Orthopedics Board Review Part II

1. Orthopedics Board ReviewPart II Satjiv Kohli Mt Sinai School of Medicine Department of Emergency Medicine

2. Which of the following is TRUE regarding gamekeeper’s thumb? A. The mechanism of injury is usually forced adduction at the MCP joint B. Delaying surgery as long as 1 month for an acutely ruptured ligament will help preserve future function C. More than 40° of radial angulation on stress testing inidicates complete rupture D. Injury to the dorsal capsule and volar plate are rare

3. C. More than 40° of radial angluation on stress testing indicates complete rupture

4. Gamekeeper’s thumb • Forced radial deviation at the MCP joint rupturing UCL • Often includes significant damage to the dorsal capsule and volar plate • Thumb spica • Requires prompt ortho f/u within 1 week

5. 2. Which of the following is TRUE regarding perilunate and lunate dislocations? A. All require emergency orthopedic consultation B. Associated carpal bone fractures are rare C. Complications of these injuries include avascular necrosis and median nerve compression D. Patients presents with obvious hand deformities

6. A. All require emergent orthopedic consultation

7. Lunate and Perilunate dislocations • Result from forced dorsiflexion and fall on outstretched hand • Require significant amount of force • Often have associated factors of carpal bones • Emergent ortho consultation • Complications include: • Median nerve compression, avascular necrosis, malunion, early DJD

8. 3. 22 yo female presents c/o R elbow pain and swelling after falling off her motor scooter. On exam, she is holding the R arm in 45° of flexion, and you palpate a prominent olecranon posteriorly. Xray reveals a posterior elbow dislocation. Which of the following statements is true? A. The preferred method of reduction involves hyperflexion and internal rotation until a palpable reduction occurs B. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyle C. A long arm plaster splint should be applied in full extension and appropriate ortho f/u arranged D. An intact radial pulse postreduction r/o any possibility of vascular compromise

9. B. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyle

10. Elbow dislocation • Vast majority are posterior • Patients present w/ elbow 45° flexion with prominent olecranon • Important to assess NV status • Brachial artery, ulnar, radial, median nerves (5-13%) • Long arm splint with elbow in 90° flexion • Prompt ortho f/u

11. 4. Which of the following is suggestive of radial head fractures? A. Abnormality of the capitellum B. Anterior fat pad C. Lack of pain on exam D. Pain and swelling swelling on the lateral aspect of the elbow

12. D. Pain and swelling on the lateral aspect of the elbow

13. Radial head fractures • Most common fx of elbow • Fall on outstretched hand • Often not visible on Xray on day of injury • Tenderness at radial head or pain with supination

14. 5. Which of the following is TRUE regarding supracondylar fractures? A. An anterior fat pad may be the only visible sign of a nondisplaced fracture on Xray B. Refusal to open hand, pain with pasive finger extension, and forearm tenderness are commonly found with this injury and should be treated with analgesics C. Volkmann’s ischemic contracture results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues D. Most supracondylar fractures are displaced anteriorly

15. C. Volkmann’s ischemic contractures results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues

16. Supracondylar fractures • 60% of all elbow fx in children • 95% displaced posteriorly due to extension force • Neuro complications (7%) • Radial and median nerves • Acute vascular injuries must always be suspected • Volkmann’s ischemic contracture • Post ischemic swelling in forearm compartment • Refusal to open hand in children, pain w/ passive extension of fingers, forearm tenderness

17. 6. Which of the following is TRUE regarding injury shown below? A. Associated radial head dislocations are rare B. These type of fractures are classified according to the location of the ulnar fx and direction of the radial head dislocation C. Most of these fractures are treated with closed reduction and prolonged cast immobilization D. All of the above

18. B. These type of fractures are classified according to the location of the ulnar fx and direction of radial head dislocation

19. Monteggia’s fracture - dislocation • Ulnar shaft fx w/ associated radial head dislocation • Apex of ulnar fx pts in direction of radial head dislocation • Pain and swelling at elbow • Treated w/ closed reduction of radial head dislocation and ORIF of ulnar fx

20. 7. An 8 year old football player is brought to your ED with an anxious set of parents and R shoulder pain. Xray reveals minimally displaced midshaft fx of R clavicle. The parents ask you to tell them everything they need to know about the injury. Which of the following statements is TRUE? A. This is an uncommon place for a clavicular fx B. A figure of 8 harness is necessary for proper healing C. The patient will likely have chronic shoulder pain as adult D. This fx may be associated with intrathoracic injury

21. D. This fx may be associated with intrathoracic injury

22. Clavicular fractures • Most common fx of childhood • Account for ~1/2 of significant injuries to shoulder girdle • Direct blow to shoulder • 80% of fx involve middle 1/3 • Simple sling immobilization • Heal within 4-6 weeks • Distal fx often rupture coracoclavicular ligament

23. 8. Which of the following is TRUE regarding AC joint injuries? A. It is difficult to diagnose them clinically B. Most injuries occur in the elderly C. Shoulder Xrays are needed D. Tx of most injuries consists of analgesia, rest, and immobilization in a simple sling

24. C. Shoulder Xrays are needed

25. Acromioclavicular Separation • Tears of AC and CC ligaments • Fall onto adducted arm • Young active males • Classification based on degree of ligamentous disruption and displacement • Minimally displaced can be treated with sling and early immobilization • Severely displaced or rupture of CC ligament require prompt ortho referral

26. 9. Which of the following is TRUE regarding scapular fx? A. They are seldom associated with other injuries B. Most require surgical fixation to ensure long term should fxn C. They are usually the result of severe trauma D. Fx of the acromion and the scapular spine are the most common

