#5 -- 2014-09-12 SAEM Tests Practice Questions 2013 Flashcards
Incomplete angulated fractures of long bones are denoted by the term: A. greenstick fracture B. march fracture C. open fracture D. Salter-Harris fracture E. torus fracture
A. greenstick fracture
An 18 year old man presents after twisting his right ankle playing basketball. He has tenderness over the anterior talofibular ligament and there is instability of the ankle with movement. An X-ray shows no fracture or dislocation. He has: A. a first degree sprain B. a second degree sprain C. a third degree sprain D. an occult fracture E. tendonitis
C. a third degree sprain
The correct answer is C. A first degree sprain is minor tearing of the ligamentous fibers with mild hemorrhage and swelling. A second degree sprain is a partial tear of a ligament causing moderate hemorrhage and swelling, tenderness, painful motion and loss of function. A third degree sprain is complete tearing of a ligament resulting in grossly abnormal joint movement in addition to hemorrhage, swelling and pain.
A sprain is treated with: A. analgesia B. elevation C. ice D. immobilization E. all of the above
E. all of the above
This patient fell off a roof and landed on his feet. He presents with right foot and ankle pain. Which bone is fractured as demonstrated in the Figure? [image] A. calcaneous B. cuboid C. navicular D. talus E. There are no fractures.
A. calcaneous
e correct answer is A. The calcaneous is the most commonly fractured tarsal bone. Most of these fractures are caused by falls with direct axial compression. Boehler’s angle is the angle measured on the lateral view as the angle between two lines – one between the posterior tuberosity and the apex of the posterior facet, and the other between the apex of the posterior facet and the apex of the anterior process. If this angle is less than 20 degrees, a compression fracture of the calcaneous should be suspected.
What other injury(s) may be associated with calcaneal fracture after a fall? A. C-1 fracture B. closed head injury C. lumbar compression fracture D. pelvis fracture E. spleen injury
C. lumbar compression fracture
A 46 year old woman was wearing high heels and tripped stepping off a curb. She thinks she inverted her left ankle. She complains of pain on the lateral side of her foot. On exam she has tenderness and swelling with ecchymosis on the lateral aspect of her left foot. Her X-ray shows: [image] A. 5th metatarsal tuberosity fracture B. fifth phalanx fracture C. Jones fracture D. ligamentous injury only E. no fracture, just a sesamoid bone
A. 5th metatarsal tuberosity fracture
A hemodynamically stable patient presents with pain in the forearm after isolated trauma. The neurovascular examination is normal. A single X-ray is taken, and appears as is shown in the Figure. Of the following choices, which is the best next step?
[image really bad ulnar fracture]
A. CT scan of the radius and ulna
B. MRI to assess for nerve damage
C. X-ray of the contralateral arm to assess for symmetry
D. splinting of the forearm with Orthopedic follow-up
E. obtain another view of the forearm, and also X-ray the elbow and wrist
E. obtain another view of the forearm, and also X-ray the elbow and wrist
The correct answer is E. This patient has an ulnar fracture, which like any other fracture should be imaged in at least two planes. Additionally, views of the wrist and elbow are indicated to assess for fractures or dislocations to joints adjacent to the injury.
An intoxicated 30-year old male, unable to give any history other than “knee pain,” had an X-ray ordered from triage (see Figure) before being seen by a physician. Based upon the X-ray results (see Figure), which of the following would be the most likely physical finding?
[image] A. limited ability to extend the leg B. palpable defect in the quadriceps tendon, superior to the patella C. loss of sensation in the thigh D. diminished popliteal pulse E. tenderness over the fibular head
A. limited ability to extend the leg
The correct answer is A. The X-ray demonstrates patella alta, or a high-riding patella. This X-ray finding, which is associated with patellar tendon rupture, is defined as being present when the ratio of the patellar height to the (apparent) length of the patellar tendon exceeds 1:1.2. Patella baja, a low-riding patella, is the finding when the quadriceps tendon is ruptured (in these cases there will often be a palpable defect superior to the patella). Patellar tendon rupture is less common than quadriceps tendon rupture, and patellar tendon rupture is more likely in younger patients (
A 25-year old male presents after falling off his bicycle, and breaking his fall by landing on his forearms. Based upon the X-rays (see Figure), what is the diagnosis?
