HPI - A 23 year old male patient presented to ER after a RTA where he injured his left ankle.
Patient was non-weight bearing. Severe left ankle pain, swelling, and limited ROM.
Would you order a CT scan for this patient?
HPI - Patient sustained a fall on an outstretched hand in July of 2016 (approximately 6 months ago), injuring his left elbow.
The patient had primary care in another hospital, with routine XRays of the elbow ruling out a fracture. He was treated with an above-elbow splint for 5 weeks, followed by rehabilitation.
He now presents to our clinic with left elbow deformity, pain, loss of motion and function, and a feeling of instability.
Would you order additional diagnostic studies in this patient?
HPI - History of recent numbness of the 2nd and 3rd finger of the left hand of 14 days duration, associated with mild neck pain.
What is the diagnosis?
HPI - The patient has congenital hip disease in both hips (right Hartofilakidis C2, left Hartofilakidis C1). Over the past 2 years she reports progressive right knee pain that is now unresponsive to conservative treatment. She walks with a cane.
How would you treat this patient?
HPI - I had done a TKR yesterday and the patient was on an epidural infusion for pain management. 6 hrs post-op, when she was unattended she got up (patient claims to have heard a knock at her room door and wanted to open the door - patient had been drowsy due to the epidural which had a mixture of local anaesthetic and narcotic) from the bed and buckled down with the knee hyperflexed and was on the floor. She had wound dehiscence and I took her to theatre immediately following the fall.
Intra-operatively, I found full thickness dehiscence and MCL substance tear close to tibial insertion was noted. The medial parapatellar tissues were partly ripped and friable. I performed an MCL repair. Since we don't stock implants, there was no chance I could go for a revision to a constrained prosthesis. I was not prepared to wait for a day leaving the wound open and at risk of an infection. I've applied a knee brace.
What is your post-op rehab protocol in this situation?
HPI - 58 yo female with progressive left hip pain and limp for 6 months. No history of trauma or other predisposing factors. No prior treatment.
What is the best treatment for this patient?
HPI - An 80 year old male patient presents with new onset right hip pain.
The patient sustained a right hip subtrochanteric fracture in February 2015 and underwent fixation with a short gamma nail. A follow-up X-ray showed no evidence of callus formation. Full weight bearing as tolerated started 2 months after the index surgery.
The patient presented in January 2017 with right hip pain; X-rays are shown.
How would you manage this patient?
HPI - Patient presents to the emergency room with acute left knee pain after low energy trauma.
Would you perform a needle biopsy in this patient prior to surgical intervention to confirm the diagnosis?
HPI - Presented in ER with complaint of left elbow pain after RTA.
What is the best treatment option for this complex elbow fracture-dislocation?
HPI - The patient presented to ER after RTA with Left hip pain
What is your preferred approach for ORIF of this fracture?
HPI - RTA victim
How would you choose to manage this fracture?
HPI - A 58 year old male presents with pain, swelling, and inability to weight bear without support due to complications associated with a left femur fracture.
His initial surgery was 14 years ago, which was in the form of an IM Nail which was complicated by infection 3-4 months following surgery. This was treated with nail removal, debridement, local vancomycin-impregnated cement beads, IV antibiotics, and placement of the current femoral locking plate that remains in situ.
How would you mange this patient at this point?
HPI - A 39 year old female patient presents status post-MVA 10 months ago where she suffered a right femur fracture. This was treated with a intramedullary nail (Xrays shown).
History of suspected infection with +ve CRP, mild fever, and thigh pain with swelling 3 weeks post-operatively which was treated with antibiotics, no surgical debridement was done.
No history of wound discharge, or discharging sinus.
Patient presented to me 4 weeks ago with pain at fracture site. CRP was 1/24, now its 1/12 after 4 weeks of oral empirical antibiotics administration
Update: CRP is -ve now
HPI - RTA
How would you definitively treat this injury?
HPI - motor vehicle accident
HPI - A 17 year old male presented to sports clinic for assessment after twisting his ankle while playing soccer two days earlier. Prior to this recent episode, his ankle was completely asymptomatic.
XRays were taken, which revealed an OCD lesion of the medial talar dome. He was referred for an MRI. Images are shown.
How would you manage this patient's OCD lesion?
HPI - A 74 year old female patient known to have HTN, DM, CAD, hyperthyroidism, osteoporosis and PVD S/P left below knee amputation is admitted to CCU because of diarrhea and decreased PO intake.
The patient's family reports decreased PO intake and generalized fatigue of several days duration associated with colicky abdominal pain and watery non-bloody, non-mucoisy diarrhea. The patient reports chills but no documented fever.
During her stay in ER, the patient fell down and had trauma to her leg and face. A CT brain showed only a superficial hematoma, with no other pathology.
The patient is ambulatory with a BKA prosthesis while at home doing only her activities of daily living.
