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?
Q2
A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?
Q3
A 7-year-old boy is brought by his parents to his pediatrician with a one-day history of fever, chills, and pain in the right upper extremity. The patient's mother says that he has injured his right index finger while playing in the garden 3 days earlier. His temperature is 38.8°C (101.8°F), pulse is 120/min, respiratory rate is 24/min, and blood pressure is 102/70 mm Hg. On physical examination, there is an infected wound present on the tip of the right index finger. Irregular linear subcutaneous red streaks are seen on the ventral surface of the right forearm, which is warm and tender to palpation. There is painful right infraclavicular lymphadenopathy present. Which of the following is the most common microorganism known to cause this patient's condition?
Q4
A 63-year-old female recovering from a total shoulder arthroplasty completed 6 days ago presents complaining of joint pain in her repaired shoulder. Temperature is 39 degrees Celsius. Physical examination demonstrates erythema and significant tenderness around the incision site. Wound cultures reveal Gram-positive cocci that are resistant to nafcillin. Which of the following organisms is the most likely cause of this patient's condition?
Q5
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?
Q6
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?
Q7
A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
Q8
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.
Q9
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.
Q10
A 68-year-old woman falls and sustains a displaced femoral neck fracture. She was ambulatory with a walker pre-injury, has moderate dementia, osteoporosis, and multiple comorbidities including CHF and CKD stage 3. Her family wants her to return to her assisted living facility. The orthopedic team debates between hemiarthroplasty and total hip arthroplasty. Evaluate the optimal surgical approach considering her overall status.
External fixation principles US Medical PG Practice Questions and MCQs
Question 1: 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?
A. AP and lateral radiographs of hips
B. Lateral radiograph (x-ray) of hips
C. Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area
D. Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area
E. Computed tomography (CT) scan of cervical spine, hips, and lumbar area (Correct Answer)
Explanation: ***Computed tomography (CT) scan of cervical spine, hips, and lumbar area***
- In **high-energy trauma** (fall from height), a CT scan is the **gold standard** for evaluating the **spine and pelvis**, providing detailed cross-sectional images superior to plain radiographs.
- Since the **cervical exam was not performed**, cervical spine imaging is **mandatory** per ATLS (Advanced Trauma Life Support) protocols. High-energy falls carry significant risk of **cervical spine injury** even without obvious neurological symptoms.
- CT allows comprehensive assessment of **hip fractures, pelvic injuries, and the entire spine** (cervical, thoracic, lumbar), identifying both obvious and **subtle fractures** that may be missed on plain films.
- This approach provides the most **efficient and thorough evaluation** in the acute trauma setting, allowing for appropriate surgical planning and ruling out life-threatening spinal instability.
*AP and lateral radiographs of hips*
- Plain radiographs provide **limited detail** and may **miss subtle fractures**, particularly in complex areas like the pelvis and acetabulum.
- This option **fails to address cervical spine clearance**, which is essential in all high-energy trauma patients, especially when cervical exam has not been performed.
- Radiographs are insufficient for **comprehensive trauma evaluation** after a fall from height.
*Lateral radiograph (x-ray) of hips*
- A single lateral view is **grossly insufficient** for evaluating hip and pelvic fractures, providing only a **two-dimensional perspective** that can miss significant injuries.
- This option **completely neglects spinal evaluation**, which is dangerous in an uncleared trauma patient with a high-energy mechanism.
*Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area*
- While MRI excels at evaluating **soft tissues, ligaments, and bone marrow**, it is **not the initial imaging modality** for acute bony trauma due to longer scan times and lower sensitivity for acute fractures compared to CT.
- MRI is **time-consuming and impractical** in the emergency setting for initial fracture assessment, potentially delaying definitive treatment.
- CT is superior for evaluating **acute skeletal injuries** in the trauma bay.
*Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area*
- Multiple plain radiographs have **limited sensitivity** for complex or non-displaced fractures, particularly in the **spine and pelvis**, making them inadequate for high-energy trauma evaluation.
