A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

Computed tomography (CT) scan of cervical spine, hips, and lumbar area

AP and lateral radiographs of hips

Lateral radiograph (x-ray) of hips

Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area

Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area

A 56-year-old man presents to the emergency room after being in a motor vehicle accident. He was driving on an icy road when his car swerved off the road and ran head on into a tree. He complains of severe pain in his right lower extremity. He denies loss of consciousness during the accident. His past medical history is notable for poorly controlled hypertension, hyperlipidemia, and major depressive disorder. He takes enalapril, atorvastatin, and sertraline. His temperature is 99.1°F (37.3°C), blood pressure is 155/85 mmHg, pulse is 110/min, and respirations are 20/min. On exam, he is alert and fully oriented. He is unable to move his right leg due to pain. Sensation is intact to light touch in the sural, saphenous, tibial, deep peroneal, and superficial peroneal distributions. His leg appears adducted, flexed, and internally rotated. An anteroposterior radiograph of his pelvis would most likely demonstrate which of the following findings?

Femoral head smaller than contralateral side and posterior to acetabulum

Fracture line extending between the greater and lesser trochanters

Femoral head larger than contralateral side and inferior to acetabulum

Fracture line extending through the femoral neck

Fracture line extending through the subtrochanteric region of the femur

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

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 36-year-old man comes to the emergency department 4 hours after a bike accident for severe pain and swelling in his right leg. He has not had a headache, nausea, vomiting, abdominal pain, or blood in his urine. He has a history of gastroesophageal reflux disease and allergic rhinitis. He has smoked one pack of cigarettes daily for 17 years and drinks an average of one alcoholic beverage daily. His medications include levocetirizine and pantoprazole. He is in moderate distress. His temperature is 37°C (98.6°F), pulse is 112/min, and blood pressure is 140/80 mm Hg. Examination shows multiple bruises over both lower extremities and the face. There is swelling surrounding a 2 cm laceration 13 cm below the right knee. The lower two-thirds of the tibia is tender to palpation and the skin is pale and cool to the touch. The anterior tibial, posterior tibial, and dorsalis pedis pulses are weak. Capillary refill time of the right big toe is 4 seconds. Dorsiflexion of his right foot causes severe pain in his calf. Cardiopulmonary examination is normal. An x-ray is ordered, which is shown below. Which of the following is the most appropriate next step in management?

Open reduction and internal fixation

A 23-year-old man is brought to the emergency department because of severe right shoulder pain and inability to move the shoulder for the past 30 minutes. The pain began after being tackled while playing football. He has nausea but has not vomited. He is in no apparent distress. Examination shows the right upper extremity externally rotated and slightly abducted. Palpation of the right shoulder joint shows tenderness and an empty glenoid fossa. The right humeral head is palpated below the coracoid process. The left upper extremity is unremarkable. The radial pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?

Test sensation of the lateral shoulder

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

A 16-year-old basketball player presents with chronic anterior knee pain worse with jumping and kneeling. Examination shows tenderness at the inferior pole of the patella and pain with resisted knee extension. X-ray shows elongation and fragmentation of the inferior patellar pole. He has failed 6 months of physical therapy, activity modification, and NSAIDs. His AAU season starts in 6 weeks and a college scout will be attending. His parents want definitive treatment. Evaluate the management approach balancing medical and contextual factors.

Recommend season withdrawal, continued conservative management for 6 more months

Corticosteroid injection to allow play through season with surgery after

Arthroscopic excision of inferior pole fragments allowing return to play in 4 weeks

Open excision of ossicle with patellar tendon repair, 4-6 month recovery

PRP injection series with continued play and close monitoring

Fracture classification and management principles for USMLE Step 2 CK: High-Yield Surgery Lessons

🦴 Pathology & Classification - The Bone-Break Blueprint

A fracture is a break in the continuity of bone. Key descriptors include location, pattern, displacement, and skin integrity (open vs. closed).

