HPI - Pain in the upper leg for the past 10 days, severe pain which increases with activity, not relieved by rest.
History of fracture 2.5 years ago for which surgery was done (at an outside hospital) and recovery was quite uneventful.
Patient now has suddenly developed this problem.
What is the next best step in management?
HPI - Road traffic accident.
Isolated leg trauma.
What is best treatment option for this patient?
HPI - Fall on outstretched hand.
No history of dislocation at the time of injury.
How would you manage this injury?
HPI - A 2 year old girl presented with abnormal gait - her initial XRays are shown.
She underwent open reduction of the LEFT hip after the diagnosis of DDH was made (at age 2).
Follow-up Xrays are shown below, which illustrate osteonecrosis of the left hip following open reduction.
The patient is relatively asymptomatic with normal gait following open reduction of the left hip.
She is currently 3 years old.
How would you treat this child?
HPI - Patient underwent surgery 2 years ago after falling while playing soccer. He suffered a comminuted diaphyseal radial shaft fracture, treated with open reduction and internal fixation with 2 K-wires.
How would you manage this patient?
HPI - Fall and injury to left ankle
Is the closed reduction acceptable?
HPI - Fell at home onto his left side. Inability to ambulate following the fall.
Is this closed reduction and fixation acceptable?
HPI - Back pain of 1 year's duration. Recently worse.
HPI - 7 year old male patient. Presented with history of supracondylar fracture of Left elbow 5 months ago. ORIF was performed and removal of K-wires done after 2 months. Physiotherapy done after surgery, but with little benefit and minimal improvement of ROM.
How can we obtain better elbow motion for this patient?
HPI - 90F, fall from standing height after slipping walking in her own house. Pain in right groin and unable to straight leg raise.
What should have been the initial management for the basicervical femur fracture?
HPI - Fall from a 2m high wall
What approach or combination of approaches would you use to treat this injury?
HPI - Fall whilst intoxicated
Underwent ORIF fibula by another surgeon on day on injury in attempt to get the limb out to length - complexity of fibula fracture resulted in approx. 1.5cm shortening and malrotation.
Would you plan to re-reduce and fix the fibula as part of your definitive management?
HPI - Bad landing on right knee
How would you treat this injury? (Patient has a very promising sports career in front of him)
HPI - Distal humerus fracture following an arm wrestling injury.
The patient underwent ORIF of the fracture - images are shown, both intra-op and at 4 weeks after ORIF.
Was the initial operative management (ORIF) appropriate for this patient?
HPI - Right wrist pain following a fall on outstretched hand while travelling on a motor bike 3 days ago
What is the diagnosis?
HPI - Patient suffered from a trauma 3 months ago. First, the parents went to an alternative medical center. 2 months after the trauma, patient presented to the hospital for assessment.
Would you order a CT-scan?
HPI - 36 year old, Afro-Caribbean, athletic build, in open prison at the moment.
Pain in R knee for 2-3 years. medial-sided, No sickle cell.
XRay and MRI attached.
What is your surgical management?
HPI - Factory worker, 3 year history of medial-sided knee pain, previous knee arthroscopy, and debridement of MM and MFC defect which got progressively worse.
What is your surgical management of this patient's knee pain?
HPI - A 7 year old boy presents after an aggressive reduction of a distal radius fracture more than 6 months ago.
The final XRay of the wrist and carpal bones is shown.
What is the best treatment for this patient?
HPI - LEFT arm wresting injury
What is the most common site of humeral shaft fracture in an arm wresting injury?
HPI - 57yo woman who had an XRays of her Left knee for the diagnosis of knee arthritis.
Incidental finding on the XRay was a tumor of the fibula head.
How would you manage this lesion?
HPI - Pain and swelling in LEFT wrist - patient cannot remember any history of trauma
What is the best treatment of this injury?
HPI - Injury to left leg with a grinder wheel.
HPI - The condition started six months ago after a minor twisting injury and XRays confirmed a pathologic fracture through a bone cyst in the proximal femur. The fracture was treated conservatively and completely united but the cyst persisted.
