Orthopedic Surgery

Following a fall onto an outstretched hand during a snowboarding competition, a collegiate athlete presents with worsening right wrist discomfort. The patient specifically notes a deep ache near the base of the thumb that is exacerbated by gripping objects. On physical examination, there is mild edema and focal tenderness when palpating the depression between the extensor pollicis longus and the extensor pollicis brevis tendons. Range of motion at the radiocarpal joint is slightly limited by pain. Standard four-view radiographs of the wrist reveal no cortical step-offs, radiolucent lines, or malalignment. Which of the following is the most appropriate next step in management?

During a routine sports physical, a 16-year-old adolescent female complains of persistent right lower thigh pain that has progressively worsened over the last two months. She states the pain initially occurred only after running but now throbs at night and regularly disrupts her sleep. She has experienced no fevers, chills, or unintentional weight loss. On examination, the physician palpates a firm, exquisitely tender mass fixed to the underlying bone near the distal right femur. The overlying skin is slightly warm but not erythematous. Plain radiographs of the right lower extremity exhibit a poorly marginated, destructive lytic lesion in the distal femoral metaphysis accompanied by a sunburst pattern of periosteal reaction and a Codman triangle. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical and radiographic presentation with the most likely orthopedic diagnosis.

A 52-year-old man presents to the emergency department with a 2-day history of progressive pain, swelling, and redness over his left knee. He works as a carpet layer and spends several hours a day kneeling. His temperature is 38.2°C (100.8°F), pulse is 92/min, and blood pressure is 128/82 mmHg. Physical examination reveals a fluctuant, erythematous, and exquisitely tender mass localized directly over the anterior aspect of the left patella. The overlying skin is warm to the touch. There is no bulging of the parapatellar recesses, and the patellar ballottement test is negative. The patient is able to achieve 130 degrees of passive knee flexion with minimal discomfort. Which of the following is the most appropriate immediate next step in management?

Match each patient's clinical presentation and physical examination findings with the most likely injured shoulder structure and its corresponding functional deficit.

A 28-year-old male construction worker is brought to the emergency department after a heavy concrete block fell on his right leg. His airway is patent, breathing is unlabored, and he is hemodynamically stable. The primary trauma survey reveals no other life-threatening injuries. Examination of the right lower extremity shows a 5-centimeter laceration over the anterior tibia with exposed, fragmented bone and moderate oozing of blood. The right foot is warm, with palpable dorsalis pedis and posterior tibial pulses. Motor and sensory exams of the foot are intact. Arrange the following management steps in the most appropriate chronological order.

Arriving at the trauma center via helicopter emergency medical services is a 28-year-old male who was involved in a high-speed motorcycle collision. On initial assessment, the patient is lethargic and pale. Vital signs show a temperature of 36.5°C (97.7°F), heart rate of 142/min, blood pressure of 76/40 mm Hg, and respiratory rate of 28/min. The airway is patent, and breath sounds are equal bilaterally. The abdomen is soft and non-distended. Pelvic examination reveals mechanical instability to gentle anteroposterior compression. Blood is noted at the urethral meatus. A focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the peritoneal, pericardial, or pleural spaces. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman is brought to the emergency department after a high-speed motor vehicle collision. She was an unrestrained front-seat passenger, and her knees forcibly struck the dashboard during the impact. She is in severe distress and complains of excruciating right hip pain. Vital signs are temperature 37.1°C (98.8°F), pulse 105/min, blood pressure 122/78 mm Hg, and respirations 18/min. On physical examination, the right lower extremity is shortened, adducted, and internally rotated. Peripheral pulses are 2+ and symmetric. Neurologic examination reveals decreased sensation to pinprick over the dorsum of the right foot and an inability to actively dorsiflex the right ankle. Anteroposterior radiographs of the pelvis demonstrate a posterior dislocation of the right femoral head with no obvious displaced acetabular or femoral neck fractures. Which of the following is the most appropriate next step in management?