- Obtaining multiple radiographic views requires **numerous patient repositionings**, which risks further injury if **spinal instability** is present.
- Plain films provide significantly **less diagnostic information** than CT scanning for trauma assessment.
Question 2: A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?
A. Place thumb in cup of cold milk
B. Wrap thumb in saline-moistened, sterile gauze and place in sterile bag (Correct Answer)
C. Wrap thumb in sterile gauze and submerge in a cup of saline
D. There is no need to save the thumb
E. Place thumb directly into cooler of ice
Explanation: ***Wrap thumb in saline-moistened, sterile gauze and place in sterile bag***
- This method provides a **moist, sterile environment** for the amputated part, which is crucial for preserving tissue viability.
- The use of a sterile bag helps prevent contamination and allows the part to be placed inside a cooler without direct ice contact, preventing **frostbite**.
*Place thumb in cup of cold milk*
- While cold milk might offer some cooling, it is **not sterile** and could introduce bacteria, increasing the risk of infection.
- Milk's composition is **not ideal for cell preservation** compared to saline, which is more isotonic.
*Wrap thumb in sterile gauze and submerge in a cup of saline*
- Submerging the amputated part directly in saline, even with sterile gauze, can lead to **tissue maceration** due to overhydration.
- This method also makes it more difficult to prevent contamination during transportation if the cup is not sealed.
*There is no need to save the thumb*
- **Replantation surgery** is often possible and highly desirable for thumb amputations due to its critical functional role.
- Dismissing the amputated part would deprive the patient of a chance to restore function, especially given the short time since amputation.
*Place thumb directly into cooler of ice*
- Direct contact with ice can cause **frostbite** and **tissue damage**, compromising the viability of the amputated part.
- The preferred method is to keep the amputated part cool, but not frozen, usually by placing it in a sealed bag within an ice-filled container.
Question 3: A 7-year-old boy is brought by his parents to his pediatrician with a one-day history of fever, chills, and pain in the right upper extremity. The patient's mother says that he has injured his right index finger while playing in the garden 3 days earlier. His temperature is 38.8°C (101.8°F), pulse is 120/min, respiratory rate is 24/min, and blood pressure is 102/70 mm Hg. On physical examination, there is an infected wound present on the tip of the right index finger. Irregular linear subcutaneous red streaks are seen on the ventral surface of the right forearm, which is warm and tender to palpation. There is painful right infraclavicular lymphadenopathy present. Which of the following is the most common microorganism known to cause this patient's condition?
A. Aeromonas hydrophila
B. Staphylococcus aureus
C. Group A β-hemolytic Streptococcus (Correct Answer)
D. Pseudomonas aeruginosa
E. Pasteurella multocida
Explanation: ***Group A β-hemolytic Streptococcus***
- The presentation of an infected wound with **red streaks** (lymphangitis), **lymphadenopathy**, and **fever** is highly characteristic of **cellulitis** or erysipelas, which are commonly caused by **Streptococcus pyogenes** (Group A β-hemolytic Streptococcus).
- This organism is a common cause of rapidly spreading soft tissue infections, especially following a skin breach.
*Aeromonas hydrophila*
- This bacterium is typically associated with **aquatic environments** and causes infections usually after exposure to **contaminated fresh or brackish water**.
- While it can cause wound infections, the history of playing in a garden makes it a less likely cause than common skin flora.
*Staphylococcus aureus*
- While **Staphylococcus aureus** is a common cause of skin infections, it more often presents with **abscess formation**, **pus**, or a more localized infection.
- The prominent **lymphangitis** (red streaks) and rapid spread seen here are more typical of streptococcal infections.
*Pseudomonas aeruginosa*
- **Pseudomonas aeruginosa** infections are often associated with **puncture wounds through athletic shoes**, **hot tub folliculitis**, or in **immunocompromised patients**.
- The clinical picture does not align with typical risk factors or presentation for Pseudomonas infection.
