A 6-week-old boy is brought for routine examination at his pediatrician’s office. The patient was born at 39 weeks to a 26-year-old G1P1 mother by normal vaginal delivery. External cephalic version was performed successfully at 37 weeks for breech presentation. Pregnancy was complicated by gestational diabetes that was well-controlled with insulin. The patient’s maternal grandmother has early onset osteoporosis. On physical examination, the left hip dislocates posteriorly with adduction and depression of a flexed femur. An ultrasound is obtained that reveals left acetabular dysplasia and a dislocated left femur. Which of the following is the next best step in management?
Q2
A 6-year-old boy is brought to the physician because of right hip pain that started that afternoon. His mother reports that he has also been limping since the pain developed. He says that the pain worsens when he moves or walks. He participated in a dance recital yesterday, but his mother believes that he was not injured at the time. He was born at term and has been healthy except for an episode of nasal congestion and mild cough 10 days ago. His mother has rheumatoid arthritis and his grandmother has osteoporosis. He is at the 50th percentile for height and 50th percentile for weight. His temperature is 37.5°C (99.6°F), pulse is 105/min, respirations are 16/min, and blood pressure is 90/78 mm Hg. His right hip is slightly abducted and externally rotated. Examination shows no tenderness, warmth, or erythema. He is able to bear weight. The remainder of the examination shows no abnormalities. Laboratory studies show a hemoglobin concentration of 12.3 g/dL, a leukocyte count of 8,500/mm3, and an erythrocyte sedimentation rate of 12 mm/h. Ultrasound of the right hip shows increased fluid within the joint. X-ray of the hips shows no abnormalities. Which of the following is the most likely diagnosis?
Q3
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?
Q4
A 43-year-old man is brought to the emergency department 40 minutes after falling off a 10-foot ladder. He has severe pain and swelling of his right ankle and is unable to walk. He did not lose consciousness after the fall. He has no nausea. He appears uncomfortable. His temperature is 37°C (98.6°F), pulse is 98/min, respirations are 16/min, and blood pressure is 110/80 mm Hg. He is alert and oriented to person, place, and time. Examination shows multiple abrasions over both lower extremities. There is swelling and tenderness of the right ankle; range of motion is limited by pain. The remainder of the examination shows no abnormalities. An x-ray of the ankle shows an extra-articular calcaneal fracture. Intravenous analgesia is administered. Which of the following is the most appropriate next step in the management of this patient?
Q5
A 25-year-old man comes to the physician because of left-sided knee pain for 2 weeks. The pain started while playing basketball after suddenly hearing a popping sound. He has been unable to run since this incident. He has asthma, allergic rhinitis, and had a progressive bilateral sensorineural hearing impairment at birth treated with cochlear implants. His only medication is a salbutamol inhaler. The patient appears healthy and well-nourished. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 120/80 mm Hg. Examination of the left knee shows medial joint line tenderness. Total knee extension is not possible and a clicking sound is heard when the knee is extended. An x-ray of the left knee shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?
Q6
A 17-year-old male presents to your office with right knee pain. He is the quarterback of his high school football team and developed the knee pain after being tackled in last night's game. He states he was running with the ball and was hit on the lateral aspect of his right knee while his right foot was planted. Now, he is tender to palpation over the medial knee and unable to bear full weight on the right lower extremity. A joint effusion is present and arthrocentesis yields 50 cc's of clear fluid. Which of the following exam maneuvers is most likely to demonstrate ligamentous laxity?
Q7
A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
Q8
A 31-year-old man presents to the Emergency Department with severe left leg pain and paresthesias 4 hours after his leg got trapped by the closing door of a bus. Initially, he had a mild pain which gradually increased to unbearable levels. Past medical history is noncontributory. In the Emergency Department, his blood pressure is 130/80 mm Hg, heart rate is 87/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). On physical exam, his left calf is firm and severely tender on palpation. The patient cannot actively dorsiflex his left foot, and passive dorsiflexion is limited. Posterior tibial and dorsalis pedis pulses are 2+ in the right leg and 1+ in the left leg. Axial load does not increase the pain. Which of the following is the best next step in the management of this patient?
Q9
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?
