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?
Q2
A 64-year-old male retired farmer presents to the orthopaedic surgery clinic with chronic left knee pain. Radiographic imaging demonstrates severe tricompartmental osteoarthritis. The patient has a history of diabetes mellitus, chronic kidney disease, hypertension, hyperlipidemia, and congestive heart failure. He undergoes a left knee replacement without complications. A Foley catheter was placed in the operating room and removed in the post-anesthesia care unit. He receives subcutaneous heparin and has sequential compression devices in place to prevent deep venous thromboses. On post-operative day 1, he develops suprapubic pain and dysuria and is subsequently found to have a urinary tract infection. He is discharged on post-operative day 2 with an appropriate antibiotic regimen. However, he presents to the emergency room on post-operative day 6 with severe left leg pain. Venous dopplers demonstrate an occlusive thrombus in the popliteal vein. He is readmitted for anticoagulation and monitoring. A quality improvement team in the hospital estimates that the probability of getting both a urinary tract infection and a deep venous thrombosis is 0.00008 in patients undergoing routine total knee replacement. Furthermore, they estimate that the probability of getting a urinary tract infection in a similar patient population is 0.04. Assuming that the development of urinary tract infections and deep venous thromboses are independent, what is the risk of developing a deep venous thrombosis following total knee replacement?
Q3
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?
Q4
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?
Q5
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?
Q6
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?
Q7
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?
Q8
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?
Q9
A 37-year-old-woman presents to the emergency room with complaints of fever and abdominal pain. Her blood pressure is 130/74 mmHg, pulse is 98/min, temperature is 101.5°F (38.6°C), and respirations are 23/min. The patient reports that she had a laparoscopic cholecystectomy 4 days ago but has otherwise been healthy. She is visiting her family from Nebraska and just arrived this morning from a 12-hour drive. Physical examination revealed erythema and white discharge from abdominal incisions and tenderness upon palpations at the right upper quadrant. What is the most probable cause of the patient’s fever?
Q10
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.
Open vs closed reduction techniques US Medical PG Practice Questions and MCQs
Question 1: 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?
A. Refrain from athletic activities for 1 to 2 weeks
B. Rehabilitation exercises and activity as tolerated
C. Ibuprofen and rest
D. Change antibiotics and refrain from athletic activities (Correct Answer)
Explanation: The patient is experiencing **Achilles tendonitis**, likely a side effect of **moxifloxacin**, which is known to cause **tendinopathy** and **tendon rupture**, especially in patients with **diabetes** or those initiating **corticosteroids** [1]. **Discontinuation of moxifloxacin** and avoidance of strenuous activities are crucial to prevent further tendon damage, with alternative antibiotics for sinusitis [1].
*Refrain from athletic activities for 1 to 2 weeks*
- While **refraining from activity** is important, it is insufficient on its own because the underlying cause (moxifloxacin) would persist, potentially worsening the tendon injury.
- This option does not address the need to **change the causative medication**, which is the primary intervention for fluoroquinolone-induced tendinopathy [1].
*Rehabilitation exercises and activity as tolerated*
- **Rehabilitation exercises** are typically introduced in later stages of recovery, after the acute inflammation has subsided and the causative agent is removed.
- **Activity as tolerated** is inappropriate when there is a high risk of **tendon rupture** due to drug-induced tendinopathy; initial management requires strict rest.
*Ibuprofen and rest*
- **Ibuprofen** can help with pain and inflammation, but it does not address the underlying **fluoroquinolone-induced tendinopathy**.
- While **rest** is important, the continued use of moxifloxacin would still predispose the patient to further tendon injury or rupture, making simply resting an incomplete solution.
Question 2: A 64-year-old male retired farmer presents to the orthopaedic surgery clinic with chronic left knee pain. Radiographic imaging demonstrates severe tricompartmental osteoarthritis. The patient has a history of diabetes mellitus, chronic kidney disease, hypertension, hyperlipidemia, and congestive heart failure. He undergoes a left knee replacement without complications. A Foley catheter was placed in the operating room and removed in the post-anesthesia care unit. He receives subcutaneous heparin and has sequential compression devices in place to prevent deep venous thromboses. On post-operative day 1, he develops suprapubic pain and dysuria and is subsequently found to have a urinary tract infection. He is discharged on post-operative day 2 with an appropriate antibiotic regimen. However, he presents to the emergency room on post-operative day 6 with severe left leg pain. Venous dopplers demonstrate an occlusive thrombus in the popliteal vein. He is readmitted for anticoagulation and monitoring. A quality improvement team in the hospital estimates that the probability of getting both a urinary tract infection and a deep venous thrombosis is 0.00008 in patients undergoing routine total knee replacement. Furthermore, they estimate that the probability of getting a urinary tract infection in a similar patient population is 0.04. Assuming that the development of urinary tract infections and deep venous thromboses are independent, what is the risk of developing a deep venous thrombosis following total knee replacement?
