02 Ortho

Question 1

In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “click”, and returned to
normal position with a “snapping”.

Answer 1

What is it? – Developmental dysplasia of the hip (congenital dislocation of the hip)
Diagnosis. The physical examination should suffice, but if there is any doubt, do a sonogram. (Don’t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything).
Management. Abduction splinting with Pavlik harness.

Question 2

A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the
hip is guarded.

Answer 2

In this age group, Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis). Remember that hip pathology can show up with knee pain.
Management: AP and lateral X-Rays for diagnosis. Contain the femoral head within the acetabulum by
casting and crutches.

Question 3

A 13 year old boy complains of pain in the groin ( it could be the knee) and is noted by the family
to be limping. He sits in the office with the foot on the affected side rotated towards the other foot.
Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg
goes into external rotation and it can not be rotated internally.

Answer 3

What is it? - Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency.
Management: AP and lateral X-Rays for diagnosis. The orthopedic surgeons will pin the femoral head in
place.

Question 4

A child with a febrile illness but no history of trauma has persistent, severe localized pain in a
bone.

Answer 4

What is it? - Acute hematogenous osteomyelitis
Management: don’t fall for the X-Ray option. X-Ray will not show anything for two weeks. Do bone
scan.

Question 5

A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip he will not let you move it. He has elevated sedimentation rate.

Answer 5

What is it? - Another orthopedic emergency: septic hip.
Management: Under general anesthesia the hip is aspirated to confirm the diagnosis, and open arthrotomy
is done for drainage.

Question 6

A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine
is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. The
patient has not yet started to menstruate.

Answer 6

Management: Too complicated for our purposes, but the point is that scoliosis may progress until skeletal
maturity is reached. Baseline X-Rays are needed to monitor progression. At the onset of menses skeletal
maturity is about 80%, so this patient still has a way to go. Bracing may be needed to arrest progression.
Pulmonary function could be limited if there is large deformity.

Question 7

A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X-Rays show a large bone tumor, with “sunburst” pattern and periosteal “onion skinning”.

Answer 7

What is it? - Malignant bone tumor. Either osteogenic sarcoma or Ewing’s sarcoma.
Management: The point of the vignette is that you do not mess with these. Do not attempt biopsy. Referral
is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on
bone tumors.

Question 8

A 66 year old lady picks up a bag of groceries and her arm snaps broken.

Answer 8

What is it? - A pathologic fracture (i.e: for trivial reasons) means bone tumor, which in the vast majority of
cases will be metastatic. Get X-Rays to diagnose this particular broken bone, whole body bone scans to
identify other mets, and start looking for the primary. In women, breast. In men, prostate. In heavy
smokers, lung…and so on.

Question 9

58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months,
it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8 cm. in
diameter.

Answer 9

What is it? - Soft tissue sarcoma is the concern.

Diagnosis: start with MRI. Leave biopsy and further management to the experts.

Question 10

A middle aged homeless man is brought to the ER because of very severe pain in his forearm.
The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an
indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his
forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit
excruciating pain. Pulses at the wrist are normal.

Answer 10

What is it? - Compartment syndrome.

Management; Emergency fasciotomy.

Question 11

A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture.

Answer 11

The point of this vignette is that you never give pain medication and do nothing else for pain under a cast.
The cast has to come off right away. It may be too tight, it may be compromising blood supply, it may have rubbed off a piece of skin…whatever. Your only acceptable option here is to remove the cast.

Question 12

young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration.

Answer 12

The point of this one is that open fractures are orthopedic emergencies. This fellow may need to have other problems treated first (abdominal bleeding, intracraneal hematomas, chest tubes, etc), but the open fracture should be in the OR getting cleaned and reduced within six hours of the injury.

Question 13

A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle.

Answer 13

What is it? - Anterior dislocation of the shoulder, with axillary nerve damage.
Management: Get AP and lateral X-Rays for diagnosis. Reduce.

Question 14

After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by “Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a “normal” (i.e., not externally rotated, but internally rotated) position.