*Pasteurella multocida*
- This organism is primarily associated with **animal bites, particularly from cats and dogs**, which is not indicated in the patient's history.
- Infections by Pasteurella species typically show rapid onset after an animal bite.
Question 4: A 63-year-old female recovering from a total shoulder arthroplasty completed 6 days ago presents complaining of joint pain in her repaired shoulder. Temperature is 39 degrees Celsius. Physical examination demonstrates erythema and significant tenderness around the incision site. Wound cultures reveal Gram-positive cocci that are resistant to nafcillin. Which of the following organisms is the most likely cause of this patient's condition?
A. Streptococcus pyogenes
B. Escherichia coli
C. Streptococcus viridans
D. Staphylococcus epidermidis
E. Staphylococcus aureus (Correct Answer)
Explanation: ***Staphylococcus aureus***
- The combination of **post-surgical infection**, **erythema**, and fever with **Gram-positive cocci** that are **nafcillin-resistant** is highly indicative of **Methicillin-Resistant Staphylococcus aureus (MRSA)**.
- *S. aureus* is a common cause of **surgical site infections**, and its resistance to nafcillin implies it is MRSA, a significant clinical concern for its difficulty in treatment.
*Streptococcus pyogenes*
- While *S. pyogenes* is a Gram-positive coccus that can cause skin and soft tissue infections, it is typically **susceptible to penicillin** and related antibiotics like nafcillin, unlike the organism described.
- It is more commonly associated with **streptococcal pharyngitis** or **cellulitis**, and while it can cause severe disease, its resistance profile doesn't match the clinical picture.
*Escherichia coli*
- *E. coli* is a **Gram-negative rod**, not a Gram-positive coccus.
- It is a common cause of **urinary tract infections** and **gastrointestinal infections**, making it an unlikely pathogen for a post-surgical joint infection unless contaminated from a visceral source.
*Streptococcus viridans*
- **Viridans streptococci** are Gram-positive cocci but are typically associated with **endocarditis** or dental infections, especially after poor dental hygiene or procedures.
- They are usually **susceptible to penicillin** and do not typically exhibit nafcillin resistance as the primary feature in a post-arthroplasty infection.
*Staphylococcus epidermidis*
- *S. epidermidis* is a **coagulase-negative Staphylococcus** known for forming **biofilms on prosthetic devices**, leading to chronic, low-grade infections.
- While it can be nafcillin-resistant, the **acute presentation** with fever and significant inflammation suggests a more virulent pathogen like *S. aureus*, as *S. epidermidis* infections are typically indolent.
Question 5: 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?
A. Obtain a chest x-ray
B. Perform a needle thoracostomy (Correct Answer)
C. Perform an endotracheal intubation
D. Apply a cervical collar
E. Perform an open reduction of the tibia fracture
Explanation: ***Perform a needle thoracostomy***
- The patient presents with **clinical signs of tension pneumothorax**: hypotension (95/61 mm Hg), tachycardia (131/min), decreased breath sounds, and hyperresonance over the right hemithorax following significant trauma from a fall.
- According to **ATLS (Advanced Trauma Life Support) principles**, the primary survey follows the **ABC priority**: Airway, Breathing, Circulation. A **tension pneumothorax is an immediately life-threatening condition** that compromises both breathing and circulation (obstructive shock).
- **Needle thoracostomy (needle decompression)** is the immediate, life-saving intervention for tension pneumothorax and must be performed **before** or concurrent with other interventions. This takes precedence over spinal immobilization when there is an immediate life threat.
- The clinical presentation strongly suggests tension physiology requiring immediate decompression; waiting for imaging would be inappropriate and potentially fatal.
*Apply a cervical collar*
- While **cervical spine protection** is important in this polytrauma patient with head injury and fall mechanism, it does **not take precedence over treating immediately life-threatening conditions** like tension pneumothorax.