[image] A. Monteggia fracture-dislocation B. reverse Monteggia fracture-dislocation C. Galeazzi fracture-dislocation D. supracondylar humeral fracture E. elbow dislocation
E. elbow dislocation
With regard to hip fractures, which of the following correctly pairs the letters (A through D) with the location/fracture types?
[image]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving
A. A: subcapital B: basilar neck C: intertrochanteric D: subtrochanteric
B. A: subtrochanteric B: intertrochanteric C: basilar neck D: subcapital
C. A: basilar neck B: intertrochanteric C: subtrochanteric D: subcapital
D. A: basilar neck B: subtrochanteric C: intertrochanteric D: subcapital
E. A: subcapital B: intertrochanteric C: subtrochanteric D: basilar neck
A. A: subcapital B: basilar neck C: intertrochanteric D: subtrochanteric
An 18-month old male is brought to the ED. The caretakers give a history that the child fell off of a sofa while watching TV. Which of the following statements is correct?
[image]
A. This fracture pattern is commonly associated with accidental trauma.
B. Spiral fractures are never the result of accidental trauma.
C. The chance of child abuse is small, given the lack of a second fracture, or old healing fractures, on the X-ray.
D. Treating physicians should search for other signs of nonaccidental injury and consult child protective services.
E. Physicians should only notify child protective services of potential abuse, when the evidence level for such abuse is “more likely than not”.
D. Treating physicians should search for other signs of nonaccidental injury and consult child protective services.
While lifting weights after a few months off of his training regimen, the patient depicted in the figure below felt a pop in the right arm. He has weakness of, and pain with, elbow flexion and supination. Of the choices below, which is the most likely diagnosis? [image] A. humerus fracture B. acromioclavicular separation C. rotator cuff tear D. biceps rupture E. elbow dislocation
D. biceps rupture
A 35 year old male presents with right knee swelling (see Figure), redness and pain for 1 day. He has no medical problems. He has had no injury to his knee. His oral temperature is 101.9 and he appears ill. What is the next course of action?
[image]
A. arthrocentesis
B. radiograph of joint
C. medication for presumed gout and discharge
D. knee immobilizer
E. none of the above
A. arthrocentesis
A 35 year old woman presents complaining of left wrist pain for several months. She works as a waitress and has noticed increasing wrist pain associated with intermittent numbness and tingling of her thumb, index finger and long finger on the left hand. She states the pain is worse at night and after work. On exam she has tingling in her left thumb and first digit when her wrists are held in flexion for 60 seconds. This is a positive ____________ test and suggests the diagnosis of ______________.
A. Finkelstein test/De Quervain’s tendonitis
B. Phalen’s test/carpal tunnel syndrome
C. Phalen’s test/ulnar nerve compression
D. Tinel’s sign/carpal tunnel syndrome
E. Tinel’s sign/radial nerve compression
B. Phalen’s test/carpal tunnel syndrome
A nontoxic patient without trauma history, presents with 24 hours of a swollen and painful knee (which has never occurred in the past). Review of systems is negative except for the knee findings. A radiograph is taken (see Figure). With reference to the circled section of the Figure, which of the following is most likely true?
