Orthopedics Board Review Part II Satjiv Kohli Mt Sinai School of Medicine Department of Emergency Medicine Satjiv Kohli Mt Sinai School of Medicine Department.

Orthopedics Board ReviewPart II

Orthopedics Board ReviewPart II

Satjiv KohliMt Sinai School of

MedicineDepartment of

Emergency Medicine

Satjiv KohliMt Sinai School of

MedicineDepartment of

Emergency Medicine

1. Which of the following is TRUE regarding gamekeeper’s thumb?A. The mechanism of injury is usually forced adduction at the MCP jointB. Delaying surgery as long as 1 month for an acutely ruptured ligament will help preserve future functionC. More than 40° of radial angulation on stress testing inidicates complete ruptureD. Injury to the dorsal capsule and volar plate are rare

1. Which of the following is TRUE regarding gamekeeper’s thumb?A. The mechanism of injury is usually forced adduction at the MCP jointB. Delaying surgery as long as 1 month for an acutely ruptured ligament will help preserve future functionC. More than 40° of radial angulation on stress testing inidicates complete ruptureD. Injury to the dorsal capsule and volar plate are rare

C. More than 40° of radial angluation on stress testing indicates complete rupture

C. More than 40° of radial angluation on stress testing indicates complete rupture

Gamekeeper’s thumb

Gamekeeper’s thumb

Forced radial deviation at the MCP joint rupturing UCL

Often includes significant damage to the dorsal capsule and volar plate

Thumb spicaRequires prompt ortho f/u

within 1 week

Forced radial deviation at the MCP joint rupturing UCL

Often includes significant damage to the dorsal capsule and volar plate

Thumb spicaRequires prompt ortho f/u

within 1 week

2. Which of the following is TRUE regarding perilunate and lunate dislocations?A. All require emergency orthopedic consultationB. Associated carpal bone fractures are rareC. Complications of these injuries include avascular necrosis and median nerve compressionD. Patients presents with obvious hand deformities

2. Which of the following is TRUE regarding perilunate and lunate dislocations?A. All require emergency orthopedic consultationB. Associated carpal bone fractures are rareC. Complications of these injuries include avascular necrosis and median nerve compressionD. Patients presents with obvious hand deformities

A. All require emergent orthopedic consultation

A. All require emergent orthopedic consultation

Lunate and Perilunate

dislocations

Lunate and Perilunate

dislocations Result from forced

dorsiflexion and fall on outstretched hand

Require significant amount of force Often have

associated factors of carpal bones

Emergent ortho consultation

Complications include: Median nerve

compression, avascular necrosis, malunion, early DJD

Result from forced dorsiflexion and fall on outstretched hand

Require significant amount of force Often have

associated factors of carpal bones

Emergent ortho consultation

Complications include: Median nerve

compression, avascular necrosis, malunion, early DJD

3. 22 yo female presents c/o R elbow pain and swelling after falling off her motor scooter. On exam, she is holding the R arm in 45° of flexion, and you palpate a prominent olecranon posteriorly. Xray reveals a posterior elbow dislocation. Which of the following statements is true?A. The preferred method of reduction involves hyperflexion and internal rotation until a palpable reduction occursB. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyleC. A long arm plaster splint should be applied in full extension and appropriate ortho f/u arrangedD. An intact radial pulse postreduction r/o any possibility of vascular compromise

3. 22 yo female presents c/o R elbow pain and swelling after falling off her motor scooter. On exam, she is holding the R arm in 45° of flexion, and you palpate a prominent olecranon posteriorly. Xray reveals a posterior elbow dislocation. Which of the following statements is true?A. The preferred method of reduction involves hyperflexion and internal rotation until a palpable reduction occursB. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyleC. A long arm plaster splint should be applied in full extension and appropriate ortho f/u arrangedD. An intact radial pulse postreduction r/o any possibility of vascular compromise

B. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyle

B. If full, smooth, passive ROM is not possible postreduction, the film should be examined for entrapment of the medial epicondyle

Elbow dislocationElbow dislocation Vast majority are

posterior Patients present w/

elbow 45° flexion with prominent olecranon

Important to assess NV status Brachial artery,

ulnar, radial, median nerves (5-13%)

Long arm splint with elbow in 90° flexion

Prompt ortho f/u

Vast majority are posterior

Patients present w/ elbow 45° flexion with prominent olecranon

Important to assess NV status Brachial artery,

ulnar, radial, median nerves (5-13%)

