Orthopedic Surgery

A 45-year-old man is brought to the emergency department via ambulance after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and appears confused. His temperature is 36.1°C (97.0°F), blood pressure is 78/40 mmHg, pulse is 135/min, and respirations are 26/min. The airway is patent, and breath sounds are equal bilaterally. Physical examination reveals severe ecchymosis over the lower abdomen and perineum. The pelvis is mechanically unstable to gentle anteroposterior compression. The right lower extremity is shortened and externally rotated. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal or pericardial fluid. An anteroposterior radiograph of the pelvis demonstrates a 4-cm diastasis of the pubic symphysis and widening of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 2 units of uncrossmatched packed red blood cells and 1 unit of fresh frozen plasma, his blood pressure remains 80/42 mmHg and pulse is 130/min. Which of the following is the most appropriate next step in management?

A series of patients present to the trauma bay with various acute orthopedic injuries. Match each specific fracture pattern or dislocation with its most likely associated neurovascular deficit observed on physical examination.

Match each upper extremity fracture or dislocation pattern with its most classically associated neurovascular complication.

During a collegiate rugby match, an 18-year-old athlete sustains a high-impact direct blow to the anterior right proximal tibia while the foot is firmly planted on the turf. The athlete falls to the ground in severe distress and is unable to bear weight. On examination in the emergency department 45 minutes later, there is a prominent step-off at the right knee joint, with the tibia displaced posteriorly relative to the femur. The overlying skin is intact. The patient reports severe pain but denies any numbness or tingling in the foot. Dorsalis pedis and posterior tibial pulses are palpable and symmetric to the uninjured leg. Capillary refill is less than 2 seconds. A bedside closed reduction is performed promptly under conscious sedation, successfully restoring normal anatomic alignment of the knee. Post-reduction, the distal pulses remain palpable and symmetric. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old man is brought to the emergency department after a heavy concrete pipe rolled over his lower torso at a construction site. On arrival, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/45 mmHg and his pulse is 132/min. There is no visible external hemorrhage. Physical examination reveals ecchymosis over the perineum and severe instability of the pelvic ring upon gentle lateral compression. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal free fluid. Which of the following is the most appropriate next step in management?

Match each clinical presentation to the most likely pediatric orthopedic diagnosis.

A 26-year-old man is hospitalized after sustaining a closed mid-shaft fracture of the right femur in a motor vehicle collision. Due to multiple life-threatening cases in the operating room, his fracture is temporarily managed with skeletal traction. On the second day of hospitalization, he becomes acutely confused and agitated. His temperature is 38.3°C (100.9°F), blood pressure is 118/76 mmHg, heart rate is 122/min, and respiratory rate is 28/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals a non-blanching petechial rash over the anterior chest, axillae, and conjunctivae. Lung auscultation demonstrates bilateral scattered crackles. Which of the following interventions during the initial 24 hours of admission would have most effectively decreased the risk of this patient's current complication?

A 32-year-old man is evaluated by the surgical team for severe right lower extremity pain. Twelve hours ago, he underwent an uncomplicated open reduction and internal fixation of a comminuted right tibial shaft fracture sustained in a mountain biking accident. The patient reports that over the past two hours, the pain has become agonizing and is no longer relieved by his scheduled doses of intravenous morphine. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, and heart rate is $112\text{/min}$. On physical examination, the right anterolateral leg appears tense and significantly swollen compared to the contralateral limb. The overlying skin is shiny. Passive plantar flexion of the right ankle and toes elicits a dramatic increase in pain. Capillary refill time is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?

A pediatric orthopedic clinic evaluates several patients with lower extremity complaints. Match each patient's clinical presentation with the most likely underlying diagnosis.