Answer 14

What is it? - Posterior dislocation of the shoulder. Very easy to miss on regular X-Rays.
Management: Get X-Rays again but order axillary view or scapular lateral.

Question 15

A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with
his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity
shortened, adducted, and internally rotated.

Answer 15

What is it? - Another orthopedic emergency: posterior dislocation of the hip. The blood supply of the femoral head is tenous, and delay in reduction could lead to avascular necrosis.
Management: X-Rays and emergency reduction.

Question 16

A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture.

Answer 16

The point of this vignette is that blood supply to the femoral head is compromised in this setting and the
patient is better off with a metal prosthesis put in, rahter than an attempt at fixing the bone. With
intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal.

Question 17

A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee.

Answer 17

The point here is that posterior dislocation of the knee can nail the popliteal artery.
Attention to integrity of pulses, arteriogram and prompt reduction are the key issues.

Question 18

A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal.

Answer 18

What is it? - Stress fracture.
The lesson here is that stress fractures will not show up radiologically until 2 weeks later. Treat the guy as
if he had a fracture (cast) and repeat the X-Ray in 2 weeks.

Question 19

A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order.

Answer 19

Here are the rules: Always get X-Rays at 90° to each other (for instance, AP and lateral), always include
the joints above and below, and if appropriate (this case is) check the other bones that might be in the same
line of force (here the lumbar spine).

Question 20

A healthy 24 year old man steps on a rusty nail at the stables where he works as a horse breeder. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation.

Answer 20

What is it? - Gas gangrene.
What to do? - Tons of IV penicillin and immediate surgical debridement of dead tissue, followed by a trip to the nearest hyperbaric chamber for hyperbaric O2 treatment.

Question 21

A 55 year old, obese man suddenly develops swelling, redness and exquisite pain at the first
metatarsal-phalangeal joint.

Answer 21

What is it? - Gout.
Management: Diagnosis by serum uric acid determination and identification of uric acid crystals in fluid from the joint. Rx. with colchicine, allopurinol or probenicid.

Question 22

A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot

Answer 22

What is it? - Ulcer at a pressure point in a diabetic is due to neuropathy, but once it has happened it is
unlikely to heal because the microcirculation is poor also.
Management: control the diabetes, keep the ulcer clean, keep the leg elevated..and be resigned to the
thought that you may end up amputating the foot.

Question 23

A 67 year old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer
at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity

Answer 23

What is it? - Ischemic ulcers are at the farthest away pint from where the blood comes.
Management: Doppler studies looking for pressure gradient, arteriogram. Revascularization may be
possible, and then the ulcer may heal.

Question 24

A 44 year old, obese woman has an indolent, unhealing ulcer above her right maleolus. The skin
around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins

Answer 24

What is it? – Venous stasis ulcer.

Management: Unna boot. Support stocking. Varicose vein surgery.

Question 25

A 2-year-old child is brought in by concerned parents because he is bowlegged.
A 5-year-old child is brought in by concerned parents because he is knockkneed.

Answer 25

Genu varum (bow-leg) is normal up to age 3. Genu valgus (knock-knee) is normal between
age 4–8. Thus neither of these children need therapy. Should the varum deformity (bow-legs)
persist beyond its normal age range (i.e., beyond age 3), Blount disease is the most common
problem (a disturbance of the medial proximal tibial growth plate), and surgery can be performed
for it.

Question 26

A 14-year-old boy says he injured his knee while playing football. Although there is no swelling of the knee joint, he complains of persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps. Physical examination shows localized tenderness right over the tibial tubercle.

Answer 26

This is another one with a fancy name: Osgood-Schlatter disease (osteochondrosis of the tibial tubercle). It is usually treated with immobilization of the knee in an extension or cylinder cast for 4 to 6 weeks, if more conservative management fails (rest, ice, compression, and elevation).

Question 27

A baby boy is born with both feet turned inward. Physical examination shows that there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia.

