knee yields cloudy fluid with a leukocyte count of 45,000/mm³ (90% neutrophils). Gram stain shows Gram-positive cocci in clusters. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of an acute orthopedic injury to its most likely associated neurological examination deficit.

During morning rounds, the orthopedic team evaluates a 24-year-old male who was admitted overnight following a closed mid-shaft right tibia fracture sustained during a soccer match. He was treated with closed reduction and application of a long-leg cast $8$ hours ago. The patient is now highly agitated, reporting severe, throbbing pain in his right leg that has worsened significantly despite escalating doses of intravenous hydromorphone. His medical history is notable for opioid use disorder, for which he takes daily methadone. Vital signs are within normal limits. Physical examination reveals a pink, warm right foot with a capillary refill time of $2$ seconds. Dorsalis pedis and posterior tibial pulses are easily palpable. However, passive plantar flexion of the toes elicits excruciating pain in the anterior shin, and the patient reports decreased sensation in the first dorsal web space. Which of the following is the most appropriate next step in management?

A 5-year-old girl is brought to the emergency department with a 24-hour history of high fever ($39.2^\circ\text{C}$ or $102.6^\circ\text{F}$) and refusal to bear weight on her right leg. On examination, her right hip is exquisitely tender and held rigidly in flexion, abduction, and external rotation. Any attempted passive range of motion elicits severe distress. Assuming all subsequent diagnostic findings support a diagnosis of acute septic arthritis, arrange the following clinical management steps in the most appropriate chronological sequence.

An otherwise healthy 7-year-old boy arrives at the trauma bay 45 minutes after falling from a playground structure onto his outstretched right hand. He complains of excruciating elbow pain and refuses to move his arm. Vital signs are within normal limits for his age. On physical examination, the right elbow is markedly swollen with an S-shaped deformity. The skin over the antecubital fossa is intact, taut, and slightly ecchymotic. Neurologic evaluation reveals an inability to flex the distal interphalangeal joints of the index finger and thumb to make an "OK" sign, though wrist extension and finger abduction are intact. The radial pulse is non-palpable and cannot be detected with a handheld Doppler ultrasound. However, the right hand is warm and pink, with a capillary refill time of 2 seconds. Radiographs of the right elbow reveal a completely displaced extension-type supracondylar humerus fracture. Which of the following is the most appropriate next step in management?

A 23-year-old male presents to the urgent care clinic with right wrist pain after falling on an outstretched hand while snowboarding. Physical examination reveals focal swelling and significant tenderness to palpation in the anatomic snuffbox. Initial anteroposterior, lateral, and scaphoid-view plain radiographs of the right wrist demonstrate no obvious fracture, dislocation, or joint effusion. Arrange the following management steps in the most appropriate chronological order for this patient.

A 34-year-old construction worker arrives at the trauma center following a workplace accident. He was struck on the right arm by a swinging metal pipe. He reports severe pain in his right arm. His vital signs are within normal limits. Examination of the right upper extremity reveals marked swelling and an obvious angular deformity in the middle of the upper arm. The overlying skin is intact. When asked to move his hand, the patient demonstrates a "wrist drop" and cannot actively straighten his fingers at the metacarpophalangeal joints. He reports numbness over the back of his right hand near the thumb. Radial and ulnar pulses are strong and symmetrical. An X-ray confirms a closed, displaced transverse fracture of the midshaft of the humerus. Which of the following is the most appropriate initial management for this patient?

Match each primary bone tumor with its most characteristic radiographic finding and classic anatomical location.

A 38-year-old man is brought to the emergency department after being struck by a motor vehicle while crossing the street. On arrival, he is confused but protecting his airway. His temperature is $36.5^\circ\text{C}$, blood pressure is $78/40\text{ mmHg}$, pulse is $135/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $96\%$ on room air. Primary survey reveals equal and bilateral breath sounds. The abdomen is soft and non-distended. Examination of the pelvis reveals gross instability to anteroposterior compression. There is a large scrotal hematoma and a prominent drop of blood at the urethral meatus. An extended focused assessment with sonography for trauma (E-FAST) reveals no free fluid in the pericardial, pleural, or peritoneal spaces. A pelvic binder is immediately applied, and the patient is resuscitated with 2 liters of isotonic crystalloid and 2 units of uncrossmatched type O-negative packed red blood cells. Re-evaluation 15 minutes later shows a blood pressure of $82/45\text{ mmHg}$ and a pulse of $130/\text{min}$. Which of the following is the most appropriate next step in management?

