HPI - Traumatic event causing dislocation right shoulder dislocation. The patient has no prior history of dislocation.
Following closed reduction (see postop P1 images below), how would you treat this injury?
HPI - Increasing pain over last few yrs with onset of swelling over last year. Pain has increased to the point that now there is pain with rest.
What do you think is the most likely diagnosis of the cyst?
HPI - Child age 8 sustained supracondylar fracture on 20 July 2015, admitted in Hospital and urgently operated. Due to lack of C arm in operation theatre doctor didn't check fracture position and somehow decided not to reoperate later when he confirmed position of fracture by x rays.
How would you treat this patient
HPI - Patient was involved in a car accident 1 year ago with severe head injury, coma for 1 month, neglected humeral head fracture for 10 months, underwent open rotator cuff repair 2 months ago.
How would you treat the patient at this time (P1 images above)?
HPI - 14 year old playing soccer and sustained twisting injury. Fell to the ground. Presented to me with swollen knee. Place in KI and MRI obtained.
MRI shows significant lateral patellar subluxation with some tilt.
Trochlear dysplasia (flat trochlea)
Large medial facet chondral deficiency with loose fragment in suprapatellar pouch.
Medial patellar facet fx.
MPFL seems to be attached to medial fx fragment.
I measured TTTG to be 19-20
I did not appreciate patella alta.
What are your guys thoughts?
Scope and see if cartilage piece can be fixated?
Or let medial facet fx heal then go back and do tibial tubercle transfer with lateral release, medial plication / mpfl and denovo for chondral defect?
What would be your next step in treatment of this patient?
HPI - h/o fall in the park a week before presentation.was treated in a slab in another hospital.
How would you treat this fx now that it is seven days old?
HPI - Fall from height at work place. Sustained injury to back and left ankle
How would you treat this fx?
HPI - RTA
How would you treat this fx after closed reduction (see postprocedure P1 below)?
HPI - neglected clubfoot treatment in childhood
HPI - Valgus deformity of right knee, corrected with distal femoral varus osteotomy. Postoperative x-rays showed good correction with intact medial hidge. 50 days later, during physical therapy, patient felt acute pain and x-rays revealed fractured medial hidge and loss of correction
How would you treat the patient at this time (Postoperative P1 images below)?
HPI - 2 wheeler rider - head on collision with a bus - presented to us 8 hours after injury with compound femur fracture and compound tibia fractures on the right side.
Would you approach this patient with a staged approach (provisional fixation with definitive fixation at a later date)?
HPI - The condition started sense one year when the patient suffered road traffic accident whitch resulted in open grade II fracture of the distal part rt humerus witch was treated at this time by OR and multiple K wires and Ilizarov application. The soft tissue healed without complications. For unknown reason Ilizarov was removed after one and half month and the pt was put in cast.the pt came to me after that, I removed most of the K wires ,with debridement and refreshening of fracture edges and applied Ilizarov frame
How would you treat this patient at this time?
HPI - Distal radius-ulna open fracture 16 weeks ago treated initially with ex-fi. Then due to an infection , antibiotics were administered and pins were introduced for an extra fracture stability. The ex -fi was remover after 10 weeks from the accident
How would you treat this synostosis after treatment of a distal radius fx with an ex-fix?
HPI - Patient had a sudden onset of pain in the right hip 14 days back.. she felt a clicking sensation while having her bath, no history of trauma... by the next day she developed an increase of pain and mild swelling of the hip and had developed fever and had pain in performing movements of the right hip.... usg report show hemarthrosis
Based on the clinical presentation and radiographs above, what is the most likely diagnosis?
HPI - History of closed mid-diaphyseal fracture of the left femur whitch was treated by ORIF nine months ago
There was chronic wound discharge after the operation for three months treated by oral antibiotics
Investigations of deep infections are positive
What is the cyst noted in the pre op x ray
HPI - gradual onset progressive course now interfering with activities
What is the most likely diagnosis of the right foot condition?
HPI - Pilon fracture operated 4 years ago. Bone scan and CT scan rule out osteomyelitis.
Assuming on has evaluated for, and eliminated any infection, how would you treat this patient?
HPI - Recent fall from height at worksite
How would you treat this fracture?
HPI - Electric shock followed by direct fall on the left shoulder
Where would you perform the closed reduction and what type of sedation would you use?
HPI - An otherwise healthy male complains of right foot pain that has gradually progressed over the last year. He denis any history of trauma. Now the pain is severe and limiting his function.
The patient has a history of a similar condition in left foot 11 years ago (patient reports "death" of navicular) that was treated by bone grafting years ago. He reports relief of his symptoms and now he has tolerable left foot pain.