Common Fracture Patterns:
Open Fractures (Gustilo-Anderson Classification): | Type | Wound Size | Injury Characteristics | | :--- | :--- | :--- | | I | < 1 cm | Clean, minimal soft tissue damage | | II | > 1 cm | Moderate soft tissue damage, no flap needed | | IIIA | > 10 cm | High energy, adequate soft tissue coverage | | IIIB | > 10 cm | Periosteal stripping, requires flap coverage | | IIIC | > 10 cm | Associated arterial injury requiring repair |* Pediatric Physeal Fractures (Salter-Harris): $Salter-Harris fracture classification with SALTER mnemonic$ 📌 SALTER Mnemonic: Straight, Above, Lower, Through, ERasure/cRush.

⭐ Salter-Harris Type II (fracture through physis and metaphysis) is the most common. Type V has the worst prognosis due to risk of growth arrest.

🦴 Radiology - Reading the Cracks

Rule of Twos: A fundamental principle for adequate imaging.
- 2 Views: At least two orthogonal views (e.g., AP & Lateral at $90^\circ$).
- 2 Joints: Image the joint above and below the suspected fracture.
- 2 Sides: Compare with the contralateral side, especially in pediatrics.
- 2 Occasions: Repeat imaging if high clinical suspicion persists despite negative initial X-rays.

$Distal radius fracture with displacement and angulation$

Describing Fractures (The 4 A's):
- Alignment: Relationship of the longitudinal axes of fracture fragments.
- Angulation: Deviation of the distal fragment from the normal axis.
- Apposition: Percentage of fracture surface contact.
- Displacement: Shift of the distal fragment relative to the proximal.

⭐ A negative X-ray does not rule out a fracture. High-risk injuries (e.g., scaphoid, femoral neck) with negative initial films warrant further imaging (CT/MRI) or repeat X-rays in 7-14 days.

Special Views: Often required for anatomically complex areas (e.g., scaphoid view, ankle mortise view).

🧩 Management - Putting Pieces Together

Initial Fracture Management Flowchart:

Immobilization:
- Temporary (Acute): Splint - Accommodates swelling; non-circumferential.
- Definitive: Cast - Circumferential; applied after acute swelling subsides.

Application of a short leg splint

Indications for ORIF (Open Reduction Internal Fixation):
- Open fractures
- Intra-articular displacement (>2 mm)
- Failed closed reduction / Unstable fractures
- Pathologic fractures
- Nonunion / Malunion
- Associated neurovascular injury

⭐ Compartment Syndrome: A surgical emergency! Suspect with pain out of proportion to injury, pain on passive stretch, and paresthesias. Pulselessness is a late sign.

🤕 Complications - When Healing Goes Wrong

Early (Hours to Days)	Late (Weeks to Years)
* Neurovascular Injury: Direct damage	* Malunion: Heals in wrong position
* Compartment Syndrome: ↑ Pressure	* Nonunion: Fails to heal (>6-9 mo)
- 📌 6 P's: Pain, Pallor, Paresthesia, Pulselessness, Paralysis, Poikilothermia	* Delayed Union: Heals too slowly
- ⚠️ Dx: $\Delta P$ < 20-30 mmHg	* Avascular Necrosis (AVN)
* Fat Embolism: Triad (neuro, resp, petechiae)	* Post-traumatic Arthritis: Joint damage
* DVT/PE: Immobility risk
* Infection: Open fx, surgery

⚡ Biggest Takeaways

Open fractures are surgical emergencies requiring immediate irrigation, debridement (I&D), and IV antibiotics.

Always assess distal neurovascular status before and after reduction; any compromise is an emergency.

Suspect compartment syndrome with pain out of proportion to injury; treat emergently with fasciotomy.

Salter-Harris fractures involve the pediatric physis (growth plate); Type II is the most common.

Management principles are Reduction (alignment), Immobilization (stabilization), and Rehabilitation.

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