orthopedics board review part ii satjiv kohli mt sinai school of medicine department of emergency...
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Orthopedics Board ReviewPart II
Orthopedics Board ReviewPart II
Satjiv KohliMt Sinai School of
MedicineDepartment of
Emergency Medicine
Satjiv KohliMt Sinai School of
MedicineDepartment of
Emergency Medicine
1. Which of the following is TRUE regarding gamekeeper’s thumb?A. The mechanism of injury is usually forced adduction at the MCP jointB. Delaying surgery as long as 1 month for an acutely ruptured ligament will help preserve future functionC. More than 40° of radial angulation on stress testing inidicates complete ruptureD. Injury to the dorsal capsule and volar plate are rare
1. Which of the following is TRUE regarding gamekeeper’s thumb?A. The mechanism of injury is usually forced adduction at the MCP jointB. Delaying surgery as long as 1 month for an acutely ruptured ligament will help preserve future functionC. More than 40° of radial angulation on stress testing inidicates complete ruptureD. Injury to the dorsal capsule and volar plate are rare
C. More than 40° of radial angluation on stress testing indicates complete rupture
C. More than 40° of radial angluation on stress testing indicates complete rupture
Gamekeeper’s thumb
Gamekeeper’s thumb
Forced radial deviation at the MCP joint rupturing UCL
Often includes significant damage to the dorsal capsule and volar plate
Thumb spicaRequires prompt ortho f/u
within 1 week
Forced radial deviation at the MCP joint rupturing UCL
Often includes significant damage to the dorsal capsule and volar plate
Thumb spicaRequires prompt ortho f/u
within 1 week
2. Which of the following is TRUE regarding perilunate and lunate dislocations?A. All require emergency orthopedic consultationB. Associated carpal bone fractures are rareC. Complications of these injuries include avascular necrosis and median nerve compressionD. Patients presents with obvious hand deformities
2. Which of the following is TRUE regarding perilunate and lunate dislocations?A. All require emergency orthopedic consultationB. Associated carpal bone fractures are rareC. Complications of these injuries include avascular necrosis and median nerve compressionD. Patients presents with obvious hand deformities
Lunate and Perilunate
dislocations
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
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
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 occursB. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyleC. A long arm plaster splint should be applied in full extension and appropriate ortho f/u arrangedD. An intact radial pulse postreduction r/o any possibility of vascular compromise
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 occursB. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyleC. A long arm plaster splint should be applied in full extension and appropriate ortho f/u arrangedD. An intact radial pulse postreduction r/o any possibility of vascular compromise
B. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyle
B. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyle
Elbow dislocationElbow 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
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
4. Which of the following is suggestive of radial head fractures?A. Abnormality of the capitellumB. Anterior fat padC. Lack of pain on examD. Pain and swelling swelling on the lateral aspect of the elbow
4. Which of the following is suggestive of radial head fractures?A. Abnormality of the capitellumB. Anterior fat padC. Lack of pain on examD. Pain and swelling swelling on the lateral aspect of the elbow
D. Pain and swelling on the lateral aspect of the elbow
D. Pain and swelling on the lateral aspect of the elbow
Radial head fractures
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
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
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 XrayB. Refusal to open hand, pain with pasive finger extension, and forearm tenderness are commonly found with this injury and should be treated with analgesicsC. Volkmann’s ischemic contracture results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissuesD. Most supracondylar fractures are displaced anteriorly
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 XrayB. Refusal to open hand, pain with pasive finger extension, and forearm tenderness are commonly found with this injury and should be treated with analgesicsC. Volkmann’s ischemic contracture results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissuesD. Most supracondylar fractures are displaced anteriorly
C. Volkmann’s ischemic contractures results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues
C. Volkmann’s ischemic contractures results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues
Supracondylar fractures
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
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
6. Which of the following is TRUE regarding injury shown below?A. Associated radial head dislocations are rareB. These type of fractures are classified according to the location of the ulnar fx and direction of the radial head dislocationC. Most of these fractures are treated with closed reduction and prolonged cast immobilizationD. All of the above
6. Which of the following is TRUE regarding injury shown below?A. Associated radial head dislocations are rareB. These type of fractures are classified according to the location of the ulnar fx and direction of the radial head dislocationC. Most of these fractures are treated with closed reduction and prolonged cast immobilizationD. All of the above
B. These type of fractures are classified according to the location of the ulnar fx and direction of radial head dislocation
B. These type of fractures are classified according to the location of the ulnar fx and direction of radial head dislocation
Monteggia’s fracture - dislocation
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 elbowTreated w/ closed reduction of
radial head dislocation and ORIF of ulnar fx
Ulnar shaft fx w/ associated radial head dislocation
Apex of ulnar fx pts in direction of radial head dislocation
Pain and swelling at elbowTreated w/ closed reduction of
radial head dislocation and ORIF of ulnar fx
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 fxB. A figure of 8 harness is necessary for proper healingC. The patient will likely have chronic shoulder pain as adultD. This fx may be associated with intrathoracic injury
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 fxB. A figure of 8 harness is necessary for proper healingC. The patient will likely have chronic shoulder pain as adultD. This fx may be associated with intrathoracic injury
D. This fx may be associated with intrathoracic injury
D. This fx may be associated with intrathoracic injury
Clavicular fracturesClavicular 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
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
8. Which of the following is TRUE regarding AC joint injuries?A. It is difficult to diagnose them clinicallyB. Most injuries occur in the elderlyC. Shoulder Xrays are neededD. Tx of most injuries consists of analgesia, rest, and immobilization in a simple sling
8. Which of the following is TRUE regarding AC joint injuries?A. It is difficult to diagnose them clinicallyB. Most injuries occur in the elderlyC. Shoulder Xrays are neededD. Tx of most injuries consists of analgesia, rest, and immobilization in a simple sling