- C-spine can be protected with **manual in-line stabilization** during the needle thoracostomy procedure.
- Modern trauma protocols emphasize that **life threats to airway, breathing, and circulation must be addressed immediately**, even if it requires brief spinal movement with appropriate precautions.
*Obtain a chest x-ray*
- **Tension pneumothorax is a clinical diagnosis** that requires immediate intervention without waiting for imaging confirmation.
- The combination of hypotension, tachycardia, decreased breath sounds, and hyperresonance in a trauma patient is sufficient to warrant emergent needle decompression.
- Delaying treatment for imaging in a hemodynamically unstable patient would be dangerous and violates patient safety principles.
*Perform an endotracheal intubation*
- While the patient has a **GCS of approximately 10** (eyes open spontaneously = 4, no verbal response = 1-2, localizes pain = 5-6), intubation is not the immediate priority.
- The **tension pneumothorax must be decompressed first** before attempting intubation, as positive pressure ventilation could worsen the tension pneumothorax and cause cardiovascular collapse.
- If intubation is needed, it should occur after needle decompression.
*Perform an open reduction of the tibia fracture*
- While the open tibia fracture requires urgent surgical management, it is **not immediately life-threatening** in the same timeframe as tension pneumothorax.
- According to ATLS principles, **life-threatening injuries are addressed before limb-threatening injuries**.
- The fracture should be stabilized temporarily, and definitive surgical management can occur after the patient is hemodynamically stable.
Question 6: 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?
A. Open reduction and internal fixation with a compression plate
B. Open reduction and internal fixation with an intramedullary nail
C. Figure-of-eight splinting (Correct Answer)
D. Mobilization
E. Open reduction and internal fixation with lag screws
Explanation: ***Figure-of-eight splinting***
- For **undisplaced or minimally displaced midshaft clavicle fractures**, conservative management with a **simple arm sling or figure-of-eight splint** is the preferred initial treatment.
- Both methods provide **adequate immobilization** and support for healing, especially in pediatric and adolescent patients, with excellent functional outcomes.
- Current evidence suggests **simple sling support** is equally effective and often better tolerated than figure-of-eight splinting.
*Open reduction and internal fixation with a compression plate*
- **ORIF with a compression plate** is typically reserved for **displaced or comminuted clavicle fractures** (displacement >2cm, shortening >2cm, or open fractures), or those with associated neurovascular compromise, which are not present in this non-displaced fracture.
- Surgical intervention for non-displaced fractures carries **risks of infection, hardware irritation**, and non-union that often outweigh the benefits when conservative options are effective.
*Open reduction and internal fixation with an intramedullary nail*
- **Intramedullary nailing** is an alternative surgical option for some clavicle fractures but is generally considered for **displaced or comminuted fracture patterns**, and is not indicated for a non-displaced fracture.
- It involves specific technical challenges and is **less commonly used** for routine, non-displaced mid-shaft clavicle fractures, especially when simpler conservative measures suffice.
*Mobilization*
- **Immediate mobilization** without any form of immobilization would **risk further displacement** of the non-displaced fracture and hinder proper bone healing in the acute phase.
- Although early motion is introduced during the healing process, **initial support and immobilization** is crucial for stability and pain control.
*Open reduction and internal fixation with lag screws*
- **Lag screws** are primarily used for **interfragmentary compression** in specific oblique or spiral fracture patterns, which is not the typical mechanism for midshaft clavicle fractures.
- This method is a form of surgical fixation, which is **not indicated for a non-displaced clavicle fracture** given the excellent outcomes (>95% union rate) with conservative care.
Question 7: A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
A. Insertion of nasogastric tube and enteral nutrition
B. Intravenous antibiotic therapy
C. Intubation and mechanical ventilation (Correct Answer)
D. Immediate bronchoscopy
E. Intravenous corticosteroid therapy
Explanation: ***Intubation and mechanical ventilation***
- The patient exhibits several signs of impending **airway compromise** due to **inhalation injury**, including perioral burns, black sediments in the nose and mouth, and being trapped in a fire.
