Orthopedic Surgery

A 28-year-old man is evaluated in the intensive care unit. He was involved in a high-speed motor vehicle collision 24 hours ago. His injuries include a severe traumatic brain injury and a closed, comminuted midshaft fracture of the right tibia. He is currently intubated, sedated, and unresponsive to commands. His vital signs include a blood pressure of $105/65\text{ mm Hg}$ and a heart rate of $98/\text{min}$. The nursing staff reports that the patient's right lower leg has become increasingly firm over the past two hours. On physical examination, the right calf is tense, swollen, and non-compressible. The right dorsalis pedis and posterior tibial pulses are easily palpable, and capillary refill in the toes is less than 2 seconds. Which of the following is the most appropriate next step in the management of this patient's extremity?

Match the following specific orthopedic injuries with their most commonly associated neurovascular complication.

A 32-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He reports severe pain in his hips and lower back. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 82/50 mmHg, pulse of 134/min, and respiratory rate of 22/min. Physical examination reveals an ecchymotic and unstable pelvis upon gentle anterior-posterior compression. A focused assessment with sonography for trauma (FAST) is negative for free intra-abdominal fluid, and a chest x-ray is clear. There are no obvious external sources of bleeding. Large-bore intravenous access is established, and aggressive fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Match the following complex orthopedic injuries with their defining pathophysiologic mechanism, critical diagnostic finding, or absolute surgical management principle.

Emergency medical services bring a 45-year-old male construction worker to the trauma bay after he fell two stories from scaffolding. On arrival, he is restless, agitated, and diaphoretic. Vital signs show a heart rate of 135/min and a blood pressure of 82/45 mmHg. Oxygen saturation is 96% on room air. Primary survey reveals clear lungs and a non-distended abdomen. A bedside ultrasound for trauma is negative for free fluid. His pelvis is stable to gentle compression. The right thigh is tense, markedly swollen, and shortened compared to the left, but there is no break in the overlying skin. Bilateral pedal pulses are faint but palpable. Following securing of intravenous access and initiation of crystalloid fluids, which of the following is the most appropriate next step in management?

A 19-year-old female collegiate gymnast is brought to the emergency department after a severe fall during a dismount. She landed awkwardly, sustaining a hyperextension injury to her left knee. On arrival, she is in severe pain. Examination reveals a gross deformity with a prominent anterior tibia. The overlying skin is intact but tense. She has decreased sensation over the dorsum of her left foot and is unable to actively dorsiflex her left ankle. Palpation reveals absent dorsalis pedis and posterior tibial pulses on the left. The emergency physician immediately performs a closed reduction, which restores anatomical alignment. Following the reduction, the patient's pain significantly improves. Her left foot becomes warm and pink, and both the left dorsalis pedis and posterior tibial pulses are now palpable and graded as 2+ (normal). Her blood pressure is 125/75 mm Hg and heart rate is 88/min. Doppler ultrasound is used to measure systolic pressures: the left brachial pressure is 130 mm Hg, the left ankle pressure is 104 mm Hg, and the right ankle pressure is 130 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A forestry worker is airlifted to a regional trauma center after his leg was crushed under a fallen tree. Due to the remote location and complex extrication, the total time from the moment of injury to hospital arrival is seven and a half hours. Upon arrival, the patient is hemodynamically stable. The primary survey is otherwise clear, but the secondary survey reveals a grossly deformed left knee with an open, highly comminuted distal femur fracture (Gustilo-Anderson IIIB). The left foot is pale, poikilothermic, and cold, with absent dorsalis pedis and posterior tibial pulses. Capillary refill is completely absent. A rapid on-table angiogram in the hybrid operating room demonstrates a complete transection of the popliteal artery with no distal flow. The trauma and orthopedic surgery teams prepare for immediate combined surgical intervention.

Arrange the following operative steps in the most appropriate chronological sequence for this patient's limb salvage.

An overweight 13-year-old boy is brought to the outpatient clinic by his parents. He has been complaining of left knee and anterior thigh pain for the past four weeks. The pain is described as a dull ache that worsens with physical activity such as walking or climbing stairs. There is no history of recent trauma, falls, or fever. His temperature is 36.8°C (98.2°F), blood pressure is 112/72 mm Hg, pulse is 76/min, and respirations are 14/min. His body mass index is 31 kg/m². Upon physical evaluation, the left knee shows no evidence of erythema, swelling, or localized tenderness, and ligamentous testing is normal. However, examination of the left hip reveals restricted internal rotation. Furthermore, when the clinician passively flexes the patient's left hip, the thigh obligatorily rotates outward. Motor strength and sensory examinations in the lower extremities are unremarkable. Distal pulses are palpable and equal bilaterally.

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

Match the following common musculoskeletal injuries with their classic, diagnostic physical examination findings.

Following a high-velocity motorcycle collision, a 26-year-old male driver is evaluated in the trauma resuscitation unit. He was intubated at the scene for a Glasgow Coma Scale score of 7. On arrival, his temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $85/50 \text{ mm Hg}$, and heart rate is $132\text{/min}$. Primary survey reveals decreased breath sounds on the right. A tube thoracostomy is performed, yielding a large rush of air and $50 \text{ mL}$ of blood; his oxygen saturation improves to 94%, but his blood pressure remains $90/55 \text{ mm Hg}$ despite the rapid infusion of $2 \text{ L}$ of warmed crystalloids. The focused assessment with sonography for trauma (FAST) is negative. A pelvic radiograph shows no fractures. Examination of the extremities reveals a grossly deformed and swollen right thigh with intact overlying skin. Dorsalis pedis and posterior tibial pulses are palpable and symmetric. A portable chest radiograph shows bilateral patchy infiltrates and a right-sided chest tube in good position. A radiograph of the right femur confirms a comminuted diaphyseal fracture. Arterial blood gas analysis reveals a pH of $7.21$, $\text{PaCO}_2$ of $48 \text{ mm Hg}$, $\text{PaO}_2$ of $65 \text{ mm Hg}$, and a lactate level of $5.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient's femur fracture?