Acromioclavicular Separation
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
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
9. Which of the following is TRUE regarding scapular fx?
A. They are seldom associated with other injuriesB. Most require surgical fixation to ensure long term should fxnC. They are usually the result of severe traumaD. Fx of the acromion and the scapular spine are the most common
9. Which of the following is TRUE regarding scapular fx?
A. They are seldom associated with other injuriesB. Most require surgical fixation to ensure long term should fxnC. They are usually the result of severe traumaD. Fx of the acromion and the scapular spine are the most common
Scapular fxScapular 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
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
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/uB. L shoulder XrayC. Chest CTD. End-expiratory CXR
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/uB. L shoulder XrayC. Chest CTD. End-expiratory CXR
Sternoclavicluar dislocation
Sternoclavicluar dislocation
Uncommon Anterior
dislocations more frequent Promiment
medial clavicle Posterior
dislocations Clavicle end is
not palpable Impingement of
mediastinal contents
Uncommon Anterior
dislocations more frequent Promiment
medial clavicle Posterior
dislocations Clavicle end is
not palpable Impingement of
mediastinal contents
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 structuresB. Injuries to transverse ligament of the odontoid can occur w/o bony fx and should be considered unstable injuriesC. The flexion-teardrop fx is considered mechanically stableD. A bilateral interfacetal dislocation (“locked facets”) is considered mechanically stable
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 structuresB. Injuries to transverse ligament of the odontoid can occur w/o bony fx and should be considered unstable injuriesC. The flexion-teardrop fx is considered mechanically stableD. A bilateral interfacetal dislocation (“locked facets”) is considered mechanically stable
B. Injuries to transverse ligament of odontoid can occur w/o bony fx and should be considered unstable injuries
B. Injuries to transverse ligament of odontoid can occur w/o bony fx and should be considered unstable injuries
C spine injuriesC 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
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
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 fxB. Flexion-distraction fxC. Spinous process fxD. Transverse process fxE. Wedge fx
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 fxB. Flexion-distraction fxC. Spinous process fxD. Transverse process fxE. Wedge fx
C spine fracturesC spine fractures
Burst FxAxial loading
mechanism of injury
Neurological deficit from retropulsion of bony fragments into the spinal canal
Burst FxAxial loading
mechanism of injury
Neurological deficit from retropulsion of bony fragments into the spinal canal
C spine fracturesC spine fractures
Flexion-distraction accel/decel
injuries
Spinous process fx (Clay shoveler’s injury) Stable Flexion
Flexion-distraction accel/decel
injuries
Spinous process fx (Clay shoveler’s injury) Stable Flexion
C spine fracturesC 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
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
C spine fracturesC spine fractures Flexion teardrop
Anterior cord syndrome due impingement
Mechanically unstable
Bilateral interfacetal dislocation Articular masses
to dislocate superiorly and anteriorly
Mechanically unstable
Flexion teardrop Anterior cord
syndrome due impingement
Mechanically unstable
Bilateral interfacetal dislocation Articular masses
to dislocate superiorly and anteriorly
Mechanically unstable
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 fxB. Management is primarily supportive care and surgery is rarely necessaryC. Associated vertebral fx are classic but not commonly foundD. The patient is at risk for developing compartment syndrome
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 fxB. Management is primarily supportive care and surgery is rarely necessaryC. Associated vertebral fx are classic but not commonly foundD. The patient is at risk for developing compartment syndrome
D. Patient is at risk for developing compartment syndrome
D. Patient is at risk for developing compartment syndrome
Calcaneal fractures (Lovers fx)
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)
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)
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 obtainedB. Call orthopod on call immediately to request assistance with reductionC. Perform immediate reduction prior to obtaining XraysD. Attempt reduction only after films and ABI have obtained for BLE
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 obtainedB. Call orthopod on call immediately to request assistance with reductionC. Perform immediate reduction prior to obtaining XraysD. Attempt reduction only after films and ABI have obtained for BLE
C. Perform immediate reduction prior to obtaining Xrays
C. Perform immediate reduction prior to obtaining Xrays
Ankle dislocationAnkle dislocation
Dislocations can occur in 1 of 4 planes
Frequently associated with fxPosterior dislocation most
commonConsiderable risk of
neurovascular compromiseRequire emergent reduction by
EM physician
Dislocations can occur in 1 of 4 planes
Frequently associated with fxPosterior dislocation most
commonConsiderable risk of
neurovascular compromiseRequire emergent reduction by
EM physician
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 aspiratedC. This patient is at high risk for neurovascular injuries and should be admitted regardless of the neurovascular examD. Xrays should be ordered to r/o fx, and the patient should receive prompt outpatient f/u to evaluate potential ligamentous injuries
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 aspiratedC. This patient is at high risk for neurovascular injuries and should be admitted regardless of the neurovascular examD. Xrays should be ordered to r/o fx, and the patient should receive prompt outpatient f/u to evaluate potential ligamentous injuries
C. The patient is at high risk for neurovascular injuries and should be admited regardless of the neurovascular exam
C. The patient is at high risk for neurovascular injuries and should be admited regardless of the neurovascular exam
Knee dislocationKnee dislocation
Posterior dislocation most commonComplete disruption of ACL & PCL
and posterior joint capsule Spontaneous reduction of knee
often occurs High incidence of associated
complicationsPopliteal artery and peroneal
nerve (1/3 of dislocations) All patients should be admitted
Posterior dislocation most commonComplete disruption of ACL & PCL
and posterior joint capsule Spontaneous reduction of knee
often occurs High incidence of associated
complicationsPopliteal artery and peroneal
nerve (1/3 of dislocations) All patients should be admitted