- While current oxygen saturation is 96%, **airway edema** can rapidly worsen, leading to respiratory failure. **Early intubation** is crucial to secure the airway before it becomes obstructed.
*Insertion of nasogastric tube and enteral nutrition*
- A nasogastric tube is often placed in burn patients to decompress the stomach and provide nutritional support, but it is **not the immediate priority** when there is a risk of airway obstruction.
- **Enteral nutrition** is important but should be initiated only after airway control is established and the patient is stable for feeding.
*Intravenous antibiotic therapy*
- **Prophylactic antibiotics** are generally **not recommended** in the immediate management of burn patients unless there is clear evidence of infection, which is not present here.
- Unnecessary antibiotic use can lead to **antibiotic resistance** and fungal infections.
*Immediate bronchoscopy*
- While **bronchoscopy** can confirm the extent of inhalation injury, it is not the primary immediate step. **Securing the airway** through intubation takes precedence over diagnostic procedures when airway compromise is imminent.
- Bronchoscopy can be considered *after* intubation to assess the lower airway for damage and guide further management.
*Intravenous corticosteroid therapy*
- **Corticosteroids** are typically **contraindicated** in the management of inhalation injury because they can **impair immune function** and increase the risk of infection in burn patients.
- Evidence does not support the routine use of corticosteroids to reduce inflammation in inhalation injury, and they may worsen outcomes.
Question 8: 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.
A. EMG/NCS to evaluate for nerve injury
B. Psychiatric evaluation for malingering assessment
C. Repeat surgery for hardware removal and capsular release
D. Independent functional capacity evaluation
E. Triple-phase bone scan and referral to pain management (Correct Answer)
Explanation: ***Triple-phase bone scan and referral to pain management***
- The presence of **allodynia** (pain with light touch), **autonomic dysfunction** (mottled skin, hair changes), and **atrophy** following trauma is classic for **Complex Regional Pain Syndrome (CRPS)**.
- A **triple-phase bone scan** typically shows increased periarticular uptake in the delayed phase, and multidisciplinary **pain management** is the gold standard for treatment.
*EMG/NCS to evaluate for nerve injury*
- While nerve injury can cause pain, it does not explain the **vasomotor changes** and skin/hair trophic changes seen in this patient.
- This patient likely has **CRPS Type I** (reflex sympathetic dystrophy), which occurs in the absence of a defined nerve injury.
*Psychiatric evaluation for malingering assessment*
- Despite the **secondary gain** considerations (lawsuit/disability), the physical findings of **mottled skin** and decreased hair growth are objective clinical signs that cannot be faked.
- Labeling the patient as malingering before ruling out organic conditions like **CRPS** is inappropriate and delays necessary care.
*Repeat surgery for hardware removal and capsular release*
- Additional surgery is often **contraindicated** in the acute/active phase of CRPS as it can significantly worsen the pain and inflammatory response.
- Stiffness in CRPS is due to **neurogenic inflammation** and sympathetic overactivity rather than simple mechanical obstruction by hardware.
*Independent functional capacity evaluation*
- While useful for measuring work readiness, this is a **diagnostic tool** for disability status rather than a clinical management step for an active pathology.
- The priority is to confirm the diagnosis of **CRPS** and initiate treatment to prevent permanent **joint contracture** and functional loss.
Question 9: 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.
A. Recommend season withdrawal, continued conservative management for 6 more months (Correct Answer)
B. Corticosteroid injection to allow play through season with surgery after
C. Arthroscopic excision of inferior pole fragments allowing return to play in 4 weeks
D. Open excision of ossicle with patellar tendon repair, 4-6 month recovery
E. PRP injection series with continued play and close monitoring
Explanation: ***Recommend season withdrawal, continued conservative management for 6 more months***
- This patient presents with **Sinding-Larsen-Johansson syndrome**, a traction **apophysitis** of the inferior patellar pole that typically resolves with skeletal maturity and conservative care.