Q10
A 35-year-old man is referred to a physical therapist due to limitation of movement in the wrist and fingers of his left hand. He cannot hold objects or perform daily activities with his left hand. He broke his left arm at the humerus one month ago. The break was simple and treatment involved a cast for one month. Then he lost his health insurance and could not return for follow up. Only after removing the cast did he notice the movement issues in his left hand and wrist. His past medical history is otherwise insignificant, and vital signs are within normal limits. On examination, the patient’s left hand is pale and flexed in a claw-like position. It is firm and tender to palpation. Right radial pulse is 2+ and left radial pulse is 1+. The patient is unable to actively extend his fingers and wrist, and passive extension is difficult and painful. Which of the following is a proper treatment for the presented patient?
Pediatric orthopedic emergencies US Medical PG Practice Questions and MCQs
Question 1: A 6-week-old boy is brought for routine examination at his pediatrician’s office. The patient was born at 39 weeks to a 26-year-old G1P1 mother by normal vaginal delivery. External cephalic version was performed successfully at 37 weeks for breech presentation. Pregnancy was complicated by gestational diabetes that was well-controlled with insulin. The patient’s maternal grandmother has early onset osteoporosis. On physical examination, the left hip dislocates posteriorly with adduction and depression of a flexed femur. An ultrasound is obtained that reveals left acetabular dysplasia and a dislocated left femur. Which of the following is the next best step in management?
A. Pavlik harness (Correct Answer)
B. Closed reduction and spica casting
C. Observation
D. Physiotherapy
E. Open reduction and femoral osteotomy
Explanation: ***Pavlik harness***
- A Pavlik harness is the **gold standard treatment** for **developmental dysplasia of the hip (DDH)** in infants younger than 6 months. It maintains the hips in a **flexed and abducted position**, promoting proper acetabular development and hip reduction.
- The patient's age (6 weeks), clear diagnosis of **acetabular dysplasia**, and a dislocated hip on ultrasound make the Pavlik harness the **most appropriate and least invasive initial treatment**.
*Closed reduction and spica casting*
- This treatment is typically reserved for children older than 6 months or those who **fail Pavlik harness treatment**.
- It involves a more aggressive reduction technique, often requiring **anesthesia**, and is followed by prolonged immobilization in a **spica cast**.
*Observation*
- **Observation is not appropriate** for a 6-week-old infant with a **diagnosed dislocated hip** and **acetabular dysplasia**.
- Untreated DDH can lead to **permanent hip instability**, pain, and early arthritis.
*Physiotherapy*
- While physiotherapy may play a role in rehabilitation after other interventions, it is **not sufficient as a primary treatment** for a dislocated hip in an infant.
- It cannot achieve or maintain the necessary **reduction and stabilization** required for proper hip development.
*Open reduction and femoral osteotomy*
- This is an **invasive surgical procedure** typically reserved for older children (older than 18-24 months) or in cases of **failed non-operative management** and closed reduction, especially in irreducible or severely dysplastic hips.
- It involves directly opening the joint to reduce the hip and may include reshaping bone (osteotomy) to improve hip stability. This is **premature** for a 6-week-old.
Question 2: A 6-year-old boy is brought to the physician because of right hip pain that started that afternoon. His mother reports that he has also been limping since the pain developed. He says that the pain worsens when he moves or walks. He participated in a dance recital yesterday, but his mother believes that he was not injured at the time. He was born at term and has been healthy except for an episode of nasal congestion and mild cough 10 days ago. His mother has rheumatoid arthritis and his grandmother has osteoporosis. He is at the 50th percentile for height and 50th percentile for weight. His temperature is 37.5°C (99.6°F), pulse is 105/min, respirations are 16/min, and blood pressure is 90/78 mm Hg. His right hip is slightly abducted and externally rotated. Examination shows no tenderness, warmth, or erythema. He is able to bear weight. The remainder of the examination shows no abnormalities. Laboratory studies show a hemoglobin concentration of 12.3 g/dL, a leukocyte count of 8,500/mm3, and an erythrocyte sedimentation rate of 12 mm/h. Ultrasound of the right hip shows increased fluid within the joint. X-ray of the hips shows no abnormalities. Which of the following is the most likely diagnosis?
A. Transient synovitis (Correct Answer)
B. Osteomyelitis
C. Slipped capital femoral epiphysis
D. Developmental dysplasia of the hip
E. Legg-Calve-Perthes disease
Explanation: ***Transient synovitis***
- This is the most likely diagnosis given the **recent viral illness**, acute onset of hip pain and limp, and **normal inflammatory markers** (WBC, ESR). Ultrasound showing **increased joint fluid** further supports this benign, self-limiting condition.
