Free orthopedic injury board review questions sample from Med-Challenger.
Orthopedic injuries sprains and strains are common among patients with extremity trauma. Med-Challenger offers orthopedic injury review and other traumatic disorder review questions along with everything else to specialize in diagnosing and treating a variety of orthopedic injuries and conditions. More free orthopedic injuries review questions of the hand, elbow, knee, and shoulder can be accessed via this week’s Quick Quiz, and via free trial of the following specialty courses:
This week’s case-based question:
A 2-year-old boy is brought in for elbow pain and lack of elbow use after a fall off playground equipment onto his outstretched arm. The following x-rays are obtained (see Figures 1 and 2).
Which of the following statements is CORRECT?
The patient has radial head subluxation.
Radial nerve injury is the most common soft-tissue trauma associated with this injury.
The x-rays show 2 abnormalities that both indicate the presence of fracture.
The injury visible on the x-ray should be treated with a posterior splint, with the elbow flexed as tolerated and the forearm pronated.
And the answer is …
Correct Answer:The x-rays show 2 abnormalities that both indicate the presence of fracture.
Identify supracondylar fracture on x-ray in a pediatric patient.
Especially in children with greenstick fracture through the supracondylar area, the inconspicuous posterior fat-pad sign may be the only–and easily missed–radiographic clue to occult supracondylar fracture.
The lateral x-ray shows both nondisplaced supracondylar fracture and an (easily overlooked) posterior fat-pad sign. In this x-ray, the fracture itself is plainly visible, but the educational point is to notice the associated, faint posterior fat-pad sign. Incidentally, this patient’s lateral x-ray also shows a very faint anterior fat-pad sign and abnormal anterior humeral line. The anteroposterior x-ray just shows the supracondylar fracture.
Nondisplaced supracondylar fractures can be splinted in a posterior splint at 90-degree elbow flexion and with the forearm in a neutral position (thumb pointing up). Typically, protected range-of-motion exercises are started within 3 weeks. Nondisplaced supracondylar fractures tend to heal uneventfully, although associated soft-tissue swelling can lead to neurovascular compromise and ischemic Volkmann contracture. To prevent this devastating complication, this fracture requires careful patient and caretaker education (and documentation of that education) about signs of neurovascular compromise.
In nondisplaced supracondylar fractures, the radial nerve is not at any higher risk for injury than the other neurovascular structures.
Beware that the posterior fat-pad sign may also indicate the presence of an occult radial head fracture.
The mnemonic CRITOE helps with memorizing the ossification “schedule” of the pediatric elbow:
R: Radial head
I: Internal (medial) epicondyle
E: External (lateral) epicondyle
The general rule of thumb for the time of appearance of the ossification centers is “1-3-5-7-9-11,” which are roughly the ages in years (≤ 1 year later in boys) that the ossification centers appear, corresponding to CRITOE. In the patient in this case, the capitellum has begun ossification and appears as a round ball in line with the radial head.
Bookman K. Humerus and elbow. In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 530-548.e1.
Smithuis R. Elbow – fractures in children. Accessed March 21, 2018.
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