A. 0.02
B. Cannot be determined
C. 0.002 (Correct Answer)
D. 0.00002
E. 0.0002
Explanation: ***0.002***
- For **independent events**, the probability of both occurring is: **P(A and B) = P(A) × P(B)**
- Rearranging: **P(DVT) = P(UTI and DVT) / P(UTI)**
- Calculation: P(DVT) = 0.00008 / 0.04 = **0.002** (or 0.2%)
- This represents the baseline risk of DVT despite prophylactic measures (subcutaneous heparin and sequential compression devices)
*0.02*
- This represents an error in decimal placement during division
- This would suggest a 2% DVT risk, which is **10 times higher** than the correct value
- Does not result from correct application of the multiplication rule for independent probabilities
*Cannot be determined*
- This is incorrect because **sufficient information is provided** to calculate P(DVT)
- When two events are independent and we know P(A and B) and P(A), we can always determine P(B)
- The independence assumption is explicitly stated in the question stem
*0.00002*
- This value results from calculation error, possibly **inverting the division** (0.04 / 0.00008 instead of 0.00008 / 0.04) and then applying additional incorrect operations
- This would suggest a DVT risk of 0.002%, which is **100 times lower** than the correct value
- Does not reflect proper application of probability rules for independent events
*0.0002*
- This represents a **decimal point error** during calculation (0.00008 / 0.04)
- This would suggest a 0.02% DVT risk, which is **10 times lower** than the correct value
- Results from miscalculation rather than correct mathematical reasoning
Question 3: 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?
A. “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.”
B. 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.
C. 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. (Correct Answer)
D. 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.
E. 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.
Explanation: ***"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."***
- This response acknowledges the patient's reported discomfort while gently highlighting the **discrepancy between symptoms and objective findings**, which is crucial in cases of suspected **somatoform or functional pain**.
- It also opens communication about potential **psychosocial stressors** related to his job change, which could be contributing to his symptoms, without dismissing his pain or making a premature diagnosis.
*"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."*
- While this option correctly identifies the lack of physical findings, it can be perceived as dismissive of the patient's pain, potentially damaging the **physician-patient relationship**.
- Suggesting regular meetings without a clear plan for addressing his immediate concerns or exploring underlying issues might not be the most effective initial approach.
*“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.”*
- This response would **validate the patient's claim of severe pain** without objective evidence, potentially reinforcing illness behavior and avoiding addressing the underlying issue.
- Providing a doctor's note for inability to work without a clear diagnostic basis or understanding of the pain's origin is **medically inappropriate** and could set a precedent for future such requests.
*"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."*
- Directly labeling the problem as "psychological" can be **stigmatizing and alienating** to the patient, leading to distrust and resistance to care.
- While a psychological component might be present, immediately referring to mental health without further exploration of the patient's situation or current stressors is premature and lacks empathy.
*"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."*
- Similar to the previous option, explicitly stating a "psychological problem" can be **stigmatizing**.
- Jumping directly to recommending **cognitive-behavioral therapy (CBT)** without a comprehensive discussion and patient buy-in is premature and may lead to non-compliance.
Question 4: 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?
A. Central line-associated blood stream infection (Correct Answer)
B. Catheter-associated urinary tract infection
C. Surgical site infection
D. Bowel ischemia
E. Ventilator-associated pneumonia
Explanation: ***Central line-associated blood stream infection***
- The patient exhibits signs of **sepsis** (fever, hypotension, tachycardia) following central line insertion, and **coagulase-negative cocci** (e.g., *Staphylococcus epidermidis*) were isolated from both central and peripheral blood cultures with differential times to positivity, indicating a central line origin.
- The organism isolated, **coagulase-negative cocci**, is a common cause of **central line-associated bloodstream infections** (CLABSI).
*Catheter-associated urinary tract infection*
- While a **Foley catheter** is present, there are no specific signs or symptoms of a **urinary tract infection**, such as dysuria, frequency, or hematuria.
- The microbiology results (coagulase-negative cocci in blood, not urine) do not support a urinary source for the infection.
*Surgical site infection*
- There is **erythema** around the sternal wound, suggesting a superficial infection, but no **discharge** or deepening wound involvement is noted.
- A surgical site infection would typically manifest with more prominent localized signs and would be less likely to cause a systemic bloodstream infection with coagulase-negative cocci detected *before* peripheral line cultures.