Answer 27

This is the complex deformity known as club foot (fancy name: talipes equinovarus). The child needs serial plaster casts started in the neonatal period. The sequence of correction starts with the adducted forefoot, then the hindfoot varus, and finally the equinus. About half the patients respond completely and need no surgery. Those who require surgery are operated on after the age of 6–8 months, but before 1–2 years of age.

Question 28

An 8-year-old boy falls on his right hand with the arm extended, and he breaks his elbow by hyperextension. X-rays show a supracondylar fracture of the humerus. The distal fragment is displaced posteriorly.

Answer 28

This type of fracture is common in children, but it is important because it may produce vascular or nerve injuries—or both—and end up with a Volkmann contracture. Although it can usually be treated with appropriate casting or traction (and rarely needs surgery), the answer revolves around careful monitoring of vascular and nerve integrity, and vigilance regarding development of a compartment syndrome.

Question 29

A child sustains a fracture of a long bone, involving the epiphyses and growth plate. The epiphyses and growth plate are laterally displaced from the metaphyses, but they are in one piece, i.e., the fracture does not cross the
epiphyses or growth plate and does not involve the joint.
A child sustains a fracture of a long bone that extends through the joint, the epiphyses, the growth plate, and a piece of the metaphyses.

Answer 29

In the first of these two, even though the dreaded growth plate is involved, it has not been divided by the fracture. Treatment by closed reduction is sufficient. In the second example, there are two pieces of growth plate. Unless they are very precisely aligned, growth will be disturbed.
Open reduction and internal fixation will be needed.

Question 30

A 16-year-old boy complains of low-grade but constant pain in the distal femur present for several months. He has local tenderness in the area, but is otherwise
asymptomatic. X-rays show a large bone tumor breaking through the cortex into the adjacent soft tissues and exhibiting a “sunburst” pattern.

A 10-year-old complains of persistent pain deep in the middle of the thigh. X-rays show a large, fusiform bone tumor, pushing the cortex out and producing periosteal “onion skinning.”

Answer 30

Primary malignant bone tumors are also diseases of young people. The most common one is
osteogenic sarcoma, which is seen in ages 10 to 25 and usually occurs around the knee (lower
femur or upper tibia). The second-most common is Ewing sarcoma, which affects younger children (5 to 15) and grows in the diaphyses of long bones. Our vignettes illustrate each of these, but this is such a specialized field that they may just ask you to diagnose “malignant bone
tumor” without picking the specific kind. As for management, the point of the vignette is that
you do not mess with these. Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every 3 years), but to a specialist on bone tumors.

Question 31

A 60-year-old man complains of fatigue and pain at specific places on several bones. He is found to be anemic, and x-rays show multiple punched out lytic
lesions throughout the skeleton.

Answer 31

Multiple lytic lesions in an old anemic man suggest multiple myeloma. X-rays are diagnostic and additional tests include: Bence-Jones protein in the urine and abnormal immunoglobulins in the blood. The latter are detectable by serum electrophoresis and better yet by immunoelectrophoresis.
Management. Chemotherapy is the usual treatment. Thalidomide is used for refractory cases.

Question 32

While playing football, a college student fractures his clavicle. The point of tenderness is at the junction of the middle and distal thirds of the clavicle.

Answer 32

Place the arm in a sling or figure of 8 splint. Young women may request fixation by surgery, to achieve a better cosmetic result.

Question 33

An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a “dinner fork.” X-rays show a dorsally displaced, dorsally angulated fracture of the distal radius and small, nondisplaced fracture of the ulnar stylus.

Answer 33

The famous Colles fracture. It is treated with close reduction and long arm cast

Question 34

During a rowdy demonstration and police crackdown, a young man is hit with a nightstick on his outer forearm that he had raised to protect himself. He is found to have a diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head.

Answer 34

Another classic with a fancy name: Monteggia fracture. He needs closed reduction of the radial head, and he may need an open reduction and internal fixation of the ulnar fracture.

