Orthopedic Surgery

A $6$-year-old girl is brought to the emergency department by her parents after falling from monkey bars onto her outstretched left hand $30$ minutes ago. She is crying and clutching her left arm. Vital signs show a temperature of $37.1^\circ$ C, blood pressure of $105/65$ mmHg, heart rate of $115$/min, and respiratory rate of $22$/min. Physical examination reveals a significantly swollen left elbow with a prominent S-shaped deformity. The overlying skin is intact. Neurovascular assessment of the left upper extremity demonstrates a pale hand with a capillary refill time of $4$ seconds. The radial pulse is not palpable but is faintly detectable via Doppler ultrasound. The patient is unable to make an "OK" sign with her left hand, but sensation over the palmar aspect of the first three digits is intact. Radiographs of the left elbow show a completely displaced, extension-type supracondylar fracture of the humerus. Which of the following is the most appropriate next step in management?

A 14-year-old boy with a BMI of $31 \text{ kg/m}^2$ is brought to the clinic by his mother due to a 3-week history of right knee pain and a progressive limp. He denies any recent trauma, fever, or weight loss. Vital signs are within normal limits. On physical examination, there is no effusion, erythema, or tenderness to palpation over the right knee. Ligamentous testing of the right knee is intact. When the patient's right hip is passively flexed to $90^\circ$, the right thigh obligatorily rotates externally. Internal rotation of the right hip is significantly limited and elicits pain. Which of the following is the most appropriate next step in management?

A 52-year-old male with a history of poorly controlled type 2 diabetes mellitus presents to the emergency department with a 2-day history of severe right knee pain, swelling, and subjective fevers. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, heart rate is $110/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a markedly swollen, erythematous, and warm right knee. The patient refuses to bear weight, and there is exquisite pain with even minimal passive range of motion. Blood cultures are drawn in the emergency department.

Arrange the following next steps in the most appropriate sequential order for the acute management of this patient.

Match the following primary bone lesions with their most characteristic clinical presentation and radiographic features.

A 42-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He was the restrained driver. Upon arrival, he is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/50 mm Hg, pulse is 132/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. The airway is patent, and breath sounds are clear and equal bilaterally. A focused assessment with sonography for trauma (FAST) examination reveals no free fluid in the peritoneal cavity or pericardial sac. Physical examination demonstrates marked ecchymosis over the lower abdomen and perineum, with severe instability of the pelvic ring on gentle anteroposterior compression. There is blood at the urethral meatus. Bilateral lower extremity pulses are palpable but weak. Motor and sensory examinations of the lower extremities are limited due to patient confusion, but there are no gross deformities of the legs. Two large-bore intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Which of the following is the most appropriate next step in management?

A $65$-year-old woman is evaluated on postoperative day $7$ following a right total knee arthroplasty for severe osteoarthritis. She reports sudden, severe pain in the right knee that began yesterday and has progressively worsened. The patient has been compliant with prophylactic apixaban and routine postoperative physical therapy. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $130/80$ mmHg, pulse is $102$/min, and respirations are $16$/min. Physical examination reveals a right knee that is significantly swollen, erythematous, and warm to the touch. The surgical incision is closed and intact without any frank purulent drainage, but there is marked tenderness over the joint capsule. Passive range of motion is extremely limited due to severe pain. Laboratory studies show a leukocyte count of $14,000/\text{mm}^3$ and an erythrocyte sedimentation rate of $85\text{ mm/h}$. Which of the following is the most appropriate next step in management?

A 24-year-old university student presents to the outpatient clinic reporting persistent right wrist pain. Approximately 24 hours ago, he fell forward while skateboarding and braced his impact with an outstretched right hand. He describes a constant, dull ache located near the base of his thumb. On physical examination, there is minimal visible swelling and no obvious deformity. Palpation reveals distinct tenderness in the triangular depression on the radial aspect of the wrist when the thumb is fully extended. Capillary refill is less than 2 seconds, and sensation is intact in all digits. Initial anteroposterior, lateral, and scaphoid-view radiographs of the right wrist show no evidence of acute fracture, cortical disruption, or dislocation. Based on these findings, which of the following is the most appropriate next step in patient management?

A 78-year-old woman is brought to the emergency department after slipping and falling in her kitchen. She complains of severe left groin pain and is unable to bear weight on her left leg. She has a medical history of hypertension, type 2 diabetes mellitus, and osteoporosis. Vital signs are temperature 37.1°C (98.8°F), heart rate 82/min, blood pressure 138/86 mm Hg, and respiratory rate 16/min. Physical examination reveals normal alignment of the left lower extremity with no shortening or external rotation. However, severe pain is elicited with active straight leg raise and gentle internal rotation of the left hip. The dorsalis pedis and posterior tibial pulses are 2+ and symmetric. Sensation is intact to light touch in all distal dermatomes. Anteroposterior and cross-table lateral radiographs of the left hip and pelvis show severe osteopenia and degenerative joint disease but no cortical step-off or radiolucent fracture lines. Which of the following is the most appropriate next step in management?

An $82$-year-old female resident of an assisted living facility is evaluated in the hospital following a mechanical fall. The patient reports that she tripped over an electrical cord in her room earlier today. She now experiences severe pain in her right groin and is completely unable to bear weight. Prior to this incident, she was ambulatory and walked independently with a cane. Her past medical history is notable for osteoporosis, type $2$ diabetes mellitus, and essential hypertension. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $14/\text{min}$. On physical examination, the right lower extremity is noticeably shorter than the left and lies in an externally rotated position. Distal pulses are strong and symmetric, and sensory function is intact in both legs. Plain radiographs of the pelvis and right hip demonstrate a complete, displaced fracture line extending across the transcervical region of the right femur. The greater and lesser trochanters are intact. What is the most appropriate definitive surgical management for this patient's injury?

Match each of the following eponymous forearm and wrist fractures with its correct anatomical injury description.

A 30-year-old man is brought to the emergency department after a fall from a height of 6 meters (20 feet). He is confused and agitated. His temperature is 36.8°C (98.2°F), blood pressure is 75/40 mm Hg, and pulse is 135/min. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. A focused assessment with sonography for trauma (FAST) examination is negative for intraperitoneal or pericardial fluid. Pelvic examination shows stability to anteroposterior and lateral compression, and a portable anteroposterior pelvic radiograph is normal. Examination of the left lower extremity reveals a visibly deformed, shortened thigh with tense swelling. There are no open wounds. Distal pulses are palpable but diminished in the left foot compared to the right. Which of the following is the most appropriate next step in management?

A 22-year-old collegiate athlete is brought to the emergency department immediately after sustaining a severe hyperextension injury to his left leg during a rugby match. He is in agonizing pain. On physical examination, there is a gross step-off deformity at the left knee joint. The left foot is cold and pale. The dorsalis pedis and posterior tibial pulses are absent on the left side but are robust on the right. Capillary refill time in the left toes is delayed at 5 seconds. Assuming evidence of arterial compromise persists throughout the initial evaluation, arrange the following management steps in the most appropriate sequential order.