Long arm splint with elbow in 90° flexion

Prompt ortho f/u

4. Which of the following is suggestive of radial head fractures?A. Abnormality of the capitellumB. Anterior fat padC. Lack of pain on examD. Pain and swelling swelling on the lateral aspect of the elbow

4. Which of the following is suggestive of radial head fractures?A. Abnormality of the capitellumB. Anterior fat padC. Lack of pain on examD. Pain and swelling swelling on the lateral aspect of the elbow

D. Pain and swelling on the lateral aspect of the elbow

D. Pain and swelling on the lateral aspect of the elbow

Radial head fractures

Radial head fractures

Most common fx of elbow

Fall on outstretched hand

Often not visible on Xray on day of injury

Tenderness at radial head or pain with supination

Most common fx of elbow

Fall on outstretched hand

Often not visible on Xray on day of injury

Tenderness at radial head or pain with supination

5. Which of the following is TRUE regarding supracondylar fractures?A. An anterior fat pad may be the only visible sign of a nondisplaced fracture on XrayB. Refusal to open hand, pain with pasive finger extension, and forearm tenderness are commonly found with this injury and should be treated with analgesicsC. Volkmann’s ischemic contracture results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissuesD. Most supracondylar fractures are displaced anteriorly

5. Which of the following is TRUE regarding supracondylar fractures?A. An anterior fat pad may be the only visible sign of a nondisplaced fracture on XrayB. Refusal to open hand, pain with pasive finger extension, and forearm tenderness are commonly found with this injury and should be treated with analgesicsC. Volkmann’s ischemic contracture results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissuesD. Most supracondylar fractures are displaced anteriorly

C. Volkmann’s ischemic contractures results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues

C. Volkmann’s ischemic contractures results from postischemic swelling in forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues

Supracondylar fractures

Supracondylar fractures

60% of all elbow fx in children 95% displaced posteriorly due to

extension force Neuro complications (7%)

Radial and median nerves Acute vascular injuries must always be

suspected Volkmann’s ischemic contracture

Post ischemic swelling in forearm compartment

Refusal to open hand in children, pain w/ passive extension of fingers, forearm tenderness

60% of all elbow fx in children 95% displaced posteriorly due to

extension force Neuro complications (7%)

Radial and median nerves Acute vascular injuries must always be

suspected Volkmann’s ischemic contracture

Post ischemic swelling in forearm compartment

Refusal to open hand in children, pain w/ passive extension of fingers, forearm tenderness

6. Which of the following is TRUE regarding injury shown below?A. Associated radial head dislocations are rareB. These type of fractures are classified according to the location of the ulnar fx and direction of the radial head dislocationC. Most of these fractures are treated with closed reduction and prolonged cast immobilizationD. All of the above

6. Which of the following is TRUE regarding injury shown below?A. Associated radial head dislocations are rareB. These type of fractures are classified according to the location of the ulnar fx and direction of the radial head dislocationC. Most of these fractures are treated with closed reduction and prolonged cast immobilizationD. All of the above

B. These type of fractures are classified according to the location of the ulnar fx and direction of radial head dislocation

B. These type of fractures are classified according to the location of the ulnar fx and direction of radial head dislocation

Monteggia’s fracture - dislocation

Monteggia’s fracture - dislocation

Ulnar shaft fx w/ associated radial head dislocation

Apex of ulnar fx pts in direction of radial head dislocation

Pain and swelling at elbowTreated w/ closed reduction of

radial head dislocation and ORIF of ulnar fx

Ulnar shaft fx w/ associated radial head dislocation

Apex of ulnar fx pts in direction of radial head dislocation

Pain and swelling at elbowTreated w/ closed reduction of

radial head dislocation and ORIF of ulnar fx

7. An 8 year old football player is brought to your ED with an anxious set of parents and R shoulder pain. Xray reveals minimally displaced midshaft fx of R clavicle. The parents ask you to tell them everything they need to know about the injury. Which of the following statements is TRUE?A. This is an uncommon place for a clavicular fxB. A figure of 8 harness is necessary for proper healingC. The patient will likely have chronic shoulder pain as adultD. This fx may be associated with intrathoracic injury

7. An 8 year old football player is brought to your ED with an anxious set of parents and R shoulder pain. Xray reveals minimally displaced midshaft fx of R clavicle. The parents ask you to tell them everything they need to know about the injury. Which of the following statements is TRUE?A. This is an uncommon place for a clavicular fxB. A figure of 8 harness is necessary for proper healingC. The patient will likely have chronic shoulder pain as adultD. This fx may be associated with intrathoracic injury