Question 35

Another victim of the same melee has a fracture of the distal third of the radius and dorsal dislocation of the distal radioulnar joint.

Answer 35

We are running out of proper names. This one is Galeazzi fracture, which is quite similar to the previous one in terms of the resultant instability. The fractured radius may need open reduction and internal fixation, while the dislocated joint may be manipulated back into proper position and casted in supination

Question 36

A young adult falls on an outstretched hand and comes in complaining of wrist pain. On physical examination, he is distinctly tender to palpation over the anatomic snuff-box. AP and lateral x-rays are read as negative.

Answer 36

Another classic (blissfully devoid of eponym). This is a fracture of the scaphoid bone (carpal navicular). They are notorious because x-rays will not show them for 2 or 3 weeks, and they are also infamous because of a high rate of nonunion. The history and physical findings (the
tenderness in the snuff-box) are sufficient to indicate the use of a thumb spica cast, with repeat x-rays 3 weeks later.

Question 37

A young adult falls on an outstretched hand and comes in complaining of wrist pain. On physical examination, he is distinctly tender to palpation over the anatomic snuff-box. AP, lateral, and oblique x-rays show a displaced and
angulated fracture of the scaphoid.

Answer 37

Displaced and angulated; will need open reduction and internal fixation.

Question 38

During a barroom fight, a young man throws a punch at somebody, but misses and ends up hitting the wall. He comes in with a swollen and tender right hand. X-rays show fracture of the fourth and fifth metacarpal necks.

Answer 38

Metacarpal necks, typically the fourth or the fifth (or both), take the brunt of your anger when you try to hit somebody but miss. Treatment depends on the degree of angulation, displacement, or rotary malalignment. Closed reduction and ulnar gutter splint for the mild ones, Kirschner-wire or plate fixation for the bad ones.

Question 39

A 77-year-old man falls in the nursing home and hurts his hip. He shows up with the affected leg shortened and externally rotated. X-rays show that he has a displaced femoral neck fracture.

Answer 39

The point of this vignette is that blood supply to the femoral head is compromised in this setting, and the patient is better off with a metal prosthesis put in, rather than an attempt at fixing the bone.

Question 40

A 77-year-old man falls in the nursing home and hurts his hip. He shows up with the affected leg shortened and externally rotated. X-rays show that he has an intertrochanteric fracture.

Answer 40

These can be fixed with less concern about avascular necrosis. Open reduction and pinning are usually performed. Immobilization in these old people often leads to deep venous thrombosis and pulmonary embolus; thus an additional choice for postoperative anticoagulation may be offered in the question.

Question 41

The unrestrained front-seat passenger in a car that crashes sustains a closed fracture of the femoral shaft.

Answer 41

There are many ways to deal with fractured femurs, but intramedullary rod fixation is commonly done.

Question 42

The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80 over 50, a pulse rate of 110, and a venous pressure of 0. The rest of his physical examination and x-ray survey (chest, pelvis) are unremarkable, and sonogram of the abdomen done in the ER was likewise negative

Answer 42

A throwback to the trauma vignettes to remind you that femur fractures may bleed into the tissues sufficiently to cause hypovolemic shock. Fixation will diminish the blood loss, and fluid resuscitation and blood transfusions will take care of the shock.

Question 43

The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Twelve hours after admission, he
develops disorientation, fever, and scleral petechia. Dyspnea is evident shortly thereafter, at which time blood gases show a Po2 of 60.

Answer 43

Another repeated topic: fat embolism. Respiratory support is the centerpiece of the treatment.

Question 44

A college student is tackled while playing football, and he develops severe knee pain. When examined shortly thereafter, the knee is swollen, and he has pain
on direct palpation over the medial aspect of the knee. With the knee flexed at 30°, passive abduction elicits pain in the same area, and the leg can be abducted further out than the normal, contralateral leg (valgus stress test).
A college student is tackled while playing football, and he develops severe knee pain. When examined shortly thereafter, the knee is swollen, and he has pain on direct palpation over the lateral aspect of the knee. With the knee flexed at 30°, passive adduction elicits pain in the same area, and the leg can be adducted further out than the normal, contralateral leg (varus stress test).