- The hip being held in **abduction and external rotation** is a common compensatory posture to maximize joint space and minimize pain in transient synovitis.
*Osteomyelitis*
- This would typically present with **fever**, significant systemic symptoms, and **elevated inflammatory markers** (ESR, CRP), which are absent here.
- Imaging might show bone changes, and the child would likely be **unable to bear weight** due to severe pain.
*Slipped capital femoral epiphysis*
- SCFE typically affects **adolescents** (obese males) and presents with chronic, progressive pain.
- X-rays would show a **displacement of the femoral head** from the femoral neck, which is not noted in this case.
*Developmental dysplasia of the hip*
- This is a condition usually diagnosed in **infancy or early childhood** through screening and clinical examination (e.g., Ortolani and Barlow maneuvers), often requiring early intervention.
- It would not typically present acutely in a 6-year-old with a recent viral prodrome and normal X-rays.
*Legg-Calve-Perthes disease*
- This condition involves **avascular necrosis of the femoral head** and typically presents in children between **4 and 8 years old** with a **chronic limp** and hip pain, often worsening over weeks to months.
- X-rays would show characteristic changes in the femoral head (e.g., fragmentation, flattening), which are absent in this case.
Question 3: 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 4: A 43-year-old man is brought to the emergency department 40 minutes after falling off a 10-foot ladder. He has severe pain and swelling of his right ankle and is unable to walk. He did not lose consciousness after the fall. He has no nausea. He appears uncomfortable. His temperature is 37°C (98.6°F), pulse is 98/min, respirations are 16/min, and blood pressure is 110/80 mm Hg. He is alert and oriented to person, place, and time. Examination shows multiple abrasions over both lower extremities. There is swelling and tenderness of the right ankle; range of motion is limited by pain. The remainder of the examination shows no abnormalities. An x-ray of the ankle shows an extra-articular calcaneal fracture. Intravenous analgesia is administered. Which of the following is the most appropriate next step in the management of this patient?
A. Short leg splint and orthopedic consultation
B. Broad-spectrum antibiotic therapy
C. MRI of the right ankle
D. Open reduction and internal fixation
E. X-ray of the spine (Correct Answer)
Explanation: ***X-ray of the spine***
- A **high-energy calcaneal fracture** (especially from a fall from height) is often associated with other injuries, particularly to the **spine**, due to axial loading.
- Approximately **10% of calcaneal fractures** are associated with **lumbar spine compression fractures**, making imaging of the spine an essential next step to rule out this potentially serious concomitant injury.
*Short leg splint and orthopedic consultation*
- While a **short leg splint** is appropriate for initial immobilization and pain control of the ankle fracture, and **orthopedic consultation** is necessary, these steps do not address the immediate need to exclude other critical injuries like spinal fractures in high-impact trauma.
- This option represents definitive management of the ankle rather than comprehensive early trauma assessment in a high-risk patient.
*Broad-spectrum antibiotic therapy*
- **Antibiotic therapy** is primarily indicated for **open fractures** to prevent infection, or in cases of significant soft tissue injury with high contamination risk; the provided information describes an extra-articular fracture with abrasions, but not explicitly an open fracture requiring immediate broad-spectrum antibiotics.
- The focus should first be on skeletal integrity elsewhere and definitive fracture management rather than presumptive infection prevention unless an open fracture is confirmed.
*MRI of the right ankle*
- While an **MRI** can provide detailed imaging of soft tissues, ligaments, and cartilage, and may be useful later for surgical planning or to assess subtle injuries, a plain **X-ray has already confirmed a calcaneal fracture**.
- The immediate priority after a high-energy trauma is to rule out other significant, potentially disabling or life-threatening bony injuries, particularly to the spine, rather than further detailed imaging of the already-identified ankle fracture.
*Open reduction and internal fixation*
- **Open reduction and internal fixation (ORIF)** is a surgical procedure for definitive management of certain fractures; however, it is not the **immediate next step** in the emergency department for initial patient assessment following trauma.
- Before surgical intervention, a comprehensive assessment to rule out other injuries (especially spinal fractures) and to thoroughly plan the specific surgical approach is required.
