HPI - 45 y/o male with elbow pain after a fall.
How would you treat this patient?
HPI - One month history of pain in the right thigh, increasing in intensity.
No weight loss, no fever.
What is the most likely diagnosis?
HPI - Simple fall on the ground 3 months ago
Analgesics and bed rest since that time
What further investigations would you order in this patient?
HPI - Initial trauma was 3 months ago. Patient was not treated properly because she was in a remote area. Partial weight bearing starting 1 week after the trauma. Full weight bearing now.
How would you manage this patient given she is now 3 months from the injury?
HPI - Fall from stairs 3 days ago.
What classification is this fracture?
HPI - While walking the patient twists her ankle and had a bimaleolar ankle fracture 6 months ago. The fracture was treated with ORIF 3 weeks after the fracture (XRays shown). She progressed well until 2 months ago when she notes heel deformity and ankle swelling.
What is your diagnosis?
HPI - The patient was alright 8 months ago when she gradually started to develop pain in her right leg below the knee which was sudden in onset, persistent in nature, non-radiating, worse at night, relieved with painkillers and aggravated by activity.
The pain progressive over the period of 8 months associated with swelling which appeared 4 months later below the knee, gradually increased in size, no discharge or redness.
No history of trauma, joint pains, backache, morning stiffness, swelling of 1st MTP, swelling in neck, blood in sputum, flank pains, blood in urine, dark coloured stools, fever or weight loss.
How would you manage this patient?
HPI - The condition started 6 months ago by pain in both hips during exercise that gradually increased and affected her performance. This pain improved with rest and analgesics and reccurs with activity. Not present at rest or during sleep.
Would you obtain addition imaging studies in this patient?
HPI - A 71-year-old female presents with pain and swelling in the wrist and forearm after a ground-level fall 2 days ago. She was initially treated with closed reduction and cast immobilization. Radiographs are shown before and after reduction.
How would you treat this fracture based on the post-reduction radiographs?
HPI - A 25-year-old male presents at his general practitioner with a 3-day history of left knee pain and swelling, mainly on the anterior/medial aspect of the joint. This presentation is part of a series of self-limiting episodes, that have started since he sustained an injury (single leg landing) during a football match. At the time he was assessed in A&E with no abnormalities on physical exam and plain radiographs
Would you attempt ACL reconstruction a year after the original injury if the patient reports minimal effects in his activities of daily living?
HPI - 2 w ago patient felt intense (10/10) left knee pain while playing football without any obvious injury. Localized tender edema developed on his left upper tibila metaphysis on the medial side. After a short oral NSAID regimen and ice application his pain subsided almost completely (2/10). He underwent CT and MRI (+IV paramagnetic agent) examination
What is your opinion on cruciate ligaments integrity based on 02-21-2018 MRI sequences?
HPI - A right knee injury occurred while running hurdles. He experienced immediate pain and swelling along with right foot numbness and weakness. An obvious knee deformity was recognized.The patient was transferred by ambulance to the local emergency room.
What would you do first in the ER?
HPI - A 54-year-old female presents pain and swelling in the wrist and forearm after a ground-level fall 7 days ago. She was initially treated with closed reduction and cast immobilization. Radiographs are shown before and after reduction.
How would you treat this fracture based on the post-reduction radiographs?
HPI - Fall from height
HPI - Fall on bent knee
Would you order further imaging in this patient?
HPI - The patient is an 18-year-old male high school football player (position: offensive line) who is 18 months s/p RIGHT ACL reconstruction with an ipsilateral BTB autograft who injured his RIGHT knee while playing football.
The mechanism of injury was an opposing player landing on the outside of his leg, resulting in a valgus-type, twisting knee injury. The patient was unable to bear weight following the injury and was carted off the field.
Examination on the sideline immediately following the injury revealed a positive Lachman's and a grossly positive valgus stress test with the knee in full extension.
An MRI revealed complete rupture of the ACL graft and a grade 3 (complete) tear of the MCL.
Initial management included a hinged knee brace for 8 weeks in an attempt to treat the MCL tear conservatively.
At 8 weeks post-injury, valgus-stress radiographs (XRays shown) showed:
Medial grapping LEFT knee = 7mm
Medial gapping RIGHT knee = 15mm
A CT scan was also done to assess for osteolysis of the tunnels. Maximum tunnel diameters are 13mm (femoral tunnel) and 14mm (tibial tunnel). The position of the femoral and tibial tunnels looks adequate.