The patient underwent cardiac catheterization during this admission which showed 80% stenosis in LAD, 90% stenosis in circumflex artery, 90% stenosis in right coronary artery.
Knowing her high cardiac risk for operative treatment, what is the best method of management for her fracture?
HPI - A 68 year old female who works as a house wife presents with a history of backache and lower back pain that started 3 months ago.
The pain started gradually with an insidious onset but progressed in nature. In the beginning, the pain was worse with long standing and walking with no radiculopathy. It was relieved with analgesic medications.
Later on, approximately 1 month ago, the pain became more severe, radiated to left leg and associated with paraesthesia at the level of L4,5 and present while lying in bed at night. The pain was associated with a feeling of weakness, weight loss, and poor appetite. The patient has not had a clear fever. Currently, the pain is not controlled with analgesic medications (including tramadol).
HPI - 20 year old male presents with finger pain after a fall on outstretched hand. Closed injury. XRays are shown.
Is the current position of the fracture acceptable?
HPI - Traumatic paraplegia at T4 level (ASIA A) 12 years ago with progressive spasticity and difficulty with hygiene since the injury.
HPI - A 50 year old female patient presents with insidious onset of pain over the lateral aspect of her left elbow and forearm, which has started radiating down to the left hand.
Her symptoms started 10 days ago. The pain was initially aggravated with activity and relieved with rest. More recently, the pain has persisted even at rest and is increased with activity involving extension of the wrist and elbow as well as shoulder abduction.
She is currently unable to lift a small amount of weight secondary to pain. There was no gross weakness of wrist or finger extension.
What is the likely diagnosis?
HPI - 35 year old patient presents with new onset Left hip pain after a fall at home. He previously underwent ORIF with a 95 degree condylar screw and plate construct for a traumatic proximal femur fracture.
Was the management of this patient's initial fracture adequate?
HPI - 68 year old male patient presents with the chief complaint of bilateral hip and sacral pain. He has bilateral lower extremity paralysis since the age of ~20 after receiving the rabies vaccination. He is admitted for management of a grade 4 pressure ulcer of the sacrum.
What is the underlying diagnosis?
HPI - 40 year old male presents with an ongoing history of right knee pain. He describes a 2 year history of aching knee pain that has recently gotten worse after injuring his knee while lifting a heavy object at work. He works as a general laborer in a warehouse. He does not describe any mechanical symptoms related to the knee (no clicking, catching, popping, or locking). His MRI does not reveal a meniscal tear. He isolates his pain to the medial aspect of his knee.
HPI - Proximal humerus fracture 6 months ago, operated on overseas (open reduction, internal fixation) Progressive pain and disability after initial improvement. Complete skin closure, no history of wound complications or infection. Normal WBC, ESR, and CRP.
What additional imaging, if any, would you order?
HPI - A 67 year old patient presents complaining of a 1 year history of pain in his right knee. The pain is aggravated with walking and other activity. He notices an audible click and swelling around the right knee. The patient is 5 years status post a TKA in the same knee.
What is the most probable diagnosis?
HPI - Ankle fracture 9/12 ago.
1st operation 9/12 ago at another institution.
Re-operation 6/12 ago with ex-fix, deltoid ligament reconstruction and syndesmosis screw at a different institution.
Patient presents with persistent pain on ambulation, ESR CRP normal, no neurovascular deficit.
HPI - 48 year old man who fell 10 feet from a ladder while painting his house.
Calcaneus fractures in patients who smoke:
HPI - The patient is a 52 year old man who works as a landscaper. He fell on the job sustaining a twisting injury to his ankle.
Is the medial clear space increased with the original external rotation stress?
HPI - 60 year old woman (nurse) status post motor vehicle accident.
Are XRays enough to determine whether or not a posterior malleolus fracture requires fixation?
HPI - A 33 year old male patient presents with a 4 year history of pain over the tibial tubercle of his right knee.
The patient works in construction as a general laborer and states that his pain has become much worse over the past few weeks.
What further imaging, if any, would you order on this patient?
HPI - 20 year old college football player with "mild" right midfoot pain after being tackled 3 days ago. The other player landed on the back of his foot. MRI was read by the University radiologist as a "partial Lisfranc ligament tear." He states that he feels better and wants to resume play immediately.
With a negative stress image obtained in the office, how would you treat this patient?
HPI - 33F presents 4 months after an MVA where she suffered a thoracic spine fracture-dislocation. NO neurologic deficit.
The patient stayed in a poor small city hospital for 4 months waiting to be transferred to a spine center. She came to our institution walking, with no neuro deficits.
HPI - 5 y/o male patient is brought in with progressive scoliosis. Diagnosis of spondyloepiphyseal dysplasia (SED) is confirmed by genetics.