In the emergency trauma setting, acute musculoskeletal injuries frequently compromise adjacent anatomical structures. Match each acute orthopedic injury pattern with its most commonly associated critical neurovascular consequence or expected physical examination finding.

A 13-year-old boy is brought to the pediatric orthopedic clinic by his parents due to a two-month history of a persistent left-sided limp and intermittent, dull pain in his left knee. The pain is worse after walking long distances and improves with rest. He denies any history of trauma, recent illnesses, fevers, or night sweats. He is at the 95th percentile for weight and 60th percentile for height. Vital signs are within normal limits.

On physical examination, the patient has an antalgic gait. Inspection of the left knee reveals no swelling, erythema, or deformity. Palpation of the left knee and thigh elicits no tenderness, and knee range of motion is full and painless. However, when the examiner passively flexes the patient's left hip to 90 degrees, the thigh obligatorily rotates outward. Internal rotation of the left hip is limited compared to the right and elicits mild discomfort. Distal pulses are 2+ bilaterally, and sensation is intact throughout both lower extremities.

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

A $13$-year-old boy is brought to the pediatric clinic by his mother due to a $4$-week history of a right-sided limp and intermittent dull pain in his right anterior thigh and knee. He denies any recent trauma, fever, or prior episodes of similar pain. His medical history is unremarkable. His height is at the $50^{\text{th}}$ percentile and weight is at the $97^{\text{th}}$ percentile for his age. Vital signs are within normal limits. Physical examination reveals a waddling, antalgic gait. The right knee examination shows no effusions, joint line tenderness, or ligamentous laxity. On examination of the right hip, internal rotation is significantly restricted compared to the left. When the clinician passively flexes the right hip to $90^\circ$, the right thigh obligatorily rotates externally. Radiographs of the pelvis demonstrate posterior and inferior displacement of the right proximal femoral epiphysis. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old carpenter is brought to the emergency department after accidentally severing his left index finger with an electric table saw 30 minutes ago. His blood pressure is 135/85 mmHg, heart rate is 98/min, and respiratory rate is 16/min. On physical examination, the patient is alert and cooperative. The proximal stump of the left index finger is cleanly amputated at the level of the proximal phalanx. Bleeding is effectively controlled with a sterile compressive dressing. The amputated digit has been brought to the hospital by his coworkers, currently resting on a dry, dirty cloth. Arrange the following steps in the most appropriate chronological order for the optimal preservation and transport of the amputated digit to a microsurgical replantation center.

An industrial worker is rushed to the trauma bay after a forklift accident caused a direct crush injury to his left shin. The primary trauma survey is completed, and his airway, breathing, and circulation are stable. The secondary survey reveals an obvious gross deformity of the left tibia with a 5-centimeter anterior laceration. Fractured bone segments are protruding through the skin, and the wound is heavily contaminated with grease and debris. Arrange the following acute management steps for this patient's extremity injury in the most appropriate chronological sequence, from first to last.

A $68$-year-old man is evaluated in the surgical ward for a fever on postoperative day $5$ following an uncomplicated right total knee arthroplasty. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), pulse is $98/\text{min}$, respirations are $16/\text{min}$, and blood pressure is $135/85\text{ mmHg}$. The patient reports a new, deep aching pain in his right calf that is distinct from his surgical site pain. He has a medical history of hypertension and type $2$ diabetes mellitus. Current medications include prophylactic subcutaneous enoxaparin, lisinopril, and metformin. Physical examination reveals a clean and dry surgical incision with mild, expected postoperative swelling around the knee, but no erythema, fluctuance, or purulent drainage. There is moderate, asymmetric swelling and tenderness in the right posterior calf. Passive dorsiflexion of the right foot elicits pain in the calf. Lungs are clear to auscultation bilaterally. A Foley catheter was removed on postoperative day $1$, and he has been voiding without dysuria. Which of the following is the most appropriate next step in management?