Full-length standing XRays show neutral alignment.
An MRI one day after injury reveals a complete rupture of the ACL graft and a grade 3 MCL tear, no meniscal pathology. What is your initial management of this patient?
HPI - A left knee injury occurred during a football game when he jumped over an opposing player and landed with a valgus twisting force to his left knee. He felt a pop and experienced immediate pain and swelling.
Radiographs, MRI images & arthroscopy photos are shown.
What would be your definitive management for this patient? (See arthroscopic view of meniscal tear below)
HPI - Left knee injury six years ago playing basketball, but did not seek medical attention. He continued to play basketball & volleyball despite numerous giving way episodes. He presents with pain, swelling and the feeling of instability. No specific treatment to date.
Radiographs and MRI images are shown.
At this time, how would you manage this patient?
HPI - The patient suffered a comminuted humeral shaft fracture 9 months ago which was neglected. He presents now with pain and loss of function in his arm.
How would you manage this patient at this point?
HPI - Heavy weight injury 18 days ago, immediate pain, swelling ; diagnosed with left ankle fracture.
Is this a case of a simple lateral malleolus fracture?
HPI - Twisting injury to the hand
How would you manage this fracture?
HPI - Driver of a bike who hit a car and fell on the road
What do you think of the reduction of this fracture?
HPI - Motorcycle vs. car; immediate pain, swelling and deformity; diagnosed with right ankle fracture.
What Lauge-Hansen type of ankle fracture is this case?
HPI - History of fall down on left wrist one month ago.
The patient is neurovascular intact. The fracture was an open fracture (type 1) with a small wound on the volar aspect of the distal ulna. At the time of the injury, this was treated operatively with irrigation and debridement and placement of an ex-fix spanning the fractures.
Currently, the wound has healed. There is no sign of infection.
CRP and ESR are normal. XRays are shown.
How would you manage this patient at this time?
HPI - Frail 84F. Admitted with LRTI. Fall on medical ward sustaining Grade 1 Open Periprosthetic Tibial Shaft Fracture. Fracture around tip of stem of long stem revision TKR. Revision TKR is Depuy LPS Distal Femoral Replacement with MBT Tibial Tray and Stem. This was implanted 7 years ago for failed distal femoral fracture fixation. Wound was debrided and closed day after injury. Currently in backslab. Referred on for further management. Apologies for poor quality images.
HPI - Symptoms started 2.5 years ago. History as below:
1) 01/2015: Pain at Right Ankle. No history of trauma. MRI: Bone marrow edema of Right Calcaneus. Non-weight bearing improved the clinical symptoms.
2) 10/2015: Pain at Right Hip. No history of Trauma. MRI: Bone marrow edema of Right Hip (Femoral head and small bone marrow edema of acetabulum). Non-weight bearing improved the symptoms.
3) 06/2016: Pain at Left Ankle. No history of trauma. MRI (Both ankles): Bone marrow edema of Left Calcaneus. No Bone marrow edema in Right Ankle.
4) 09/2016: Pain at Right Ankle. No history of trauma. MRI (on both ankles, images attached).
MRI(Right Ankle): Bone marrow edema of Cuboid, Base of 2nd metatarsal and medial cuneiform bone.
MRI(Left Ankle): Bone marrow edema of Cuboid, Middle & Medial cuneiform bones, base of 2nd and 4th metatarsal bone. Osteochondral dissecans of talar dome.
Non-weight bearing improved the symptoms.
5) 12/2017: Pain at Right ankle. No history of trauma. MRI of Right Ankle (images attached): Bone marrow edema of distal/metaphysis & epiphysis of right tibia.
CBC, Glucose, Urea, Creatinine, HDL, LDL, SGOT, SGPT, ALP, Fe, Ca, P, LDH, K, Na, PT, aPTT, d-dimers, TSH, FT4, CRP, ESR, Ra-Test, C3, C4, Anti-CCP, ANA, ACA-G/M, β2 GPI IgG/IgM: ALL NORMAL VALUES
What's your opinion? What's next in lab test/imaging/differential diagnosis?
HPI - Traffic accident resulting in an injury to the right knee and ankle.