Answer 44

The medial collateral ligament is injured in the first of these two vignettes, whereas the second one depicts an injury to the lateral collateral ligament. A hinged cast is the usual treatment for either isolated injury. When several ligaments are torn, surgical repair is preferred.

Question 45

A college student is tackled while playing football, and he develops severe knee swelling and pain. On physical examination with the knee flexed at 90°, the leg can be pulled anteriorly, like a drawer being opened. A similar finding can be elicited with the knee fixed at 20° by grasping the thigh with one hand, and pulling the leg with the other.

Answer 45

This is a lesion of the anterior cruciate ligament, shown by the anterior drawer test and the Lachman test. Further definition of the extent of internal knee injuries can be done with MRI. Sedentary patients may be treated just with immobilization and rehabilitation, but athletes require arthroscopic reconstruction.

Question 46

A college athlete injured his knee while playing basketball. He has been to several physicians who have prescribed pain medication and a variety of
splints and bandages, but he still has a swollen knee and knee pain. He describes catching and locking that limit his knee motion, and he swears that when his knee is forcefully extended there is a “click” in the joint. He has been told that his x-rays are normal,

Answer 46

Meniscal tears may be difficult to diagnose clinically, but MRI will show them beautifully. Arthroscopic repair is done, trying to save as much of the meniscus as possible. If complete meniscectomy is done, late degenerative arthritis will ensue. Some orthopedic surgeons prefer to repair meniscal injuries with an open operation.

Question 47

A pedestrian is hit by a car. Physical examination shows the leg to be angulated midway between the knee and the ankle. X-rays confirm fractures of the shaft
of the tibia and fibula.

Answer 47

Casting takes care of the ones that can be easily reduced. Intramedullary nailing is needed for the ones that cannot be aligned.

Question 48

A pedestrian is hit by a car. Physical examination shows the leg to be angulated midway between the knee and the ankle. X-rays confirm fractures of the shaft of the tibia and fibula. Satisfactory alignment is achieved, and a long leg cast applied. In the ensuing 8 hours the patient complains of increasing pain. When the cast is removed, the pain persists, the muscle compartments feel tight, and
there is excruciating pain with passive extension of the toes.

Answer 48

Compartment syndrome is a distinct hazard after fractures of the leg (the forearm and the lower leg are the two places with the highest incidence of compartment syndrome). Fasciotomy is needed here.

Question 49

An out-of-shape, recently divorced 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud “pop” is heard (like a gunshot), and the man falls to the ground
clutching his ankle. He limps off the courts, with pain and swelling in the back of the lower leg, but still able to flex his foot in the plantar position. When he seeks medical help the next day, palpation of his Achilles tendon reveals an obvious defect right beneath the skin.

Answer 49

A classic presentation for rupture of the Achilles tendon. Casting in equinus position will allow healing after several months, or open surgical repair may do it sooner.

Question 50

While running to catch a bus, an old man twists his ankle and falls on his inverted foot. AP, lateral, and mortise X-rays show displaced fractures of both malleoli.

Answer 50

A very common injury. When the foot is forcefully rotated (in either direction), the talus pushes and breaks one malleolus and pulls off the other one. Open reduction and internal fixation is needed in this case because the fragments are displaced.

Question 51

A 48-year-old man breaks his arm when he falls down the stairs. X-rays demonstrate an oblique fracture of the middle to distal thirds of the humerus. Physical examination shows that he cannot dorsiflex (extend) his wrist.

Answer 51

Fractures of the humeral shaft can injure the radial nerve, which courses in a spiral groove right around the posterior aspect of that bone. However, surgical exploration is not usually needed. Hanging arm cast or coaptation splint are used, and the nerve function returns eventually. However, if the nerve was okay when the patient came in, and becomes paralyzed after closed
reduction of the bone, the nerve is entrapped and surgery has to be performed.