27. C. They are usually the result of severe trauma

28. Scapular fx • Scapular embedded in muscle and therefore not easily fx • Associated injures to lung, thorax cage, and shoulder girdle frequent • Fx of body and neck of glenoid are most common • Isolated fx are treated with sling and early ROM

29. 10. 56 yo male presents after industrial accident where the patients chest was pinned btw heavy machinery. He is c/o left anterior neck and chest discomfort as well as dysphagia. On exam, you note an obese man. BP is 150/80, HR is 90, and RR is 24. Patient has swelling and tenderness along the L clavicular area and over the sternum, with pain exacerbated upon movement of L shoulder. CXR reveals no fx or PTX. What is the MOST appropriate next diagnostic step? A. PO challenge and d/c with f/u B. L shoulder Xray C. Chest CT D. End-expiratory CXR

30. C. Chest CT

31. Sternoclavicluar dislocation • Uncommon • Anterior dislocations more frequent • Promiment medial clavicle • Posterior dislocations • Clavicle end is not palpable • Impingement of mediastinal contents

32. 11. Which of the following is TRUE regarding C spine injuries? A. Fanning or widening of the spinous processes may indicate an injury to the anterior ligamentous structures B. Injuries to transverse ligament of the odontoid can occur w/o bony fx and should be considered unstable injuries C. The flexion-teardrop fx is considered mechanically stable D. A bilateral interfacetal dislocation (“locked facets”) is considered mechanically stable

33. B. Injuries to transverse ligament of odontoid can occur w/o bony fx and should be considered unstable injuries

34. C spine injuries • Transverse ligament • Runs along posterior surface of dens • Pure ligamentous disruption w/o associated fx can occur in older patients with direct blow to occiput • Predental space (>3mm ligament damage, >5mm ligament rupture) • Immediate Neurosurgery consult

35. 12. 17 yo female attended a pool party where ETOH was being served. She dove head first into the shallow end of the pool and landed directly on her head. In the ED, she has severe neck pain and minimal movement below the level of the shoulders. Which of the following is the most likely injury? A. Burst fx B. Flexion-distraction fx C. Spinous process fx D. Transverse process fx E. Wedge fx

36. A. Burst fracture

37. C spine fractures • Burst Fx • Axial loading mechanism of injury • Neurological deficit from retropulsion of bony fragments into the spinal canal

38. C spine fractures • Flexion-distraction • accel/decel injuries • Spinous process fx (Clay shoveler’s injury) • Stable • Flexion

39. C spine fractures • Wedge fracture • Flexion injury • Stable and rarely associated w/ neuro deficit • Anterior wedge fx>50% of the height of the vertebral body might become unstable over long term

40. C spine fractures • Flexion teardrop • Anterior cord syndrome due impingement • Mechanically unstable • Bilateral interfacetal dislocation • Articular masses to dislocate superiorly and anteriorly • Mechanically unstable

41. 13. 35 yo male presents after jumping from 3 story building in a suicide attempt. He is unconscious on arrival and immediately intubated. His feet are swollen and appear deformed, and Xrays are obtained to r/o calcaneal fx. Which of the following is TRUE regarding calcaneal injuries? A. Boehler’s angle measured at 10° r/o the possibility of occult fx B. Management is primarily supportive care and surgery is rarely necessary C. Associated vertebral fx are classic but not commonly found D. The patient is at risk for developing compartment syndrome

42. D. Patient is at risk for developing compartment syndrome

43. Calcaneal fractures (Lovers fx) • High velocity axial load injury • Boehler’s angle measurement helps to discern otherwise negative xrays • High risk of developing compartment syndrome • Frequently associated with injuries to axial spine (Don Juan fx)

44. 14. 26 yo male is brought to trauma room after high speed motorcycle accident. He has suspected injuries to abdomen and head as well as an obvious deformity of the L ankle. The L foot is dusky and cool, and pulses are difficult to palpate. What is the MOST appropriate next step in the management of this injury? A. Obtain ankle films immediately as other trauma Xrays are obtained B. Call orthopod on call immediately to request assistance with reduction C. Perform immediate reduction prior to obtaining Xrays D. Attempt reduction only after films and ABI have obtained for BLE

45. C. Perform immediate reduction prior to obtaining Xrays

46. Ankle dislocation • Dislocations can occur in 1 of 4 planes • Frequently associated with fx • Posterior dislocation most common • Considerable risk of neurovascular compromise • Require emergent reduction by EM physician

47. 15. 29 yo male is BIBA s/p high speed motorcycle accident. The paramedics state that when they arrived on the scene the patient’s left knee, appeared severely deformed, and a splint was immediately applied. Upon removal of splint in the ED, you do not appreciate any obvious deformity but do note severe swelling of the joint. The patient is severe pain at the knee, and you appreciate severe instability of the knee in multiple directions. Which of the following is TRUE regarding this patient? A. He most likely has quadriceps tendon rupture and should be splinted in a knee immobilizer B. Any effusions presents should be immediately aspirated C. This patient is at high risk for neurovascular injuries and should be admitted regardless of the neurovascular exam D. Xrays should be ordered to r/o fx, and the patient should receive prompt outpatient f/u to evaluate potential ligamentous injuries

48. C. The patient is at high risk for neurovascular injuries and should be admited regardless of the neurovascular exam

49. Knee dislocation • Posterior dislocation most common • Complete disruption of ACL & PCL and posterior joint capsule • Spontaneous reduction of knee often occurs • High incidence of associated complications • Popliteal artery and peroneal nerve (1/3 of dislocations) • All patients should be admitted