What is your preferred management of the Pilon fracture?
HPI - The patient had a right hip arthroscopy 5 years ago that included a femoral head re-contouring, os acetabuli resection, and labral reconstruction. Patient has had persistent pain and stiffness ever since that limits his ability to walk distances.
HPI - Fell while hiking 9 days ago; immediate pain, swelling and deformity; went to outside hospital and diagnosed with right ankle fracture.
How would you have addressed the syndesmosis in this patient?
Which approach do you prefer for the fracture of the radius ?
HPI - 50M, RHD.
Known history of rotator cuff tear about 2 years ago.
History of 3 prior right shoulder surgeries (? RCR).
History of successful RCR on opposite (left) shoulder >1.5 years ago.
+ painful ADLS, + night pain, + pain with overhead activities.
Difficulty raising his right arm in forward flexion and abduction. Significant weakness.
HPI - 45-year-old male with severe ankle pain following nonoperative treatment of ankle fracture when he was 23 years old. Patient has received cortisone injections, stem cell treatments, and has used a brace on/off for the last 2 years
Would you try additional nonoperative treatment modalities in this patient?
HPI - An 18 year old male presents for follow-up 6 months after suffering a transverse femur fracture in a motorcycle accident. He was treated with an external fixator as he was diagnosed with a pulmonary embolism soon after his admission.
HPI - A 34 year old healthy, active female presents to clinic on crutches after a fall yesterday where she injured her ankle. She has no significant past medical history. She is otherwise healthy.
Would you order additional imaging in this patient?
HPI - RHD female who complains of elbow pain after falling off her bike onto her left elbow
Assuming you only had the injury radiographs, what additional imaging would you obtain in this patient?
HPI - Active patient, denies trauma, bilateral painless hallux valgus deformity since adolescence, no associated neuromuscular conditions, shoe modifications have failed to provide relief
Which foot would you operate on?
HPI - 50 year old, right-handed female patient suffered from trauma one year ago. The patient sought medical advice and was told that she had a scaphoid fracture that required fixation. The patient refused surgery and a cast was applied for two months.
What additional imaging would you order in this patient?
HPI - Injury occurred two day ago - crush injury to the big toe.
What is your treatment plan for this patient?
HPI - 6 months hx of postoperative ankle pain
If there is evidence of infection, what is the best choice of treatment for this case?
HPI - Patient complains of chronic pain at the lateral side of the foot. The pain is somewhat relieved by NSAIDs then reoccurs.
What is the diagnosis?
HPI - Right sided ankle pain increased during ambulation after failed open reduction internal fixation (ORIF) of a tibial plafond fracture (AO classification 43-B)
What is the best initial management for this case?
HPI - Right knee and leg pain with swelling after a heavy object fell directly onto the right lower limb
What is the best definitive fixation for this patient's injuries?
HPI - Run over accident, non-compliant patient who does not speak English
HPI - -Multiple discharging sinuses from distal thigh 1 year ago, healed after debridement and dressings.
- Presently has deformity of the knee with painful gait
HPI - Machine twist and injury right forearm
How would you manage this patient at this point?
HPI - Injury while playing football.
What is the fracture mechanism according to Lauge-Hansen Classification?
HPI - Trip and fall whilst hiking
How would you treat this injury?
HPI - Pain and deformity of the right hip/proximal femur.
The patient underwent a cephalomedullary nailing of the fracture shown. Intra-op and post-op XRays are shown.
Is this a nonunion?
HPI - FEB 2017 TRAUMA:
TYPE AO B3 CLOSED PILON FRACTURE.
FIBULA AND SYNDESMOSIS INTACT.
HIGH ARTICULAR DAMAGE ON THE CENTRAL/ANTERIOR TIBIAL SIDE.
AVULSION FRACTURE OF THE CALCANEAL TUBEROSITY.
HPI - 20 male patient presents following a segmented tibial fracture, sustained in a motorcycle accident 1 year ago.
The fracture was treated with ORIF with plate and screws at another institution (XRays shown).
The patient had skin problems with exposed plate at approximately 8 months post-op
I removed the plates on the tibia and one fibula plate for dynamization and I used a monolateral external fixator.
Now, the skin and bone look like this after 2 months due to surgery.
How would you suggest managing this patient?