Question 52

A window cleaner falls from a third-story scaffold and lands on his feet. Physical examination and x-rays show comminuted fractures of both calcanei.

Answer 52

Compression fractures of the thoracic or lumbar spine are the associated, hidden injuries that have to be looked for in this case.

Question 53

In a head-on automobile collision, the unrestrained front-seat passenger strikes the dashboard and windshield. He comes in with facial lacerations, upper extremity fractures, and blunt trauma to his chest and abdomen.

Answer 53

In the confusion of dealing with multiple trauma, less-obvious injuries may be missed. In this particular scenario, as the knees strike the dashboard, the femoral heads may drive backward into the pelvis, or out of the acetabulum

Question 54

The unrestrained front-seat passenger in a car that crashes at high speed is brought into the ER with multiple facial fractures and a closed head injury.

Answer 54

We have dealt with this one before, but it is worth repeating. The ultimate hidden injury (because of the devastating complications if missed) is the fracture of the cervical spine. This scenario demands that a CT scan be done to rule it out.

Question 55

A 43-year-old female secretary who does a lot of typing complains about numbness and tingling in her hand, particularly at night. On physical examination, when asked to hang her hand limply in front of her, numbness
and tingling are reproduced over the distribution of the median nerve (the radial side 3 1/2 fingers). The same happens when her median nerve is pressed over the carpal tunnel, or when it is percussed.

Answer 55

Carpal tunnel syndrome is diagnosed clinically, and this vignette is typical. The American
Academy of Orthopedic Surgery recommends that wrist x-rays (including carpal tunnel view) be done, primarily to rule out other things. Initial treatment is splints and antiinflammatories. If surgery is needed, electromyography should precede it (electro-diagnostic studies of nerve conduction).

Question 56

A 58-year-old woman describes that she wakes up at night with her right middle finger acutely flexed, and she is unable to extend it. She can do it only by pulling on it with her other hand, at which time she feels a painful “snap.”

Answer 56

Trigger finger. Steroid injections are tried first. Surgery is performed if needed.

Question 57

A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the
wrist into ulnar deviation.

Answer 57

De Quervain tenosynovitis. Splints and antiinflammatories can help, but steroid injection is best. Surgery is rarely needed.

Question 58

A 72-year-old man of Norwegian ancestry has a contracted hand that can no longer be extended and be placed flat on a table. Palmar fascial nodules can be felt.

Answer 58

Dupuytren contracture. Surgery may be needed.

Question 59

A 33-year-old carpenter accidentally drives a small nail into the pulp of his index finger, but he pays no attention to the injury at the time. Two days later he shows up in the ER, with throbbing pulp pain, fever, and all the signs of an abscess within the pulp of the affected finger.

Answer 59

This kind of abscess is called a felon, and like all abscesses it has to be drained. But there is a certain urgency to do it, because the pulp is a closed space and the process is equivalent to a compartment syndrome.

Question 60

A young man falls while skiing, and as he does so he jams his thumb into the snow. Physical examination shows collateral laxity at the thumb metacarpophalangeal joint.

Answer 60

This one is “gamekeeper’s thumb.” The injury was to the ulnar collateral ligament of the thumb. If not treated it can be dysfunctional and painful, and can lead to arthritis. Casting is usually done.

Question 61

Two hoodlums grab a woman’s purse and run away with it. She tries to grab one of the offenders by his jersey, but he pulls away, hurting the woman’s hand in the process. When she makes a fist now, the distal phalanx of her ring
finger does not flex with the others.
While playing volleyball, a young lady injures her middle finger. She cannot extend the distal phalanx.

Answer 61

Two classic tendon injuries, with appropriate names: jersey finger (to the flexor), and mallet finger (to the extensor). Splinting is usually the first line of treatment.

Question 62

While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base.