A 5-year-old boy is brought to the emergency department after falling from a trampoline onto his outstretched right hand. He is crying and refuses to move his right arm. Physical examination reveals a gross, "S-shaped" deformity of the right elbow with significant soft tissue swelling. The right hand is pale and cool, and the radial pulse is absent on palpation. Radiographs show a completely displaced, extension-type supracondylar fracture of the humerus. The patient is immediately taken to the operating room, where closed reduction and percutaneous pinning are performed. Following stabilization of the fracture, the right hand remains pale and cool, and the radial pulse cannot be detected by Doppler ultrasound. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old man with a history of congestive heart failure is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. He was an unrestrained driver and required a prolonged extrication from the vehicle. Upon arrival, he is lethargic and confused. Vital signs show a heart rate of 142/min, blood pressure of 72/40 mmHg, and a respiratory rate of 28/min. The airway is patent, and breath sounds are clear and equal bilaterally. A Focused Assessment with Sonography in Trauma (FAST) examination reveals no intraperitoneal free fluid or pericardial effusion. Inspection of the perineum demonstrates severe scrotal ecchymosis and a drop of blood at the urethral meatus. Gentle inward compression of the iliac crests reveals profound mechanical instability of the pelvic ring. Dorsalis pedis pulses are faint bilaterally, and the lower extremities are cool to the touch. Which of the following is the most appropriate next step in management?

A 27-year-old collegiate athlete is evaluated on the surgical ward twelve hours after undergoing closed reduction and circumferential casting of a right tibial shaft fracture. The injury was sustained during a rugby match. Over the past two hours, he reports agonizing, unrelenting pain in his right leg that has progressively worsened despite receiving scheduled doses of intravenous hydromorphone. He states the pain feels like a "bursting pressure" and is entirely different from his initial fracture pain. On physical examination, the patient appears visibly distressed. The right foot is pink, and the dorsalis pedis pulse is easily palpable. However, passive plantar flexion of the foot and toes produces excruciating, sharp pain in the anterior leg. Sensation to light touch is diminished over the dorsal aspect of the first web space of the foot. Which of the following is the most appropriate next step in management?

A 32-year-old recreational skier is admitted after sustaining a closed diaphyseal fracture of the right tibia. Following closed reduction and immobilization in a circumferential long-leg cast, he is monitored on the orthopedic ward. Fourteen hours later, he develops excruciating leg pain that worsens with passive movement and is entirely refractory to high-dose intravenous analgesia. Arrange the following clinical steps in the appropriate chronological sequence for the definitive management of this patient's evolving condition.

A 32-year-old male is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. Primary and secondary trauma surveys reveal that he is hemodynamically stable with no life-threatening injuries. The patient reports excruciating left hip pain and is unable to move his left leg. On physical examination, the left lower extremity is shortened, internally rotated, and adducted. The skin is intact. Initial assessment reveals palpable dorsalis pedis and posterior tibial pulses, as well as normal sensation over the dorsum and plantar aspects of the left foot.

Arrange the following interventions in the most appropriate chronological sequence for the definitive evaluation and management of this patient's orthopedic injury.

A 22-year-old man is evaluated in the trauma intensive care unit for acute-onset respiratory distress and altered mental status. Twenty hours ago, he was involved in a motorcycle collision, sustaining a closed, comminuted fracture of the right femoral shaft and a nondisplaced fracture of the left radius. He was initially hemodynamically stabilized, splinted, and placed in skeletal traction while awaiting definitive surgical fixation. His current temperature is 37.9°C (100.2°F), blood pressure is 112/68 mm Hg, pulse is 126/min, and respiratory rate is 28/min. Pulse oximetry reveals an oxygen saturation of 86% on room air. Physical examination demonstrates scattered, non-blanching erythematous macules over the anterior chest and axillae. Lung auscultation reveals bilateral diffuse crackles. Neurologic examination shows a restless and confused patient without focal motor or sensory deficits. Which of the following is the most likely diagnosis?