*Bowel ischemia*
- This condition is often associated with **abdominal pain**, distension, and signs of organ dysfunction.
- The abdominal examination is explicitly stated as normal, making bowel ischemia unlikely.
*Ventilator-associated pneumonia*
- The patient has crackles at lung bases and is mechanically ventilated, but there are no specific findings like new infiltrates on chest imaging or purulent sputum that would strongly indicate **pneumonia**.
- The isolated organism in the blood (coagulase-negative cocci) is not a typical pathogen for ventilator-associated pneumonia, which usually involves Gram-negative rods or *Staphylococcus aureus*.
Question 5: 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?
A. Replace the cast with a sling
B. Measurement of compartment pressure (Correct Answer)
C. Ibuprofen and reassurance
D. Emergency fasciotomy
E. Radiography
Explanation: ***Measurement of compartment pressure***
- The patient exhibits classic signs of **compartment syndrome**, including severe pain out of proportion to injury, pain with passive stretching, and a history of trauma followed by casting. Measuring compartment pressure is crucial for diagnosis despite palpable pulses.
- Early measurement of compartment pressures can confirm the diagnosis and guide the decision for an **emergency fasciotomy** to prevent irreversible tissue damage.
*Replace the cast with a sling*
- This action would likely worsen the patient's condition by delaying the diagnosis and treatment of potential **compartment syndrome**.
- A sling does not address the underlying issue of increased pressure within the muscle compartments.
*Ibuprofen and reassurance*
- Administering **Ibuprofen (NSAID)** might mask the pain but will not resolve the increased pressure within the compartment, which is a surgical emergency.
- Reassurance without proper assessment of compartment syndrome could lead to irreversible muscle and nerve damage.
*Emergency fasciotomy*
- While a fasciotomy is the definitive treatment for confirmed compartment syndrome, it should only be performed **after compartment pressures have been measured** and the diagnosis confirmed, unless the clinical suspicion is extremely high and pressures cannot be obtained.
- Performing a fasciotomy without objective confirmation is generally not the immediate next step, as it is an invasive procedure with its own risks.
*Radiography*
- **Radiography** would be useful to assess the healing of the fracture or rule out new fractures, but it will not provide information about the soft tissue pressure changes characteristic of compartment syndrome.
- The patient's symptoms are more indicative of a circulatory or soft tissue issue rather than a new bony problem.
Question 6: 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 7: 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 8: 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 9: A 37-year-old-woman presents to the emergency room with complaints of fever and abdominal pain. Her blood pressure is 130/74 mmHg, pulse is 98/min, temperature is 101.5°F (38.6°C), and respirations are 23/min. The patient reports that she had a laparoscopic cholecystectomy 4 days ago but has otherwise been healthy. She is visiting her family from Nebraska and just arrived this morning from a 12-hour drive. Physical examination revealed erythema and white discharge from abdominal incisions and tenderness upon palpations at the right upper quadrant. What is the most probable cause of the patient’s fever?
A. Pulmonary atelectasis
B. Residual gallstones
C. Urinary tract infection
D. Wound infection (Correct Answer)
E. Pulmonary embolism
Explanation: ***Wound infection***
- The presence of **erythema**, **white discharge from abdominal incisions**, and **fever** 4 days post-laparoscopic cholecystectomy strongly indicates a surgical site infection.
- This is a common complication after surgery, especially with visible signs of local inflammation and purulent discharge.
*Pulmonary atelectasis*
- **Atelectasis** typically presents within **24-48 hours post-op** and usually resolves spontaneously.
- While it can cause fever, the prominent local wound signs and the timing (4 days post-op) make it less likely to be the primary cause of fever.
*Residual gallstones*
- **Residual gallstones** would typically present with symptoms resembling acute cholecystitis or cholangitis, such as **right upper quadrant pain**, **jaundice**, or **elevated liver enzymes**, without direct signs of wound infection.
- These do not account for the **erythema and discharge from the incision sites**.
*Urinary tract infection*
- A **urinary tract infection (UTI)** would present with **dysuria**, **frequency**, **urgency**, or **suprapubic pain**, and would not explain the local wound findings.
- While surgery can increase the risk of nosocomial UTIs, the clinical presentation is primarily focused on the surgical site.
*Pulmonary embolism*
- A **pulmonary embolism (PE)** would likely cause **dyspnea**, **tachycardia**, **hypoxia**, and **pleuritic chest pain**, which are not reported in this case.
- Though prolonged immobility (e.g., long drive) is a risk factor, the specific local signs of infection are not consistent with PE.
Question 10: 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.
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