Answer 62

Replantation of severed digits is no longer “miracle surgery.” It is commonly done at specialized centers, and regular physicians should know how to handle the amputated part. The answer is to clean it with sterile saline, wrap it in a saline-moistened gauze, place it in a plastic bag, and place the bag on a bed of ice. The digit should not be placed in antiseptic solutions or alcohol,
put in dry ice, or allowed to freeze.

Question 63

A 45-year-old man gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very
severe back pain that came on when he tried to lift a heavy object. The pain is like an electrical shock that shoots down his leg, it is aggravated by sneezing, coughing, or straining, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg-raising gives excruciating pain.

Answer 63

What is it? Lumbar disk herniation. The peak age incidence is 45, and virtually all of these are at either L4–L5 or L5–S1. If the “lightning” exits the foot by the big toe, it is L4–L5, if it exits by the little toe, it is L5–S1.
Management. MRI for diagnosis. Bed rest and pain control will take care of most of these. Neurosurgical intervention only if there is progressive weakness or sphincteric deficits.

Question 64

46-year-old man has sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is like an electrical shock that shoots down his leg, and it prevents him from ambulating. He keeps the
affected leg flexed. Straight leg-raising test gives excruciating pain. He has a distended bladder, flaccid rectal sphincter, and perineal saddle area anesthesia.

Answer 64

The cauda equina syndrome is a surgical emergency.

Question 65

A young man began to have chronic back pain at age 34. Pain and stiffness have been progressive. He describes morning stiffness, and pain that is worse at rest, but improves with activity. Two years ago, he was treated for uveitis.

Answer 65

Think ankylosing spondylitis. X-rays will eventually show “bamboo spine.” Antiinflammatory agents and physical therapy are used.

Question 66

A 72-year-old man has had a 20-pound weight loss, and he complains of low back pain. The pain is worse at night and is unrelieved by rest or positional changes.

Answer 66

Suggestive of metastatic malignancy. If advanced, x-rays will show it. At a higher cost, an MRI will make a reliable, early diagnosis.

Question 67

I. A 40-year-old man has had a chronic draining sinus in his lower leg since he had an episode of osteomyelitis at age 12. In the last few months he has developed an indolent, dirty-looking ulcer at the site, with “heaped up” tissue growth at the edges.
II. Ever since she had an untreated third-degree burn to her lower leg at the age of 14, a 38-year-old immigrant from Latin America has had shallow ulcerations at the scar site that heal and break down all the time. In the last few months she has developed an indolent, dirty-looking ulcer at the site, with “heaped up” tissue growth around the edges, which is steadily growing and shows no
sign of healing.

Answer 67

Both of these are classic vignettes for the development of squamous cell carcinoma at longstanding, chronic irritation sites. The name Marjolin ulcer has been applied to these tumors. Obviously biopsy is the first diagnostic step, and wide local excision (with subsequent skin grafting) is the appropriate therapy.

Question 68

An older, overweight man complains of disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-rays show a bony spur matching the location of his pain, and physical examination shows exquisite tenderness right over that heel spur.

Answer 68

Although all the signs point to that bony spur as the culprit, this is in fact plantar fasciitis— a very common but poorly understood problem that needs symptomatic treatment until it resolves spontaneously within 12 to 18 months. Podiatrists often remove the spur anyway;
although the spur is not the initial problem, its removal can accelerate recovery.

Question 69

A woman who usually wears high-heeled, pointed shoes complains of pain in the forefoot after prolonged standing or walking. Physical examination shows a very tender spot in the third interspace, between the third and fourth toes.

Answer 69

This one is a Morton neuroma, which is an inflammation of the common digital nerve. If conservative management (more-sensible shoes, among other things) does not suffice, the neuroma may be excised.

Question 70

A 55-year-old obese man suddenly develops swelling, redness, and exquisite pain at the first metatarsal–phalangeal joints.

Answer 70

Gout. The diagnosis of the acute attack is done with identification of uric acid crystals in fluid from the joint. Treatment of the acute attack relies on indomethacin and colchicine. Long-term control of serum uric acid levels is done with allopurinol or probenecid.