D. This fx may be associated with intrathoracic injury

D. This fx may be associated with intrathoracic injury

Clavicular fracturesClavicular fractures

Most common fx of childhood

Account for ~1/2 of significant injuries to shoulder girdle

Direct blow to shoulder

80% of fx involve middle 1/3

Simple sling immobilization

Heal within 4-6 weeks Distal fx often rupture

coracoclavicular ligament

Most common fx of childhood

Account for ~1/2 of significant injuries to shoulder girdle

Direct blow to shoulder

80% of fx involve middle 1/3

Simple sling immobilization

Heal within 4-6 weeks Distal fx often rupture

coracoclavicular ligament

8. Which of the following is TRUE regarding AC joint injuries?A. It is difficult to diagnose them clinicallyB. Most injuries occur in the elderlyC. Shoulder Xrays are neededD. Tx of most injuries consists of analgesia, rest, and immobilization in a simple sling

8. Which of the following is TRUE regarding AC joint injuries?A. It is difficult to diagnose them clinicallyB. Most injuries occur in the elderlyC. Shoulder Xrays are neededD. Tx of most injuries consists of analgesia, rest, and immobilization in a simple sling

C. Shoulder Xrays are needed

C. Shoulder Xrays are needed

Acromioclavicular Separation

Acromioclavicular Separation

Tears of AC and CC ligaments

Fall onto adducted arm Young active males Classification based on

degree of ligamentous disruption and displacement Minimally displaced

can be treated with sling and early immobilization

Severely displaced or rupture of CC ligament require prompt ortho referral

Tears of AC and CC ligaments

Fall onto adducted arm Young active males Classification based on

degree of ligamentous disruption and displacement Minimally displaced

can be treated with sling and early immobilization

Severely displaced or rupture of CC ligament require prompt ortho referral

9. Which of the following is TRUE regarding scapular fx?

A. They are seldom associated with other injuriesB. Most require surgical fixation to ensure long term should fxnC. They are usually the result of severe traumaD. Fx of the acromion and the scapular spine are the most common

9. Which of the following is TRUE regarding scapular fx?

A. They are seldom associated with other injuriesB. Most require surgical fixation to ensure long term should fxnC. They are usually the result of severe traumaD. Fx of the acromion and the scapular spine are the most common

C. They are usually the result of severe trauma

C. They are usually the result of severe trauma

Scapular fxScapular fx

Scapular embedded in muscle and therefore not easily fx

Associated injures to lung, thorax cage, and shoulder girdle frequent Fx of body and

neck of glenoid are most common

Isolated fx are treated with sling and early ROM

Scapular embedded in muscle and therefore not easily fx

Associated injures to lung, thorax cage, and shoulder girdle frequent Fx of body and

neck of glenoid are most common

Isolated fx are treated with sling and early ROM

10. 56 yo male presents after industrial accident where the patients chest was pinned btw heavy machinery. He is c/o left anterior neck and chest discomfort as well as dysphagia. On exam, you note an obese man. BP is 150/80, HR is 90, and RR is 24. Patient has swelling and tenderness along the L clavicular area and over the sternum, with pain exacerbated upon movement of L shoulder. CXR reveals no fx or PTX. What is the MOST appropriate next diagnostic step?A. PO challenge and d/c with f/uB. L shoulder XrayC. Chest CTD. End-expiratory CXR

10. 56 yo male presents after industrial accident where the patients chest was pinned btw heavy machinery. He is c/o left anterior neck and chest discomfort as well as dysphagia. On exam, you note an obese man. BP is 150/80, HR is 90, and RR is 24. Patient has swelling and tenderness along the L clavicular area and over the sternum, with pain exacerbated upon movement of L shoulder. CXR reveals no fx or PTX. What is the MOST appropriate next diagnostic step?A. PO challenge and d/c with f/uB. L shoulder XrayC. Chest CTD. End-expiratory CXR

C. Chest CTC. Chest CT

Sternoclavicluar dislocation

Sternoclavicluar dislocation

Uncommon Anterior

dislocations more frequent Promiment

medial clavicle Posterior

dislocations Clavicle end is

not palpable Impingement of

mediastinal contents

Uncommon Anterior

dislocations more frequent Promiment

medial clavicle Posterior

dislocations Clavicle end is

not palpable Impingement of

mediastinal contents

11. Which of the following is TRUE regarding C spine injuries?A. Fanning or widening of the spinous processes may indicate an injury to the anterior ligamentous structuresB. Injuries to transverse ligament of the odontoid can occur w/o bony fx and should be considered unstable injuriesC. The flexion-teardrop fx is considered mechanically stableD. A bilateral interfacetal dislocation (“locked facets”) is considered mechanically stable

