Orthopedic Surgery

An obese 13-year-old adolescent is brought to the clinic by his parents due to a four-week history of a right-sided limp and intermittent right knee pain. The pain is exacerbated by physical activity and relieved by rest. There is no history of trauma, fever, or weight loss. His body mass index is $33 \text{ kg/m}^2$. Vital signs are within normal limits. On physical examination, there is no swelling, erythema, or localized tenderness over the right knee. Ligamentous testing of the knee is normal. However, when the patient's right hip is passively flexed, the thigh obligately deviates into external rotation. Internal rotation of the right hip is significantly limited compared to the left. Which of the following is the most appropriate next step in management?

Match the following classic mechanisms of knee injury with their most characteristic diagnostic physical examination finding.

A $68$-year-old man comes to the clinic reporting a $6$-month history of bilateral leg pain, tingling, and cramping. The symptoms consistently begin after walking for about $10$ minutes and radiate from his lower back down the posterior aspect of both thighs to the calves. He notes that the discomfort is significantly relieved when he sits down or leans forward on a shopping cart at the grocery store, but it does not improve when he simply stops walking and stands upright. He has a medical history of hypertension and hyperlipidemia. Vital signs are within normal limits. Physical examination reveals normal muscle strength ($5/5$) and intact deep tendon reflexes in both lower extremities. Dorsalis pedis and posterior tibial pulses are $2+$ bilaterally. The skin on the lower legs is warm with normal hair distribution. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 7-year-old boy is brought to the emergency department by his parents 30 minutes after falling from a playground structure. He fell onto his outstretched left arm and immediately complained of severe elbow pain. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 105/65 mm Hg, heart rate of 112/min, and respiratory rate of 20/min. Physical examination reveals a distressed child holding his left arm. There is marked swelling and an "S-shaped" deformity at the left elbow. There are no open wounds or visible ecchymoses.

Neurovascular assessment demonstrates a palpable radial pulse and a capillary refill time of 1 second in the fingers. When asked to make an "OK" sign with his left hand, the patient is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Sensation to light touch is intact over the median, ulnar, and radial nerve distributions. Anteroposterior and lateral radiographs of the left elbow show a displaced extension-type supracondylar humerus fracture with posterior displacement of the distal fragment.

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

Emergency medical services arrive at the trauma bay with a 28-year-old roofing contractor who fell from a residential building. The fall distance was approximately $4.5$ meters ($15$ feet). The patient is fully conscious and reports agonizing pain in his left leg. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $105/\text{min}$, blood pressure of $130/80\text{ mm Hg}$, and a respiratory rate of $18/\text{min}$. The initial trauma assessment confirms a patent airway, normal breathing, and no clinical evidence of intra-abdominal hemorrhage. Attention to the left lower extremity reveals a visibly angulated mid-shaft tibia. A $5\text{-cm}$ skin tear is present over the medial aspect, oozing dark blood, with underlying bone fragments exposed. The distal foot is noticeably pale and cold compared to the contralateral limb. Palpation of the dorsalis pedis and posterior tibial arteries yields no pulse, and capillary refill in the toes is absent. Neurological evaluation of the foot is limited secondary to extreme pain. Which of the following is the most appropriate initial step in the management of this patient's left extremity?

A 22-year-old male is brought to the emergency department after a high-speed motorcycle collision. He complains of severe right leg pain. On physical examination, his right knee is grossly deformed with a prominent medial femoral condyle. The patient's right foot is cold and pale, and the dorsalis pedis and posterior tibial pulses are not palpable. Capillary refill is delayed. Arrange the following management steps in the most appropriate chronological order for this patient, assuming that an arterial injury is present and requires definitive treatment.

Match the following specific orthopedic injuries with their most commonly associated neurological deficit or physical examination finding.

A mother brings her 3-year-old son to an urgent care clinic because he has been crying inconsolably whenever she tries to change his diaper or move his right leg. Since yesterday morning, the child has refused to stand or walk. He had a runny nose and low-grade fever two weeks ago, which resolved without medication. Today, his temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse is $110/\text{min}$, and blood pressure is $90/60\text{ mmHg}$. Physical examination reveals a distressed child who holds his right leg flexed, abducted, and externally rotated at the hip joint. Any attempt to internally rotate the right leg causes severe guarding and screaming. Laboratory analysis reveals a leukocyte count of $17,500/\text{mm}^3$ and an erythrocyte sedimentation rate of $52\text{ mm/h}$. Plain radiographs of the pelvis and bilateral lower extremities demonstrate no fracture, dislocation, or evidence of avascular necrosis. Which of the following is the most appropriate next step in the evaluation and management of this patient?

Match the following upper extremity musculoskeletal conditions with their classic physical examination findings or provocative test results.

During a night shift, a ward nurse urgently pages the orthopedic resident regarding a patient with uncontrolled pain. The patient is a $34$-year-old right-hand-dominant carpenter who sustained a closed, displaced fracture of the right distal radius $8$ hours ago. He was treated with closed reduction and application of a circumferential fiberglass cast. He has received $2$ doses of intravenous morphine over the past hour but continues to writhe in bed, describing a severe, burning pain in his forearm. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $142/88\text{ mmHg}$, and heart rate $112\text{/min}$. Examination of the right upper extremity shows a rigid, intact cast. The exposed digits are mildly swollen but pink, and capillary refill is $< 2\text{ seconds}$. The radial pulse is palpable. Passive extension of the digits by the examiner elicits agonizing pain that causes the patient to withdraw the arm immediately. Which of the following is the most appropriate next step in management?

A 15-year-old boy presents to the orthopedic clinic with a 3-month history of progressively worsening deep pain in his right distal thigh. The pain is persistent, often awakens him at night, and is not relieved by over-the-counter analgesics. Physical examination reveals a palpable, tender, and firm mass over the anterior distal femur. There is no history of preceding trauma, and the patient is afebrile. Arrange the following steps in the most appropriate chronological sequence for the evaluation and definitive management of this patient's suspected primary bone sarcoma.

A 24-year-old man presents to the urgent care clinic with right wrist pain. Two days ago, he fell forward onto his outstretched right hand while playing basketball. He notes focal swelling and pain that worsens when gripping objects. Vital signs are temperature 36.8°C (98.2°F), blood pressure 118/76 mm Hg, heart rate 72/min, and respiratory rate 14/min. Physical examination reveals localized tenderness over the dorsal radial aspect of the right wrist, specifically in the depression bounded by the extensor pollicis longus and extensor pollicis brevis tendons. Pain is reproduced with axial compression of the first metacarpal. Neurovascular assessment shows 2+ radial and ulnar pulses with brisk capillary refill and normal sensation to light touch in all digits. Initial anteroposterior, lateral, and scaphoid-view radiographs of the right wrist demonstrate no fracture lines, step-offs, or dislocations. Which of the following is the most appropriate next step in management?

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 42-year-old construction worker is brought to the emergency department after a heavy steel beam fell on his left leg. His primary trauma survey is intact, and he is hemodynamically stable. Examination reveals a severely angulated left lower leg with a 5-cm laceration over the medial aspect, exposing fragmented tibial bone. There is moderate bleeding, but no pulsatile hemorrhage. Arrange the following steps in the most appropriate chronological order for the acute orthopedic management of this patient's injury.