Question 5: A 25-year-old man comes to the physician because of left-sided knee pain for 2 weeks. The pain started while playing basketball after suddenly hearing a popping sound. He has been unable to run since this incident. He has asthma, allergic rhinitis, and had a progressive bilateral sensorineural hearing impairment at birth treated with cochlear implants. His only medication is a salbutamol inhaler. The patient appears healthy and well-nourished. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 120/80 mm Hg. Examination of the left knee shows medial joint line tenderness. Total knee extension is not possible and a clicking sound is heard when the knee is extended. An x-ray of the left knee shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?
A. Reassurance and follow-up
B. Arthrocentesis of the left knee
C. Open meniscal repair
D. Arthroscopy of the left knee
E. MRI scan of the left knee (Correct Answer)
Explanation: ***MRI scan of the left knee***
- The patient's presentation with a **popping sound**, inability to run, **medial joint line tenderness**, limited extension, and a clicking sound suggests a **meniscal tear**, which is not visible on X-ray.
- An **MRI scan** is the *most appropriate* next step as it is the **gold standard** for diagnosing meniscal tears and other soft tissue injuries of the knee.
*Reassurance and follow-up*
- This option is *inappropriate* given the clear signs and symptoms of a **significant knee injury** that warrants further investigation.
- Delaying diagnosis and treatment could lead to **worsening of the injury** and chronic pain.
*Arthrocentesis of the left knee*
- Arthrocentesis involves aspirating joint fluid, which is primarily indicated for diagnosing **septic arthritis** or **gout**, neither of which is suggested by this patient's acute trauma history.
- While a meniscal tear can cause an effusion, the primary diagnostic goal here is imaging the soft tissue injury, not analyzing synovial fluid.
*Open meniscal repair*
- **Open meniscal repair** is a surgical intervention, and it is *premature* to consider surgery before a definitive diagnosis is established.
- The *most appropriate* initial step after physical exam and X-ray is often an MRI to confirm the pathology.
*Arthroscopy of the left knee*
- **Arthroscopy** is both a **diagnostic and therapeutic procedure**, but it is generally reserved after non-invasive imaging like MRI has been performed.
- Although it can confirm a meniscal tear, an MRI is less invasive and can provide comparable if not superior detail for surgical planning.
Question 6: A 17-year-old male presents to your office with right knee pain. He is the quarterback of his high school football team and developed the knee pain after being tackled in last night's game. He states he was running with the ball and was hit on the lateral aspect of his right knee while his right foot was planted. Now, he is tender to palpation over the medial knee and unable to bear full weight on the right lower extremity. A joint effusion is present and arthrocentesis yields 50 cc's of clear fluid. Which of the following exam maneuvers is most likely to demonstrate ligamentous laxity?
A. Pivot shift test
B. Varus stress test
C. Anterior drawer test
D. Valgus stress test (Correct Answer)
E. Lachman's test
Explanation: ***Valgus stress test***
- The patient's presentation with a lateral blow to the knee while the foot was planted, tenderness over the **medial knee**, and an effusion strongly suggests an injury to the **medial collateral ligament (MCL)**.
- The **valgus stress test** assesses the integrity of the MCL by applying an outward (valgus) force to the knee, checking for excessive gapping on the medial side.
*Pivot shift test*
- The **pivot shift test** primarily assesses for **anterior cruciate ligament (ACL)** instability, particularly rotational laxity of the tibia on the femur.
- While an ACL injury is possible with this mechanism, the specific tenderness to palpation medially points more directly to an MCL injury.
*Varus stress test*
- The **varus stress test** evaluates the integrity of the **lateral collateral ligament (LCL)** by applying an inward (varus) force to the knee.
- This patient's mechanism of injury (lateral blow) and medial tenderness are inconsistent with an isolated LCL injury.
*Anterior drawer test*
- The **anterior drawer test** assesses the integrity of the **anterior cruciate ligament (ACL)** by pulling the tibia forward on the femur.
- While ACL injury is a concern with knee trauma, the focal tenderness on the medial side is not directly evaluated by this test.
*Lachman's test*
- **Lachman's test** is considered the most reliable clinical test for evaluating the integrity of the **anterior cruciate ligament (ACL)**, even in the acute setting with an effusion.
- However, the primary findings of medial tenderness after a lateral blow specifically point to an MCL injury, which is best assessed by the valgus stress test.