11. Which of the following is TRUE regarding C spine injuries?A. Fanning or widening of the spinous processes may indicate an injury to the anterior ligamentous structuresB. Injuries to transverse ligament of the odontoid can occur w/o bony fx and should be considered unstable injuriesC. The flexion-teardrop fx is considered mechanically stableD. A bilateral interfacetal dislocation (“locked facets”) is considered mechanically stable

B. Injuries to transverse ligament of odontoid can occur w/o bony fx and should be considered unstable injuries

B. Injuries to transverse ligament of odontoid can occur w/o bony fx and should be considered unstable injuries

C spine injuriesC spine injuries

Transverse ligament Runs along posterior

surface of dens Pure ligamentous

disruption w/o associated fx can occur in older patients with direct blow to occiput

Predental space (>3mm ligament damage, >5mm ligament rupture)

Immediate Neurosurgery consult

Transverse ligament Runs along posterior

surface of dens Pure ligamentous

disruption w/o associated fx can occur in older patients with direct blow to occiput

Predental space (>3mm ligament damage, >5mm ligament rupture)

Immediate Neurosurgery consult

12. 17 yo female attended a pool party where ETOH was being served. She dove head first into the shallow end of the pool and landed directly on her head. In the ED, she has severe neck pain and minimal movement below the level of the shoulders. Which of the following is the most likely injury?A. Burst fxB. Flexion-distraction fxC. Spinous process fxD. Transverse process fxE. Wedge fx

12. 17 yo female attended a pool party where ETOH was being served. She dove head first into the shallow end of the pool and landed directly on her head. In the ED, she has severe neck pain and minimal movement below the level of the shoulders. Which of the following is the most likely injury?A. Burst fxB. Flexion-distraction fxC. Spinous process fxD. Transverse process fxE. Wedge fx

A. Burst fractureA. Burst fracture

C spine fracturesC spine fractures

Burst FxAxial loading

mechanism of injury

Neurological deficit from retropulsion of bony fragments into the spinal canal

Burst FxAxial loading

mechanism of injury

Neurological deficit from retropulsion of bony fragments into the spinal canal

C spine fracturesC spine fractures

Flexion-distraction accel/decel

injuries

Spinous process fx (Clay shoveler’s injury) Stable Flexion

Flexion-distraction accel/decel

injuries

Spinous process fx (Clay shoveler’s injury) Stable Flexion

C spine fracturesC spine fractures

Wedge fracture Flexion injury Stable and

rarely associated w/ neuro deficit

Anterior wedge fx>50% of the height of the vertebral body might become unstable over long term

Wedge fracture Flexion injury Stable and

rarely associated w/ neuro deficit

Anterior wedge fx>50% of the height of the vertebral body might become unstable over long term

C spine fracturesC spine fractures Flexion teardrop

Anterior cord syndrome due impingement

Mechanically unstable

Bilateral interfacetal dislocation Articular masses

to dislocate superiorly and anteriorly

Mechanically unstable

Flexion teardrop Anterior cord

syndrome due impingement

Mechanically unstable

Bilateral interfacetal dislocation Articular masses

to dislocate superiorly and anteriorly

Mechanically unstable

13. 35 yo male presents after jumping from 3 story building in a suicide attempt. He is unconscious on arrival and immediately intubated. His feet are swollen and appear deformed, and Xrays are obtained to r/o calcaneal fx. Which of the following is TRUE regarding calcaneal injuries?A. Boehler’s angle measured at 10° r/o the possibility of occult fxB. Management is primarily supportive care and surgery is rarely necessaryC. Associated vertebral fx are classic but not commonly foundD. The patient is at risk for developing compartment syndrome

13. 35 yo male presents after jumping from 3 story building in a suicide attempt. He is unconscious on arrival and immediately intubated. His feet are swollen and appear deformed, and Xrays are obtained to r/o calcaneal fx. Which of the following is TRUE regarding calcaneal injuries?A. Boehler’s angle measured at 10° r/o the possibility of occult fxB. Management is primarily supportive care and surgery is rarely necessaryC. Associated vertebral fx are classic but not commonly foundD. The patient is at risk for developing compartment syndrome