HPI - A 30 year old male patient presents with the chief complaint of limited abduction of his right arm after a fall approximately 10 weeks ago.
At the time of the fall, the patient was admitted to the ER and treated as an anterior shoulder dislocation with a greater tuberosity fracture. The dislocation was reduced at time of the injury by the ER staff and the patient was advised to keep his right arm in a sling.
He presents to clinic seeking for medical advise about his condition whith the primary complaint of a limitation of abduction to approximately 80 degree .
HPI - A 22F patient presents with a prominent deformity of her spine.
She states that she has had idiopathic scoliosis since age 12, with no management (bracing or surgery) up to this point.
HPI - A 30 year old male presents with sudden onset of severe pain at the back of his right knee followed by swelling and painful range of motion after lifting a heavy object 5 days ago,
He was initially prescriped an NSAID which has not provided much relief of his symptoms.
What is your working diagnosis?
HPI - A 18 year old male patient presents with left knee pain.
He suffered trauma to his left knee 1 year ago in an explosion that caused a tibial plateau fracture and extensive burns around the lateral aspect of his left knee and left thigh.
He was treated with an Ilizarov external fixator that left this valgus deformity and a loss of knee ROM.
Physiotherapy has helped the patient gain knee ROM from 0 degrees extension to 70 degrees flexion.
Prior to management, would you order a CT scan of this patient's left knee?
HPI - A 9 year old boy is brought in by his parents with asymmetry and tilting of his head since birth.
When evaluating a patient with Sprengel deformity, what imaging is required?
HPI - A 70 year old patient presents with the primary complaint of ongoing left knee pain that has been getting worse over the past 12 months.
The patient states that she has ambulated with a limp since childhood, but has never had surgery or any other treatment up to this point.
She states that she has been taking NSAIDs for the past 12 months which are no longer providing any relief of her knee pain.
She is now having difficulty ambulating due to the pain and has recently started using a cane for support and relief.
HPI - 29 year old male with laceration to volar distal forearm from breaking glass with arm.
When examining the nerve ends after a traumatic laceration, how do you determine if there is healthy nerve tissue on each end of the nerve?
HPI - 52-year-old female presents with left wrist pain since a fall at work 4 months ago.
The pain is exacerbated by extremes of motion.
Associated with wrist clicking in extension.
Prior to referral to a hand specialist a trial of nonoperative treatment was attempted but did not lead to significant improvement.
After a period of several months of nonoperative treatment patient continued with pain and mechanical clicking during wrist motion & gripping
What further imaging after radiographs, if any, would you order on this patient?
HPI - 55 year old presented with ongoing left hip pain for the last 6 months. He was prescribed NSAIDs by his local doctor which were of no use. He attended my outpatient clinic in a wheel chair, unable to weight bear due to the hip pain.
If you chose to biopsy this lesion, which approach would you use?
HPI - A 30 year old male patient presents with right shoulder pain following an MVA. At the behest of his mother, patient wants surgery. He specifically requests an IM nail. After reviewing his radiographs, I recommended non-operative treatment.
The patient traveled to another surgeon for a second opinion, which resulted in IM fixation of his clavicle fracture. 4 weeks s/p IM nail, patient presents to the ER with complaints of pain, fever, and chills.
Physical exam yields erythematous incision, purulent drainage and wound dehiscence. Skin is warm and tender to palpation near clavicle.
How would you address the infection in this patient?
HPI - A 30 year old male patient presents with 6 months of right clavicle pain following ORIF for a clavicle nonunion after fracturing his clavicle in a motor vehicle accident.
He was initially treated non-operatively, but went on to develop a nonunion at the fracture site. He then underwent ORIF with graft and did well at first, but is now extremely painful.
XRays and CT are shown.
After ruling out infection, would you offer revision surgery?
HPI - Patient fractured his left humeral shaft and saw an outside surgeon, undergoing IM fixation. Fracture site initially looked promising, but soon went on to nonunion. One of the distal screws never seated properly and began to back out soon after his initial surgery.
At 3 months post-op, the patient returned to the outside facility and was pronounced healed by the PA.
3 years later, he presented to my clinic with significant pain and dysfunction.
Would you recommend surgery in this patient?
HPI - At age 26, patient endured a motorcycle crash in October of 2010. He was treated by an outside surgeon with revision ORIF & bone grafting from distal radius. Went on to a nonunion of the ulnar shaft, chronic radiocapitellar dislocation, and heterotopic ossification about the elbow.
Would you offer surgery?
HPI - 17 year old male had RTA 2 days back.hemodynamically stable has passed urine several time since injury without any blood traces.
What are the treatment options for the pelvic fracture?
HPI - Limping of 5 days duration.
HPI - Right hand dominant female construction worker fell from a height of 15 feet onto her right elbow, developed pain, swelling and decrease range of motion of right elbow. Bleeding was noted from wound around the elbow.