A 30-year-old man presents to his primary care physician for pain in his left ankle. The patient states that he was at karate practice when he suddenly felt severe pain in his ankle forcing him to stop. The patient has a past medical history notable for type I diabetes and is currently being treated for an episode of acute bacterial sinusitis with moxifloxacin. The patient recently had to have his insulin dose increased secondary to poorly controlled blood glucose levels. Otherwise, the patient takes ibuprofen for headaches and loratadine for seasonal allergies. Physical exam reveals a young healthy man in no acute distress. Pain is elicited over the Achilles tendon with dorsiflexion of the left foot. Pain is also elicited with plantar flexion of the left foot against resistance. Which of the following is the best next step in management?

Change antibiotics and refrain from athletic activities

Refrain from athletic activities for 1 to 2 weeks

Rehabilitation exercises and activity as tolerated

A 25-year-old man comes to the physician for severe back pain. He describes the pain as shooting and stabbing. On a 10-point scale, he rates the pain as a 9 to 10. The pain started after he lifted a heavy box at work; he works at a supermarket and recently switched from being a cashier to a storekeeper. The patient appears to be in severe distress. Vital signs are within normal limits. On physical examination, the spine is nontender without paravertebral muscle spasms. Range of motion is normal. A straight-leg raise test is negative. After the physical examination has been completed, the patient asks for a letter to his employer attesting to his inability to work as a storekeeper. Which of the following is the most appropriate response?

I understand that you are uncomfortable, but the findings do not match the severity of your symptoms. Let's talk about the recent changes at your job.

“Yes. Since work may worsen your condition, I would prefer that you stay home a few days. I will write a letter to your employer to explain the situation.”

You say you are in severe pain. However, the physical examination findings do not suggest a physical problem that can be addressed with medications or surgery. I'd like to meet on a regular basis to see how you're doing.

The physical exam findings do not match your symptoms, which suggests a psychological problem. I would be happy to refer you to a mental health professional.

The physical exam findings suggest a psychological rather than a physical problem. But there is a good chance that we can address it with cognitive-behavioral therapy.

Three days after undergoing coronary bypass surgery, a 67-year-old man becomes unresponsive and hypotensive. He is intubated, mechanically ventilated, and a central line is inserted. Vasopressin and noradrenaline infusions are begun. A Foley catheter is placed. Six days later, he has high unrelenting fevers. He is currently receiving noradrenaline via an infusion pump. His temperature is 39.6°C (102.3°F), pulse is 113/min, and blood pressure is 90/50 mm Hg. Examination shows a sternal wound with surrounding erythema; there is no discharge from the wound. Crackles are heard at both lung bases. Cardiac examination shows an S3 gallop. Abdominal examination shows no abnormalities. A Foley catheter is present. His hemoglobin concentration is 10.8 g/dL, leukocyte count is 21,700/mm3, and platelet count is 165,000/mm3. Samples for blood culture are drawn simultaneously from the central line and peripheral IV line. Blood cultures from the central line show coagulase-negative cocci in clusters on the 8th postoperative day, and those from the peripheral venous line show coagulase-negative cocci in clusters on the 10th postoperative day. Which of the following is the most likely diagnosis in this patient?

Central line-associated blood stream infection

Catheter-associated urinary tract infection

Ventilator-associated pneumonia

A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?

Measurement of compartment pressure

A 25-year-old man is admitted to the emergency department because of an episode of acute psychosis with suicidal ideation. He has no history of serious illness and currently takes no medications. Despite appropriate safety precautions, he manages to leave the examination room unattended. Shortly afterward, he is found lying outside the emergency department. A visitor reports that she saw the patient climbing up the facade of the hospital building. He does not respond to questions but points to his head when asked about pain. His pulse is 131/min, respirations are 22/min, and blood pressure is 95/61 mm Hg. Physical examination shows a 1-cm head laceration and an open fracture of the right tibia. He opens his eyes spontaneously. Pupils are equal, round, and reactive to light. Breath sounds are decreased over the right lung field, and the upper right hemithorax is hyperresonant to percussion. Which of the following is the most appropriate next step in management?