What other investigations are needed?
HPI - A 57 year old patient presented to ER with a 1-day history of right elbow posterior erythema and warmth on 27/02/2017.
Diagnosis: septic olecranon bursitis. Oral antibiotic prescribed.
The second day (28/02/2017). More warmth and erythema with pain and fever. Went back to the ER again.
An incision was made at the tip of olecranon and drained 5mL yellow liquid, sent to lab for analysis.
Lab report: Gram-positive coccus seen. Continue oral antibiotics and went home.
The third day(1/03/2017), more pain with high fever, the olecranon and the whole forearm swollen, erythema and warmth. The patient presented to Orthopaedic Clinic.
Surgical debridement and bursa excision was done. Intra-op found a lot of white spots as shown in the pictures.
The patient's general condition and arm condition got better quickly post-operatively.
Intra-op tissue pathology result showed: septic bursitis
The post-op diagnosis: septic bursitis + pseudogout?
Post-op oral antibiotics and Colchicine were prescribed.
However, pt had wound nonunion with liquid drainage. Liquid sent to lab twice: no bacteria, normal WBC, no sign of infection.
HPI - A 14 year old patient present after she had idiopathic left humeral head and shaft avascular necrosis (AVN) 6 years ago. At that stage, a fibular autograft was used to treat the AVN and fixed with a flexible nail.
After a period of time, the grafted bone underwent AVN again.
No neurological deficit, distal pulses normal.
What is the next treatment option?
HPI - 2 year old boy, fell off a two wheeler, was brought in by parents with complaints of not moving the right upper limb. No other significant injuries
How would you manage this fracture?
HPI - Patient felt a mass about 6 months ago in her left gluteal area. Diagnostic work-up with Ultrasound, CT and MRI lead to biopsy with extraosseous pleomorphic sarcoma as the result of histology. Patient is currently status post resection of the tumor, mobilised with a G apparatus. Feels instability and pain in the area of the resection.
Is reconstruction of pelvic ring warranted and if so, what kind?
HPI - Fell from height at a construction site injuring his right ankle
How would you treat the distal fibula fracture?
HPI - A 65 year old man present to ER after a fall from 8 meters, injuring his wrist.
Would you order a CT scan to further evaluate the fracture?
HPI - A 34 year old male patient presented for assessment with ongoing left knee pain. He is an avid runner and triathlete and notes that he has been unable to run longer distances over the past 3-4 months due to ongoing pain in the medial aspect of his left knee. He does not recall any associated trauma to the affected knee; his pain has come on insidiously over the past few months and has escalated in severity.
Xrays, Standing Alignment Views, MRI, and arthroscopic images are shown.
The medial femoral condyle demonstrates a full-thickness cartilage defect in the weightbearing portion measuring 18mm AP dimension by 16mm transverse dimension.
Mild degree of chondromalacia in the anterior femur intercondylar region.
No meniscal pathology.
All ligaments intact.
Moderate effusion and debris suggestive of cartilaginous fragments.
After primary arthroscopy revealed the Grade 4 cartilage lesion of the medial femoral condyle, how would you manage this patient?
HPI - Fainted and fell with inability to move her left hip following the fall.
What is the best treatment option for this patient's fracture?
HPI - Sustained a fall from height in December 2015 for which he was operated on with a DHS. Was made to weight bearing as tolerated after 2 months after which he had pain and shortening. At present, he is walking with a single crutch.
How would you manage this patient at this stage?
HPI - 16 year old patient presents following open forearm fracture of the ulna, fixed with ulnar ORIF and skin graft, 10 months ago.
The fixation has become infected and appears that the union is not complete. Wound discharge has been present for 3 weeks.
No pain, good function of hand.
Extension at wrist causes flexion of the finger at PIP and DIP joints.
HPI - 54 yo non-smoker, relatively healthy host who is 2 years out from open distal tibia fracture treated IMN with five months of “wound vac” for open wound by private doc in town. After her insurance ran out he stopped seeing her despite having a vac on. She came to us and plastics performed a rotational fasciocutaneous flap which allowed her wound to heal. At two years she had continued pain and broken nail hardware distally with CT proven nonunion with negative laboratory workup for infection (ESR, CRP, WBC). Her wound was healed and has had no drainage after the plastics flap. See X-rays and representative CT scan below.