- Despite external pressures like college scouting, standard medical management mandates at least **12 months of conservative treatment** before considering surgery, as outcomes for surgical intervention in adolescents are often poor.
*Corticosteroid injection to allow play through season with surgery after*
- **Intratendinous corticosteroid injections** are strictly contraindicated as they significantly increase the risk of **patellar tendon rupture**.
- While they may provide short-term pain relief, they do not address the underlying **apophysitis** and compromise the structural integrity of the extensor mechanism.
*Arthroscopic excision of inferior pole fragments allowing return to play in 4 weeks*
- Surgical excision is rarely indicated in **skeletally immature** patients and is never the first-line treatment even after 6 months of failed therapy.
- A 4-week return-to-play timeline is clinically unrealistic following any surgical intervention on the **patellar tendon** or bone interface.
*Open excision of ossicle with patellar tendon repair, 4-6 month recovery*
- **Open excision** is considered only in refractory cases after the growth plates have closed and at least one year of non-operative management has failed.
- Performing an invasive repair in a 16-year-old unnecessarily risks damaging the **physes** and may lead to long-term functional deficits.
*PRP injection series with continued play and close monitoring*
- There is currently **insufficient evidence** to support the use of Platelet-Rich Plasma (PRP) as a definitive treatment for pediatric traction apophysitis.
- Continuing high-impact jumping and kneeling while relying on injections does not allow the **traction-induced inflammation** and fragmentation to heal.
Question 10: A 68-year-old woman falls and sustains a displaced femoral neck fracture. She was ambulatory with a walker pre-injury, has moderate dementia, osteoporosis, and multiple comorbidities including CHF and CKD stage 3. Her family wants her to return to her assisted living facility. The orthopedic team debates between hemiarthroplasty and total hip arthroplasty. Evaluate the optimal surgical approach considering her overall status.
A. ORIF with cannulated screws to preserve native anatomy
B. Delay surgery until medical optimization for 2-3 weeks
C. Total hip arthroplasty for better long-term function
D. Non-operative management with palliative care focus
E. Hemiarthroplasty given age and comorbidities (Correct Answer)
Explanation: ***Hemiarthroplasty given age and comorbidities***
- **Hemiarthroplasty** is the treatment of choice for displaced femoral neck fractures in elderly patients with **limited functional demands**, moderate dementia, and multiple comorbidities.
- It offers **shorter operative time**, less blood loss, and a **lower risk of dislocation** compared to total hip arthroplasty, facilitating a quicker return to baseline for this high-risk patient.
*ORIF with cannulated screws to preserve native anatomy*
- **ORIF** is associated with high rates of **nonunion** and **avascular necrosis** in displaced femoral neck fractures, especially in elderly patients with **osteoporotic bone**.
- It is typically reserved for **younger patients** or undisplaced fractures where the biological preservation of the femoral head is a priority.
*Delay surgery until medical optimization for 2-3 weeks*
- Delaying surgery beyond **24-48 hours** significantly increases the risk of mortality, **pressure ulcers**, and venous thromboembolism in elderly hip fracture patients.
- Medical optimization should be focused and **expedited** to allow for urgent surgical intervention rather than prolonged delays.
*Total hip arthroplasty for better long-term function*
- While **Total hip arthroplasty (THA)** provides better functional outcomes in active, independent elderly patients, this patient uses a **walker** and has **dementia**, making her a poor candidate.
- THA involves a higher risk of **dislocation** and more extensive surgical stress, which may not be tolerated given her **CHF** and **CKD** status.
*Non-operative management with palliative care focus*
- **Non-operative management** is generally reserved for patients who are **non-ambulatory** pre-injury or those with a very short life expectancy where surgery poses an extreme risk.
- This patient was previously **ambulatory with a walker**, and surgery is necessary to provide **pain relief** and prevent the complications of prolonged bed rest.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