What is the most likely diagnosis of the RIGHT foot pain?
HPI - 17-year-old male present to ER 10-days after gun shot wound to his left thigh. Inability to bear weight on affected limb.
For most femoral shaft fx secondary to GSW at your institution, what provisional treatment do you usually use to keep the femur "out-to-length" until definitive surgery?
HPI - Fall from 5 meter height while working
What would be your next step of treatment of the L1 compression fx based on the images provided (xray and CT)?
HPI - pain inabilty to move the rt wrist after a fall
HPI - Patient had injury of his distal radius 7 months ago. Patient was treated by closed reduction and external fixator application. The fixator removed at 6 weeks. The deformity progressed after that.
Is this a malunion or a nonunion?
HPI - History of fall 2 days ago
How would you classify this acetabular fracture?
HPI - Twisting trauma to the ankle while moving downstairs
Would you typically close reduce and ex-fix this fracture, then come back and perform definitive fixation on a delayed basis?
HPI - RTA with severe pain and inability to bear weight on rt lower limb.
HPI - Last evening, I had an interesting case of the commonly encountered "someone rolled up on my ankle". The player limped off but after removing shoe/sock he endorsed minimal tenderness throughout the ankle and no specific pain on the distal fibula. The ankle was taped and he was allowed to put weight on the ankle. at this point he mentioned pain with weightbearing and we then placed ice and reevaluated at end of 1st quarter. At this point, there was swelling over distal fibula and more tenderness. parents agreed with obtaining a XRay at the ER and images attached show a nondisplaced distal fibula fracture. (notice on the xray how much soft tissue swelling occurred just over the 70 minutes from the time of injury compared to the medial side of the ankle where there is no soft tissue swelling!) Treatment will include 6 weeks of a cast.
Do you find the ottawa ankle rules helpful in sideline evaluation of ankle injuries?
HPI - The patient had a history of a fall in childhood that was treated nonoperatively by the village bone setter. Patient went about his life with deformity but no limitation to his work.
Then 7 months ago the patient fell again and developed acute pain in his right elbow. Patient did not seek immediate treatment.
Three months after the fall, he returned to his native country and surgery was performed. (see Postop Procedure 1 films).
He now presents with persistent pain and hardware prominence.
Do you think the large lateral condyle fragment represents an acute nonunion (from fall 7 months ago) or a chronic nonunion from his pediatric lateral condyle fx?
HPI - Motorcycle accident 3 months ago, fx of the femoral neck and middle of the femur. Treated with DCP for both.
Now can not walk because of painful hip
What is your plan to treat this patient ?
HPI - Patient 29 years old from Honduras, male, sustained a Type C Weber ankle fracture in Nov last year. Soon after waking up from surgery medial aspect of the heel and sole of the foot was without sensation with concomitant pain on the dorsal aspect of the distal third of the leg, where fracture site was. Allodynia, pain and progressive contracture of the toes developed.
EMG: Sensitive-motor neuropathy with axonal lesion of right peroneal nerve and severe posterior tibial nerve.
Motor Nerve conduction study: right tibial nerve at ankle = Lat: 4.3ms; Dur:1.0ms; Amp:50.0uV; Area:0.0mVms; Segment: Ankle; Distance: 120mm; Interval: 4.3ms
What is the best treatment?
HPI - S/p car accident 5/4/2015
How would you classify this fracture on initial injury?
HPI - Fall on outstreshed hand 3ms ago
ORIF by k wires
Slap for one and half ms then removal of slap and wires
Physiotherapy till now
How would you treat this patient?
HPI - A week ago playing basketball axial loading trauma to the fourth digit of the dominant hand.
How would you treat this injury?
HPI - 30 year old right hand dominant male with AML on chronic immunosuppression, status post multiple repeat I&D of multiple joints, including right elbow, for septic arthritis and subsequent osteomyelitis. Status post left TKA due to septic arthritis, uses wheelchair for mobility. Right elbow antibiotic spacer has been in for 1 year.
What should be the next step in management?
HPI - History of road traffic accident 5 Months back. Treated conservatively with bed rest and analgesics.Started ambulation with bilateral crutches 3 months post injury. Currently complain of incapacitating low back pain.
Possible management options for this patient?
HPI - Patient had simultaneous B/L total knee joint replacement 1 year back.5 months after surgery patient developed pain in left knee joint.ESR and CRP was elevated ESR 90 CRP 35 Xrays showed lysis at the tibial base plate.
Aspirate from bilateral knee joint had polymorps more than 3000WBC/ml with majority of polymorps. Culture sensitivity was positive.