Surgical plan for this patient's nonunion?
HPI - 24 year old female presents to ER following a motor vehicle accident. She is unable to move her leg or bear weight secondary to pain.
In addition to immediate I&D, how would you manage this patient?
HPI - Direct trauma to the upper leg
What is the Schatzker classification for this injury?
HPI - 8 weeks ago, patient suffered high energy injury as a front-seat passenger involved in a traffic accident (dashboard injury). He sustained a closed femoral shaft fracture (type 32-A3). Reamed IM nailing was performed three days after the injury.
What should be done at this point to manage this patient's problem?
HPI - Closed reduction and internal fixation done 1yr back with pfna2
What should be done
HPI - Direct trauma at work by saw. Laceration tibialis anterior/EHL/EDL with neurovascular bundle preserved.
Internal degloving up to medial malleolus with small saw cut in lateral tibia.
Once the soft tissue swelling has reduced to an appropriate level and the skin openings have healed, in addition to ORIF of the medial malleolus, how would you manage the fibula fracture?
HPI - 36 year old female previously presented with a history of left hip pain 3 years ago with a lytic lesion in the left intertrochantric area. She was operated on with a fixed angle plate, bone graft and biopsy.
8 months ago removal of implant was done and attached is X-Ray post removal and result of histopathology.
1 month ago, patient presented with progressive left hip pain and X-Ray is shown with a recurrent lytic lesion with extension to the femoral neck.
What is the best option of treatment?
HPI - Neglected trauma to right wrist 15 months ago.
HPI - 03/2016 Patient underwent osteosynthesis of a tibial shaft fracture with intramedullary (IM) nail. The was complicated by post-operative compartment syndrome with fasciotomy, negative pressure wound therapy.
The patient developed a post-operative peroneal nerve palsy and required intensive rehabilitation.
Present condition good with full range of motion, without subjective problems, minimal pain, full restoration of nerve function.
Present X-ray and CT imaging with signs of pseudarthrosis of the fracture. CT and X-ray are shown. progressive osteoporosis !!!!
How would you treat this pseudarthrosis?
HPI - 66yo F with psych history jumped off approx 12 foot bridge landing on frozen river.
What approach would you use in this case?
HPI - RTA - 2 wheeler rider collided with a stationary vehicle - closed fracture of the left clavicle, scapula and left multiple rib fractures with haemopneumothorax - haemodynamically stable.
Normal neurovascular examination of the upper limb. Other injuries - L3 wedge #, Left iliac crest fracture.
How would you manage the scapular fracture?
HPI - Pain in wrist for more than 1 year. No history of trauma.
What is the likely diagnosis?
HPI - 46yo F in MVC. Presents with severe head injury, thoracic injury and deformity to left hip/thigh.
How would you classify this acetabular fracture pattern?
HPI - A 41 year old male presents with complaints of pain, limited ROM, and instability of his left knee.
The patient states that he was kicked in the knee a few months ago and developed pain in the medial compartment. He had no complaints of pain in his knee before this traumatic episode.
In August, 2016 he underwent left knee arthroscopy - torn meniscus.
In September, 2016 - re-arthroscopy - revealed a medial meniscal flap.
HPI - This patient had a fall and sustained a lateral condyle fracture which was treated in a peripheral hospital with cast immobilization.
She is now 14 months post injury.
No ulnar nerve symptoms at the moment.
Her primary complaint is a significant elbow deformity.
How would address this problem surgically?
HPI - The patient underwent a THA 15 months ago at an outside location. Since then he feels pain on the lateral aspect of his hip (greater trochanter area).
His blood results:
CRP: 12.6 mg/dl in November 2016 and 9.9 mg/dl in January 2017.
ESR: 22 mm/h in November 2016 and 21 mm/h in January 2017.
Do you believe this is a prosthetic joint infection?