Perform an endotracheal intubation

Perform an open reduction of the tibia fracture

A 17-year-old boy comes to the emergency department following an injury during football practice. He fell and landed on the lateral aspect of his right shoulder. He is holding his right arm supported by his left arm, with his right arm adducted against his side. He is tender to palpation directly over the middle third of his clavicle. Radiographs reveal a non-displaced fracture of the middle third of the clavicle. Which of the following is the most appropriate treatment at this time?

Open reduction and internal fixation with a compression plate

Open reduction and internal fixation with an intramedullary nail

Open reduction and internal fixation with lag screws

A 50-year-old manual laborer sustained a comminuted distal radius fracture treated with ORIF 3 months ago. Despite supervised hand therapy, he has persistent stiffness with 30-degree wrist extension (normal 70), weak grip strength at 40% of contralateral side, and visible muscle atrophy. He reports burning pain with light touch and keeps his hand wrapped in a sock. Skin appears mottled with decreased hair growth. He is applying for disability and has a pending lawsuit. Evaluate the clinical picture and appropriate next step.

Triple-phase bone scan and referral to pain management

EMG/NCS to evaluate for nerve injury

Psychiatric evaluation for malingering assessment

Repeat surgery for hardware removal and capsular release

Independent functional capacity evaluation

Open vs closed reduction techniques for USMLE Step 1: High-Yield Surgery Lessons

🦴 Align & Conquer

Goal: Restore anatomical alignment ("reduction") to promote optimal healing and preserve function.

Feature	Closed Reduction	Open Reduction (ORIF)
Method	Manual manipulation; no incision	Surgical incision; direct view
Infection Risk	↓ Low	↑ High
Stability	Less stable (cast/splint)	Highly stable (hardware)
Best For	Simple, stable, closed fx	Complex, unstable, open fx

*   Failed closed reduction
*   Displaced intra-articular fractures
*   Open fractures (compound)
*   Neurovascular compromise requiring repair
*   Pathologic fractures

⭐ Open Fractures: Require urgent irrigation, debridement, and typically ORIF. Prophylactic antibiotics (e.g., Cefazolin for Gustilo I/II) are critical to prevent osteomyelitis.

⚔️ Management - The Surgical Showdown

Fracture reduction aims to restore anatomical alignment. The choice between closed (non-surgical) and open (surgical) techniques depends on fracture characteristics, displacement, and stability.

Feature	Closed Reduction	Open Reduction
Procedure	External manipulation; no surgical incision.	Surgical incision for direct bone visualization.
Indications	Stable, minimally displaced fractures (e.g., Colles', torus).	Unstable, significantly displaced, intra-articular, or open fractures.
Pros	↓ Infection risk, ↓ soft tissue injury, often outpatient.	Precise anatomic alignment, allows for rigid internal fixation.
Cons	Risk of malunion, potential for neurovascular entrapment.	↑ Infection risk, soft tissue stripping, hardware complications.
Fixation	Cast, splint, traction, or percutaneous pinning.	ORIF (Open Reduction Internal Fixation).

Open Reduction Internal Fixation (ORIF):
- Uses hardware (plates, screws, nails) to maintain alignment.
- Allows for early mobilization, reducing joint stiffness.

⚠️ Complications - Post-Op Pitfalls

Universal Risks: Nonunion/malunion, avascular necrosis (AVN), compartment syndrome, DVT/PE, complex regional pain syndrome (CRPS).

Feature	Open Reduction (ORIF)	Closed Reduction & Casting
Infection	High risk of surgical site infection (SSI) & osteomyelitis.	Low risk; primarily from skin breakdown or pressure sores under cast.
Stability	Superior fixation, allows early mobilization, ↓ stiffness.	Risk of displacement/loss of reduction before healing.
Soft Tissue	Iatrogenic damage, extensive scarring, ↑ blood loss.	Less initial trauma; risk of cast sores, pressure neuropathy.
Hardware	Failure, loosening, irritation often requiring removal.	N/A

⚡ Biggest Takeaways

Closed reduction is non-surgical realignment via manipulation and traction, followed by external immobilization (e.g., cast).

Open reduction is a surgical procedure involving an incision for direct visualization and alignment of the fracture.

ORIF (Open Reduction Internal Fixation) adds hardware (plates, screws, rods) for definitive stability.

Key indications for ORIF: unstable, intra-articular, or open fractures, and failed closed reduction.

Open reduction has a higher risk of infection; closed reduction risks malunion or compartment syndrome.

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