Question 7: A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
A. Traumatic urethral injury
B. Seminoma
C. Appendicitis
D. Epididymitis
E. Testicular torsion (Correct Answer)
Explanation: ***Testicular torsion***
- The sudden onset of **unilateral scrotal pain** in an adolescent, accompanied by an **elevated testicle** with a **horizontal lie**, is highly suggestive of testicular torsion. The absence of scrotal swelling or discoloration in the early stages is also consistent.
- Testicular torsion is a **surgical emergency** requiring prompt intervention to preserve testicular viability.
*Traumatic urethral injury*
- This would typically present with **dysuria**, **hematuria**, inability to void, and potentially **blood at the urethral meatus**, none of which are described.
- A traumatic urethral injury often results from falls, straddle injuries, or pelvic fractures, not typically from playing football without direct trauma to the perineum.
*Seminoma*
- Seminoma is a type of **testicular cancer** that typically presents as a **painless testicular mass**.
- It would not cause sudden, acute abdominal pain and would not manifest with an acutely elevated testicle and horizontal lie.
*Appendicitis*
- Although appendicitis can cause abdominal pain, the **non-tender abdomen** on examination and the specific findings on **testicular examination** (elevated testicle, horizontal lie) make appendicitis unlikely.
- Appendicitis pain typically localizes to the right lower quadrant, often associated with fever, nausea, and vomiting.
*Epididymitis*
- Epididymitis causes **scrotal pain** and **swelling**, often with fever and **dysuria**, usually developing over days, not hours.
- It is often associated with the **Prehn's sign** (pain relief with elevation of the testicle), which is usually absent or negative in torsion. The patient's sexual history might suggest an STI, but the acute presentation and examination findings point away from epididymitis.
Question 8: A 31-year-old man presents to the Emergency Department with severe left leg pain and paresthesias 4 hours after his leg got trapped by the closing door of a bus. Initially, he had a mild pain which gradually increased to unbearable levels. Past medical history is noncontributory. In the Emergency Department, his blood pressure is 130/80 mm Hg, heart rate is 87/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). On physical exam, his left calf is firm and severely tender on palpation. The patient cannot actively dorsiflex his left foot, and passive dorsiflexion is limited. Posterior tibial and dorsalis pedis pulses are 2+ in the right leg and 1+ in the left leg. Axial load does not increase the pain. Which of the following is the best next step in the management of this patient?
A. Lower limb CT scan
B. Lower limb ultrasound
C. Splinting and limb rest
D. Fasciotomy (Correct Answer)
E. Lower limb X-ray in two projections
Explanation: ***Fasciotomy***
- The patient presents with classic signs and symptoms of **acute compartment syndrome**, including unrelieved pain by analgesics, paresthesias, pain with passive stretching, and a tense compartment due to the bus door trauma.
- **Fasciotomy** is the definitive and urgent treatment to relieve pressure within the muscle compartments, prevent muscle ischemia, and avoid permanent nerve damage or limb loss.
*Lower limb CT scan*
- A **CT scan** is primarily used to evaluate bony structures and soft tissue injuries but is not the most immediate or definitive diagnostic tool for acute compartment syndrome.
- Delaying **fasciotomy** for imaging in a clear case of compartment syndrome can lead to irreversible damage.
*Lower limb ultrasound*
- **Ultrasound** can assess vascular flow and some soft tissue aspects but is not accurate or rapid enough for diagnosing compartment syndrome.
- It would not provide the necessary information to guide urgent surgical intervention.
*Splinting and limb rest*
- This approach is appropriate for fractures or soft tissue injuries without compartment syndrome; however, in acute compartment syndrome, **splinting or limb rest** will worsen the condition.
- **Immobilization** and elevation are contraindicated as they can further decrease blood flow and increase compartment pressure.
*Lower limb X-ray in two projections*
- An **X-ray** is useful for ruling out fractures but will not provide information about compartment pressure or muscle viability.
- While a fracture can sometimes cause compartment syndrome, the immediate concern here is the compartment syndrome itself, for which **X-rays** are not diagnostic.
Question 9: 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?
A. Drop arm test
B. Closed reduction
C. Neer impingement test
D. Arthroscopic shoulder repair
E. Test sensation of the lateral shoulder (Correct Answer)
Explanation: ***Test sensation of the lateral shoulder***
- The patient presents with classic signs of an **anterior shoulder dislocation**, including **externally rotated** and **abducted upper extremity**, an **empty glenoid fossa**, and a **humeral head palpated below the coracoid**.