[image The figure depicts chondrocalcinosis]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving
A. Since the X-ray is pathognomonic, arthrocentesis is not indicated.
B. A knee immobilizer and Orthopedic follow-up are indicated, for a diagnosis of probable meniscal tear.
C. The patient has undergone total knee replacement.
D. Blood cultures will be positive.
E. The patient has pseudogout.
E. The patient has pseudogout.
The answer is E. The figure depicts chondrocalcinosis, which is most likely indicative of pseudogout. However, due to the possibility of co-existing infection, arthrocentesis is indicated to confirm the diagnosis and rule-out joint space infection. Blood cultures are not expected to be positive in pseudogout without infection, and in fact blood cultures are often negative even in the presence of a septic joint. There is no radiographic evidence of knee replacement, and meniscal tear is not commonly associated with radiographic findings.
Regarding the figure below, which of the following statements is true? [image]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving
A. A Salter-Harris V fracture occurs when there is compression of the bony area marked “C” towards the bony area marked “B”.
B. A Salter-Harris I fracture runs through the bony area marked “C”.
C. The area of bone indicated by “B” is the epiphysis.
D. A Salter-Harris IV fracture extends to the area of the bone indicated by “A”.
E. The area of bone indicated by “C” is the metaphysis.
A. A Salter-Harris V fracture occurs when there is compression of the bony area marked “C” towards the bony area marked “B”.
A 33 year old female presents to the ED with acute onset of pain in the right foot, first metatarsophalangeal joint. She had a renal transplant 10 years ago, and her only medication is cyclosporine. Regarding this patient’s condition, which of the following is true?
[image]
A. Inability to bear weight on the involved foot is a sign that the diagnosis is not gout, but rather a pathological fracture.
B. In about 80% of cases, podagra is accompanied by concomitant involvement of another joint.
C. Premenopausal females, compared to males of the same age, are more likely to develop gout.
D. Colchicine may result in symptomatic improvement in patients with either gout or pseudogout.
E. Though uric acid levels may be normal between gouty attacks, uric acid is virtually always elevated during an acute episode of gout.
D. Colchicine may result in symptomatic improvement in patients with either gout or pseudogout.
Recurrent cellulitis in the distal phalanx of the right thumb in a 32 year old carpenter who is otherwise healthy should prompt the ED physicians to perform:
A. Screening for Human Immunodeficiency Virus
B. Radiographic imaging for suspected retained foreign body
C. A deep, longitudinal 2-cm incision to explore the thumb for an abscess
D. Testing for diabetes mellitus
B. Radiographic imaging for suspected retained foreign body
All of the following are generally accepted indications for endotracheal intubation of the pediatric trauma patient, EXCEPT:
A. respiratory failure from hypoxia or hypoventilation
B. GCS score less than or equal 9, to secure airway and provide controlled hyperventilation
C. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function
D. any trauma patient in decompensated shock and resistant to initial fluid resuscitation
E. any inability to ventilate by bag-valve-mask methods or the need for prolonged control of the airway
C. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function
Regarding pediatric head injury, all the following are true EXCEPT:
A. Head trauma is the leading cause of death among injured children.
B. A child’s cranial vault is larger and heavier in proportion to its total body mass than an adult’s.
C. Pediatric epidural hematomas are venous in origin.
D. A brief seizure occurring immediately after the insult, with rapid return to normal level of consciousness is usually unassociated with intracranial parenchymal injury.
E. Retinal hemorrhages are a common finding in mild-moderate trauma.
E. Retinal hemorrhages are a common finding in mild-moderate trauma.
An 8 year old boy falls off his bike onto his outstretched hand with his elbow in extension. He presents to the emergency department with obvious anterior bowing of his distal humerus. His distal neurovascular exam is intact. The X-ray shows a transverse supracondylar humerus fracture with dorsal displacement and angulation of the distal fragment. Of the following, which is the most appropriate treatment?