Implant were removed bilaterally. Antibiotic Impregnated articulated cement spacer were inserted using vacomycin inserted cement. Post operative antibiotic were continued for 6 weeks and then stopped. ESR had come down to 45 andCRP had fallen to 20.
Antibiotics were stopped for 3 weeks and B/L knee joint were aspirated which still showed counts more than 2000wbc/ml.culture was negative.
ESR at present is 25 and CRP is 17
No pain and range of motion is 0 to110 degree
Considering final CRP of 17 and ESR of 25 four weeks after stopping antibiotics and 10 weeks post spacer insertion, how would you treat the patient at this time.
HPI - The pt was apparently well 1 week prior to admission, he was climbing a coconut trees on the evening and fell to the ground from a height of approximately equal to 2 story house and sustained broken both-bone fx of right forearm.
The patient had loss of consciousness and only woke up when he already in hospital with his right forearm covered with bandages. and he probably brought to hospital by passerby.
The patient is unable to recall the positioning of the limbs, head and chest when he fell. He currently complains of continued pain and inability to move right forearm. Since he regained consciousness from the accident he also complains of mild headache and double vision on his left eye .
He also complains of chest pain on breathing especially on left chest. However, the pain score is lesser compared the first day he regained consciousness.
Looking at the PIP dislocation in the ulnar gutter (post splinting radiograph), do you think it is reduced?
HPI - 64 YRS 110 KG MALE PATIENT WAS OPERATED( TOTAL KNEE REPLACEMENT ) FOR RIGHT KNEE PAIN 3 MONTHS BACK. PATIENT DEVELOPED PAIN OVER THE MEDIAL SIDE OF THE KNEE AFTER 15 DAYS. PATIET IS ABLE TO WALK CLIMB STAIRS BUT COMPLAINING OF SEVERE PAIN WHILE GETTING OUT FROM CHAIR OR BED. HE HAD A HABBIT OF CROSSING LEGS WHILE SETTING. WHILE SLEEPING PT KEEPS HIS LIMB IN EXTERNAL ROTATION AND MID FLEXION ( POSITION OF EASE).
HOW TO TREAT THIS UNRESOLVED PAIN
HPI - Pain in left hip joint for last 20 years which gradually increased to present stage. At the age of 10 years patient sustained a fall followed by symptoms, and was treated conservatively. Pain increases on walking for long distances (250 meters) and decreases with rest. No other relevant infection history,
How would you treat this patient in your institution?
HPI - swelling both lower legs for 1 year, worse by long standing and walking, no significant pain.
Based on the images provided, what do you think is the most likely cause of the edema?
HPI - Trip and fall while walking
Unipolar modular hemiarthroplasty for left subcapital neck of femur fracture in 2013 (double taper highly-polished stem)
HPI - Truck driver
Fall getting out of truck
Complex femoral shaft fracture 30 years ago
Treated with unreamed, unlocked nail -> non-union
Revised to locked Russell-Taylor nail -> united in maligned position
Hardware removed 20+ years ago
Medullary canal obliterated at level of malunion
How would you manage this subtroch fracture shown in the P2 images above?
HPI - started with fever and dicharge of pus from healed suture line for 1 week
HPI - 63 yo male with fall onto right hip
How would you treat this case?
HPI - MBA 6 years ago
Patient isn't the best historian and, as his injury was sustained in another state, we have not been able to access his imaging or notes
Right proximal humerus ?fracture ?fracture-dislocation, treated non-operatively
Associated with brachial plexus injury of uncertain extent (patient describes complete paralysis of right upper extremity)
Plexus treated expectantly with recovery over 12-18 months
States reasonable shoulder function after plexus recovery for 1-2 years, but lasts 4 years has developed increasingly severe right shoulder pain with associated stiffness
Previously a fisherman, unable to work due to pain for 6 months
States had been placed on waiting list for "rotator cuff repair" in the other state 3 years ago, but never called for surgery
Having moved states, now presents to us "only" wanting more movement and less pain
What would be your preferred treatment option for this patient bearing in mind his age?
HPI - Motorcycle accident 16 weeks ago
How would you treat this chronic lunate dislocation/injury?
HPI - 25 year old who was run over, followed by loss of consciousness, brought to local hospital and while there, was diagnosed with fat embolism & treated with IV fluids. Now his vitals are stable - BP 100|70 mmHg, pulse 96/min, respirations 22\min
Which orthopaedic injury would you want to treat first?
HPI - fixed since 6 months with IMN humerus
How would you have treated this fracture initially?
HPI - 4 year old child, presenting with bilateral clinodactyly of the distal phalanx of the thumb, with impairment for daily life activities like holding a pencil.
How would you treat the dominant hand.