- Assessing sensation of the **lateral shoulder** is crucial to check for **axillary nerve injury**, which is a common complication of shoulder dislocations and can cause deltoid weakness and sensory loss over the lateral deltoid region.
*Drop arm test*
- The **drop arm test** is used to evaluate for a **rotator cuff tear**, particularly involving the supraspinatus muscle.
- In this scenario, the primary concern is an acute shoulder dislocation, not a rotator cuff tear, although the latter can coexist.
*Closed reduction*
- While **closed reduction** is the definitive treatment for an acute shoulder dislocation, it should only be performed *after* neurovascular status has been thoroughly assessed.
- Reducing the dislocation before checking for nerve damage could mask an existing injury or worsen it.
*Neer impingement test*
- The **Neer impingement test** is used to diagnose **rotator cuff impingement syndrome**, a condition where soft tissues are compressed in the subacromial space.
- This patient's symptoms are indicative of an acute dislocation, not chronic impingement.
*Arthroscopic shoulder repair*
- **Arthroscopic shoulder repair** is a surgical procedure for certain shoulder conditions, often for recurrent instability or significant structural damage, after initial closed reduction has failed or if there are contraindications to closed reduction.
- It is not the immediate next step in managing an acute, primary shoulder dislocation before proper assessment.
Question 10: A 35-year-old man is referred to a physical therapist due to limitation of movement in the wrist and fingers of his left hand. He cannot hold objects or perform daily activities with his left hand. He broke his left arm at the humerus one month ago. The break was simple and treatment involved a cast for one month. Then he lost his health insurance and could not return for follow up. Only after removing the cast did he notice the movement issues in his left hand and wrist. His past medical history is otherwise insignificant, and vital signs are within normal limits. On examination, the patient’s left hand is pale and flexed in a claw-like position. It is firm and tender to palpation. Right radial pulse is 2+ and left radial pulse is 1+. The patient is unable to actively extend his fingers and wrist, and passive extension is difficult and painful. Which of the following is a proper treatment for the presented patient?
A. Surgical release (Correct Answer)
B. Botulinum toxin injections
C. Collagenase injections
D. Needle fasciotomy
E. Corticosteroid injections
Explanation: ***Surgical release***
- The patient presents with classic signs of **established Volkmann's ischemic contracture** (claw-like hand, firm fibrotic tissue, limited movement, decreased radial pulse), which is the end-stage result of untreated compartment syndrome that occurred during fracture healing.
- Since this is **chronic contracture (one month post-injury)**, the appropriate surgical treatment involves **reconstructive procedures** such as muscle slide operations, tendon lengthening, tendon transfers, neurolysis, or in severe cases, free functional muscle transfer to restore hand function.
- Emergency fasciotomy would have been appropriate for **acute compartment syndrome** (within 6-8 hours of onset), but at this stage, the treatment focuses on releasing fibrotic tissue and restoring function through reconstructive surgery.
*Botulinum toxin injections*
- **Botulinum toxin** is used to relax spastic muscles in neurological conditions (e.g., cerebral palsy, stroke), but it does not address the underlying **ischemic fibrosis and muscle necrosis** of Volkmann's contracture.
- It would not improve the structural contracture or restore blood flow in this patient.
*Collagenase injections*
- **Collagenase injections** are used for localized fascial contractures like Dupuytren's contracture, where enzymatic breakdown of collagen cords can restore finger extension.
- They are ineffective for **Volkmann's contracture**, which involves widespread ischemic muscle necrosis, fibrosis, and nerve damage requiring surgical reconstruction.
*Needle fasciotomy*
- **Needle fasciotomy** is a minimally invasive technique for Dupuytren's contracture, involving percutaneous disruption of fascial cords.
- It is not suitable for **Volkmann's contracture**, which requires extensive surgical release of fibrotic muscle compartments, possible tendon transfers, and neurolysis—procedures that cannot be accomplished with needle techniques.
*Corticosteroid injections*
- **Corticosteroids** reduce inflammation in conditions like tenosynovitis or trigger finger.
- They would not address the **ischemic muscle necrosis and fibrotic contracture** in Volkmann's contracture and could potentially delay appropriate surgical treatment.
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