A. Splinting the extremity in its current position, and arranging for orthopedic follow-up
B. Fracture reduction and casting by the E.D. physician
C. Orthopedic consultation for possible open reduction and internal fixation (ORIF)
D. CT scan of the elbow
E. Splinting and hospital admission for neurovascular checks
C. Orthopedic consultation for possible open reduction and internal fixation (ORIF)
A 7 year old boy falls off his bike onto his outstretched arm and sustains a supracondylar fracture. The fracture originates in the metaphysis and a portion of it extends into the physis (growth plate) without extending through to the epiphysis. How is this fracture classified? A. Salter I B. Salter II C. Salter III D. Salter IV E. Salter V
B. Salter II
A mother brings her 3 year old daughter into the emergency department for an arm injury. The mother was holding her hand to cross a busy street. She pulled hard on her daughter’s arm to hurry across the street and the child began to cry. Since the incident the child has kept her arm against her body in a slightly flexed and pronated position. She is tender over the radial head and refuses to move her elbow, but there is no swelling or ecchymosis. What is the most appropriate management for this girl?
A. Obtain immediate X-rays of the elbow to rule out fracture
B. Obtain immediate orthopaedic consult for presumed elbow dislocation
C. Apply pressure to the radial head while flexing and supinating elbow
D. Apply posterior elbow splint and follow-up with orthopedics within one day
E. Apply traction to elbow and splint under conscious sedation
C. Apply pressure to the radial head while flexing and supinating elbow
A 17 year old boy injured his right shoulder playing football. He tried to arm-tackle a player when his right arm was pulled away from his body and back (abducted and extended). He felt a sudden pain in his shoulder. He presents to the emergency department holding his arm in slight abduction and external rotation by his good arm. He has severe pain with adduction or internal rotation. What is the most common fracture associated with this injury?
A. Avulsion fracture of the greater tuberosity of the humerus
B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity)
C. Clavicle fracture
D. Acromioclavicular joint separation
E. Fracture of the anterior glenoid lip (Bankart’s fracture)
B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity)
What is the most common heart rhythm seen in pediatric arrest? A. Wolff-Parkinson-White syndrome B. ventricular fibrillation C. paroxysmal atrial tachycardia D. bradycardia E. atrial fibrillation
D. bradycardia
Which of the following factors in the fetus is NOT associated with an increased risk for neonatal resuscitation?
A. prematurity
B. alkalosis (as assessed via fetal scalp capillary monitoring)
C. multiple gestation
D. thick meconium in amniotic fluid
E. intrauterine growth failure
B. alkalosis (as assessed via fetal scalp capillary monitoring)
A 27 year old G2P1 female presents to the emergency department in labor at 41 weeks estimated gestational age. The amniotic sac breaks on admission and has thick, brown-tinted fluid. Prior to other steps in resuscitation, the newborn infant should:
A. be resuscitated with a bag-valve mask for 45 to 60 seconds.
B. receive 500,000u penicillin-G intramuscularly.
C. receive 8 mg doxycyline intravenously.
D. have his/her trachea suctioned.
E. be left unswaddled.
D. have his/her trachea suctioned.
The answer is D. In order to prevent aspiration of meconium, the infant should have his/her airway suctioned. (This recommendation is the standard of care at this time, but is becoming somewhat controversial. Some believe the introduction of the endotracheal tube may further contaminate the distal respiratory tract with meconium.) Using a bag-valve mask before suctioning could precipitate meconium aspiration. A dose of penicillin should not delay resuscitation. Doxycycline is contraindicated in patients younger than 8 years. Swaddling and placing of the newborn in an incubator helps to prevent hypothermia.
All of the following are true regarding chest compressions in the infant EXCEPT:
A. Chest compressions should be initiated whenever an infant’s heart rate is less than 60 bpm.
B. An appropriate position for performing chest compressions is to encircle the chest with both hands and place the thumbs side by side on the sternum.
C. Compressions should be performed at a rate of 90 per minute.
D. Chest compressions should be accompanied by a ventilatory rate of 30 per minute.
E. Correct depth of compressions is one-third the anteroposterior diameter of the chest.
A. Chest compressions should be initiated whenever an infant’s heart rate is less than 60 bpm.