D. Patient is at risk for developing compartment syndrome

D. Patient is at risk for developing compartment syndrome

Calcaneal fractures (Lovers fx)

Calcaneal fractures (Lovers fx)

High velocity axial load injury

Boehler’s angle measurement helps to discern otherwise negative xrays

High risk of developing compartment syndrome

Frequently associated with injuries to axial spine (Don Juan fx)

High velocity axial load injury

Boehler’s angle measurement helps to discern otherwise negative xrays

High risk of developing compartment syndrome

Frequently associated with injuries to axial spine (Don Juan fx)

14. 26 yo male is brought to trauma room after high speed motorcycle accident. He has suspected injuries to abdomen and head as well as an obvious deformity of the L ankle. The L foot is dusky and cool, and pulses are difficult to palpate. What is the MOST appropriate next step in the management of this injury?A. Obtain ankle films immediately as other trauma Xrays are obtainedB. Call orthopod on call immediately to request assistance with reductionC. Perform immediate reduction prior to obtaining XraysD. Attempt reduction only after films and ABI have obtained for BLE

14. 26 yo male is brought to trauma room after high speed motorcycle accident. He has suspected injuries to abdomen and head as well as an obvious deformity of the L ankle. The L foot is dusky and cool, and pulses are difficult to palpate. What is the MOST appropriate next step in the management of this injury?A. Obtain ankle films immediately as other trauma Xrays are obtainedB. Call orthopod on call immediately to request assistance with reductionC. Perform immediate reduction prior to obtaining XraysD. Attempt reduction only after films and ABI have obtained for BLE

C. Perform immediate reduction prior to obtaining Xrays

C. Perform immediate reduction prior to obtaining Xrays

Ankle dislocationAnkle dislocation

Dislocations can occur in 1 of 4 planes

Frequently associated with fxPosterior dislocation most

commonConsiderable risk of

neurovascular compromiseRequire emergent reduction by

EM physician

Dislocations can occur in 1 of 4 planes

Frequently associated with fxPosterior dislocation most

commonConsiderable risk of

neurovascular compromiseRequire emergent reduction by

EM physician

15. 29 yo male is BIBA s/p high speed motorcycle accident. The paramedics state that when they arrived on the scene the patient’s left knee, appeared severely deformed, and a splint was immediately applied. Upon removal of splint in the ED, you do not appreciate any obvious deformity but do note severe swelling of the joint. The patient is severe pain at the knee, and you appreciate severe instability of the knee in multiple directions. Which of the following is TRUE regarding this patient?

A. He most likely has quadriceps tendon rupture and should be splinted in a knee immobilizer

B. Any effusions presents should be immediately aspiratedC. This patient is at high risk for neurovascular injuries and should be admitted regardless of the neurovascular examD. Xrays should be ordered to r/o fx, and the patient should receive prompt outpatient f/u to evaluate potential ligamentous injuries

15. 29 yo male is BIBA s/p high speed motorcycle accident. The paramedics state that when they arrived on the scene the patient’s left knee, appeared severely deformed, and a splint was immediately applied. Upon removal of splint in the ED, you do not appreciate any obvious deformity but do note severe swelling of the joint. The patient is severe pain at the knee, and you appreciate severe instability of the knee in multiple directions. Which of the following is TRUE regarding this patient?

A. He most likely has quadriceps tendon rupture and should be splinted in a knee immobilizer

B. Any effusions presents should be immediately aspiratedC. This patient is at high risk for neurovascular injuries and should be admitted regardless of the neurovascular examD. Xrays should be ordered to r/o fx, and the patient should receive prompt outpatient f/u to evaluate potential ligamentous injuries

C. The patient is at high risk for neurovascular injuries and should be admited regardless of the neurovascular exam

C. The patient is at high risk for neurovascular injuries and should be admited regardless of the neurovascular exam

Knee dislocationKnee dislocation

Posterior dislocation most commonComplete disruption of ACL & PCL

and posterior joint capsule Spontaneous reduction of knee

often occurs High incidence of associated

complicationsPopliteal artery and peroneal

nerve (1/3 of dislocations) All patients should be admitted

Posterior dislocation most commonComplete disruption of ACL & PCL

and posterior joint capsule Spontaneous reduction of knee

often occurs High incidence of associated

complicationsPopliteal artery and peroneal

nerve (1/3 of dislocations) All patients should be admitted