A 6-year-old girl is evaluated in the emergency department after falling from a trampoline onto her outstretched left arm. She is in significant distress and refuses to move her upper extremity. Vital signs are stable. Physical examination reveals a gross S-shaped deformity and severe swelling of the left elbow. The skin over the antecubital fossa is intact without puckering. Capillary refill in the left fingers is 1.5 seconds, and the hand is warm and pink. However, the left radial pulse is completely absent to palpation and cannot be detected with a hand-held Doppler device. Neurologic examination reveals an inability to actively flex the interphalangeal joint of the left thumb, but she is able to extend her wrist and fingers against resistance. Radiographs demonstrate a completely displaced, extension-type supracondylar fracture of the distal humerus. The patient is emergently taken to the operating room, where an anatomic closed reduction and percutaneous pinning are performed. Intraoperative fluoroscopy confirms perfect alignment and stable fixation. Immediate post-procedural evaluation reveals that the left hand remains warm and pink with a capillary refill of 1.5 seconds. However, the radial pulse remains undetectable by Doppler. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old male presents to the emergency department supporting his right arm after an awkward fall during a recreational rugby match. He is in significant pain, and his right shoulder has a visibly 'squared-off' appearance. He complains of numbness over the lateral aspect of his shoulder. Arrange the following steps in the most appropriate chronological sequence for the acute management of this patient's presentation.

Match each clinical and radiographic vignette with the most likely primary bone tumor diagnosis.

A 32-year-old man is brought to the emergency department after a high-speed motorcycle collision. His airway is patent, breathing is unlabored, and he is hemodynamically stable. Examination reveals a grossly deformed right lower leg with a 4-cm anteromedial laceration through which fractured bone fragments are visible. The wound is oozing dark blood, but there is no pulsatile bleeding.

Arrange the following steps in the most appropriate sequential order for the acute management of this patient's orthopedic injury.

A 9-year-old boy is brought to the emergency department by his parents due to a 3-day history of worsening left leg pain and fever. The parents report that he initially started limping but now refuses to bear any weight on the left leg. There is no history of recent trauma, tick bites, or travel. His temperature is 38.8°C (101.8°F), blood pressure is 105/65 mmHg, heart rate is 115/min, and respiratory rate is 18/min. On physical examination, the child is ill-appearing. There is exquisite point tenderness, localized warmth, and mild swelling over the proximal anterior aspect of the left tibia. Range of motion of the left knee and ankle is fully preserved and does not elicit pain. Laboratory studies reveal a leukocyte count of 15,500/mm³ (85% neutrophils), an erythrocyte sedimentation rate (ESR) of 65 mm/hr, and a C-reactive protein (CRP) level of 82 mg/L. Plain radiographs of the left tibia and knee show no obvious abnormalities. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing an orthopedic injury with the most appropriate definitive management step.

Match each clinical presentation of lower extremity pain with its most likely orthopedic diagnosis.

Match the following acute upper extremity orthopedic injuries with their most characteristic physical examination findings and anatomical disruptions.

Match each of the following specific orthopedic injuries with its most commonly associated acute neurovascular deficit as assessed on physical examination.

A 34-year-old man is brought to the emergency department for severe right shoulder pain. Thirty minutes ago, he experienced a witnessed generalized tonic-clonic seizure that lasted 2 minutes. On physical examination, the right arm is held firmly in adduction and internal rotation. The patient actively resists any attempt at passive external rotation due to severe pain. The radial pulse is 2+ and sensation is intact to light touch over the deltoid and distal fingers. An initial anteroposterior (AP) radiograph of the right shoulder reveals a symmetric, rounded appearance of the humeral head with no obvious fracture lines. Which of the following is the most appropriate next step in the management of this patient?

A 25-year-old man is brought to the emergency department after a motorcycle collision. Examination reveals an obvious deformity of the right lower leg with a 4-centimeter laceration over the anterior tibia, exposing the underlying fractured bone. Distal pulses are palpable, and the patient has intact sensation in the foot. Arrange the following steps in the most appropriate chronological sequence for the acute management of this patient's open fracture.