An $82$-year-old woman is brought to the emergency department after a mechanical fall at home. She tripped over a rug and landed directly on her right side. She complains of severe right groin pain and is completely unable to bear weight. Her past medical history is significant for osteoporosis, hypertension, and mild chronic obstructive pulmonary disease. Her current medications include amlodipine, alendronate, and an albuterol inhaler.

Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $138/82\text{ mm Hg}$, pulse $88/\text{min}$, and respiratory rate $16/\text{min}$. On physical examination, her right lower extremity is visibly shortened and externally rotated. Palpation over the greater trochanter elicits significant tenderness. Distal pulses are intact, and there are no sensory deficits.

Anteroposterior radiographs of the right hip reveal a completely displaced fracture line extending transversely across the anatomical neck of the right femur, entirely proximal to the intertrochanteric line. There is no evidence of underlying osteolytic lesions.

Which of the following is the most appropriate definitive management for this patient's injury?

A young adult is transported to the trauma center via helicopter after a high-speed motorcycle crash. Following completion of the primary trauma survey and hemodynamic stabilization, evaluation reveals an isolated, severe left lower extremity injury. Examination shows a highly comminuted, open mid-shaft tibia fracture with a 12-cm soft tissue defect, extensive contamination, and exposed bone. The ipsilateral foot is pale and cold. Doppler ultrasonography demonstrates absent signals over the dorsalis pedis and posterior tibial arteries. Immediate operative intervention is planned. Arrange the following surgical management steps in the most appropriate chronological order for this patient.

A 22-year-old man is evaluated in the hospital for severe right leg pain. Ten hours ago, he underwent closed reduction and placement of a circumferential long-leg cast for a closed, displaced midshaft tibia fracture sustained during a soccer match. He states that the pain is agonizing, describes it as a deep 'burning' sensation, and reports that it has progressively worsened over the last three hours despite receiving scheduled doses of intravenous hydromorphone. On physical examination, the right foot is warm and pink. Capillary refill is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable. He holds his ankle in slight plantar flexion. Passive dorsiflexion of the right toes elicits excruciating pain. Sensation to light touch is decreased over the first dorsal web space. Which of the following is the most appropriate initial step in the management of this patient?

A 32-year-old man is evaluated in the orthopedic ward for severe left leg pain. Twelve hours ago, he underwent closed reduction and placement of a long-leg cast for a closed midshaft tibial fracture. He now reports excruciating, throbbing pain in his calf that is worsening and no longer relieved by intravenous morphine. Physical examination reveals a tense, 'tight' feeling in the calf musculature and profound pain with passive dorsiflexion of the toes. He also reports new-onset tingling in the first web space of his foot. Distal pulses remain palpable. Arrange the following steps in the most appropriate chronological order for the acute evaluation and management of this patient's condition.

Match each patient's clinical presentation of an orthopedic injury with the most likely associated neurovascular complication or mandatory physical examination finding.

A 13-year-old boy is brought to the clinic by his parents due to left knee pain and a limp that has progressively worsened over the past month. Yesterday, the pain became significantly more severe after he jumped down from a small wall. He has no history of direct trauma to the knee, fever, or prior medical conditions. His BMI is $34 \text{ kg/m}^2$. Vital signs are within normal limits. Physical examination of the left knee reveals no effusion, joint line tenderness, or ligamentous laxity. During examination of the left hip, flexion of the hip results in obligatory external rotation of the thigh. Internal rotation of the left hip is severely limited and elicits pain. Radiographs of the hip confirm the diagnosis. Which of the following is the most appropriate next step in management?

Correlate each pediatric or adolescent patient's musculoskeletal presentation with the most accurate orthopedic diagnosis.

A 25-year-old man is brought to the emergency department after a skiing accident in which he fell directly onto his right shoulder. He complains of severe shoulder pain and an inability to move his arm. Vital signs are within normal limits. On physical examination, the right arm is held in slight abduction and external rotation. There is a prominent acromion and a loss of the normal rounded contour of the shoulder. He has decreased sensation to pinprick over the lateral aspect of the right shoulder. Radial and brachial pulses are 2+ and symmetric. Capillary refill is less than 2 seconds. Anteroposterior and axillary lateral radiographs of the right shoulder demonstrate an anterior, subcoracoid dislocation of the humeral head. The patient undergoes closed reduction in the emergency department using procedural sedation. Post-reduction radiographs confirm anatomic alignment of the glenohumeral joint. However, upon repeat physical examination, the patient is able to actively abduct the arm to 15 degrees, but is unable to actively abduct it any further. The decreased sensation over the lateral shoulder persists. Which of the following is the most appropriate next step in the management of this patient?