Match each traumatic cervical spine fracture to its most characteristic mechanism of injury, primary structural finding, and major clinical consequence.

A 5-year-old boy is brought to the clinic by his parents because of a right-sided limp that began this morning. The parents note that he had a mild upper respiratory infection about a week ago, which has completely resolved. He is currently reluctant to bear full weight on his right leg but will take a few steps with a noticeable limp. His temperature is 37.5°C (99.5°F), blood pressure is 95/60 mm Hg, and pulse is 98/min. On physical examination, the child appears well and comfortably plays with a toy on the exam table. His right hip is held in slight flexion and external rotation. There is mild discomfort during passive internal rotation of the right hip, but no overlying erythema, warmth, or swelling.

Radiographs of the pelvis and both hips show no abnormalities. Which of the following is the most appropriate next step in management?

A previously healthy 6-year-old male child arrives at the emergency department accompanied by his parents. He complains of excruciating right knee pain that started 24 hours ago. He completely refuses to walk or bear any weight on the affected leg. His current temperature is 39.0°C (102.2°F). Physical examination reveals a right knee that is notably swollen, red, warm, and exquisitely tender during minimal passive flexion and extension. Plain radiography of the right knee demonstrates a prominent joint effusion but no osseous abnormalities. The clinical picture strongly suggests an acute bacterial joint infection. Arrange the following management steps in the correct chronological order from first to last.

A 48-year-old man is evaluated in the surgical ward on postoperative day 2 following an open reduction and internal fixation of a closed, highly comminuted midshaft tibial fracture. Over the past 4 hours, he has complained of rapidly escalating pain in his right leg that is entirely unresponsive to intravenous morphine. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $128$/min, blood pressure is $90/55$ mmHg, and respiratory rate is $24$/min. Physical examination reveals a markedly swollen right lower extremity. The skin surrounding the surgical incision is tense, erythematous, and notably discolored with scattered bullae containing dark fluid. Exquisite tenderness is present well beyond the margins of the erythema. Subcutaneous crepitus is palpable along the medial aspect of the tibia. Dorsalis pedis and posterior tibial pulses are faint but palpable. Laboratory studies show:

Leukocyte count: $28,000$/mm $^3$
Serum sodium: $129$ mEq/L
Blood urea nitrogen: $34$ mg/dL
Serum creatinine: $1.8$ mg/dL

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

During a weekend snowboarding trip, a 24-year-old man falls forward onto his outstretched right hand. He presents to an urgent care clinic three hours later reporting pain in his right wrist. On physical examination, there is mild swelling and focal tenderness over the dorsal radial aspect of the wrist, specifically in the depression bounded by the extensor pollicis longus and extensor pollicis brevis tendons. Range of motion is limited by pain, but there is no gross deformity. Sensation and radial pulses are intact. Initial anterior-posterior, lateral, and scaphoid views of the right wrist on radiography show no abnormalities. Which of the following is the most appropriate next step in management?

Match each specific orthopedic injury with its most commonly associated acute neurovascular physical exam finding.

An unrestrained 24-year-old male driver is transported to the emergency department following a severe front-end motor vehicle collision. Primary survey reveals a hemodynamically stable patient with an isolated right lower extremity injury. The right leg is visibly shortened, adducted, and internally rotated. The patient complains of intense right hip pain and an inability to feel the top of his right foot. Subsequent imaging during his care reveals an incongruent joint space requiring definitive operative intervention. Arrange the following steps in the correct chronological order for the optimal, evidence-based management of this patient's injury.

A 24-year-old man is admitted to the hospital after sustaining a closed midshaft femur fracture in a motor vehicle collision. The fracture is temporarily immobilized in a traction splint, and he is scheduled for operative fixation the following morning. Twelve hours after admission, he develops sudden-onset shortness of breath, confusion, and a new petechial rash over his chest and anterior neck. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 122/78 mmHg, pulse of 118/min, and respirations of 26/min. Oxygen saturation is 86% on room air. Auscultation of the lungs reveals scattered bilateral crackles. Which of the following is the most likely diagnosis?

A 42-year-old woman is brought to the emergency department after tripping over a rug and falling onto her right arm. She reports severe, sharp pain and an inability to move her right arm. Vital signs are within normal limits. Physical examination reveals an obvious deformity and significant swelling over the middle-to-distal aspect of the right arm. Upon initial neurologic evaluation, the patient has full active extension of the right wrist and fingers, and sensation is intact to light touch over the dorsum of the hand. Radial and ulnar pulses are 2+ and capillary refill is less than 2 seconds. Radiographs of the right upper extremity demonstrate a displaced, spiral fracture of the distal third of the humeral shaft. An orthopedic surgery resident performs a closed reduction in the emergency department, and a coaptation splint is applied. Post-reduction radiographs confirm acceptable alignment of the fracture fragments. Thirty minutes later, during a routine neurovascular reassessment, the patient is unable to actively extend her right wrist or digits. Sensation to light touch is now decreased over the dorsal web space between the thumb and index finger. Distal pulses remain 2+. Which of the following is the most appropriate next step in management?

A 32-year-old female arrives at the emergency department via ambulance following a high-speed motorcycle collision. She has an obvious deformity of her right lower leg with a 5-centimeter laceration over the anterior tibia exposing the underlying bone. Active oozing of blood is noted. Her pulse is 110/min, and blood pressure is 115/75 mm Hg. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.