General Rules about Fractures
When you suspect a fracture, order 2
views at 90° to one another and
always include the joints above and
below the broken bone.
Always x-ray other sites “in the line of
force” (e.g., lumbar spine for someone
who falls and lands on the feet, hips in
a patient who has been in a motor
vehicle accident with force of knees
against the dashboard).
Closed reduction is the answer for
fractures that are not badly displaced or
Open reduction and internal fixation
is the answer when the fracture is
everely displaced or angulated or cannot
Open fractures (the broken bone
sticking out through a wound) require
cleaning in the OR and reduction within 6
hours from the time of the injury.
Always perform cervical spine films in
any patient with facial injuries.
Fractures are always diagnosed with an x-
ray. In terms of therapy, general rules are:
• Closed reduction: mild fractures
• Open reduction and internal
fixation: severe fractures with
displacement or misalignment of bone
• Open fractures: skin must be closed
and the bone must be set in the
operating room with debridement
There are 5 main types of fractures, all
of which present with pain, swelling,
2. Stress fractures
3. Compression fractures
4. Pathologic fracture
5. Open fracture
1. Comminuted fractures: a fracture in which the
bone gets broken into multiple pieces
• Most commonly caused by crush injuries
2. Stress fractures: a complete fracture from
repetitive insults to the bone in
• Most common stress fracture is of the metatarsals.
• On the USMLE Step 2 CK, vignettes may describe
an athlete with persistent pain.
• X-ray does not show evidence, so a CT or MRI must
be conducted in order for diagnosis.
• Treatment is with rehabilitation, reduced physical
activity, and casting. If persistent, surgery is indicated.
3. Compression fractures: a specific
fracture of the vertebra in the setting of
• Approximately one-third of osteoporotic
vertebral injuries are lumbar,
one-third are thoracolumbar, and one-third
are thoracic in origin.
4. Pathologic fracture: a fracture that occurs
from minimal trauma to bone that is weakened
• Metastatic carcinoma (e.g., breast or colon),
multiple myeloma, and Paget disease are a few
examples of diseases that cause brittle bones.
• On the USMLE Step 2 CK, look for a vignette
in which an older person fractures a rib from
• Treatment is surgical realignment of the bone
5. Open fracture: a fracture when injury
causes a broken bone to pierce the skin
• An open fracture is associated with
high rates of bacterial infection to the
• Surgery is always the right answer
This is the most common shoulder
Look for an arm held close to the body but
an externally rotated forearm and
associated numbness over the deltoid
muscle (axillary nerve is stretched).
• Posterior dislocation:
The arm is held close to the body, and the
is internally rotated.
A 27-year-old woman with a known seizure
disorder has a grand mal seizure. She
complains of left shoulder pain. PA and lateral x-
rays are obtained and fail to reveal fracture or
dislocation. She is given ibuprofen for pain. She
returns 3 days later with persistent pain with her
arm held close to her side. She reports that she
is unable to move the left arm. What is the next
step in management?
a. Axillary radiograph of the left shoulder
b. Change analgesic to Percocet
c. CT of the left shoulder
d. MRI of the left shoulder
e. Ultrasound of tendon insertion sites
Answer: A. Although anterior shoulder
dislocations are easily seen on erect
posteroanterior (PA) and lateral films—
look for adducted arm and externally
rotated forearm with numbness over
deltoid (axillary nerve is stretched)—
posterior shoulder dislocations are
commonly missed on these views.
Posterior shoulder dislocations should be
suspected in a patient with a recent
seizure or electrical burn and shoulder
injury or pain. Order axillary or scapular
views of the affected shoulder.
Following are the best choices
for the management of fractures:
Clavicular fractures: Figure-eight
Colles’ fracture: Closed reduction
and casting (Presents often in an
elderly woman who falls on an
outstretched hand. Look for a painful
wrist with a “dinner-fork” deformity.”)
Direct blow to the ulna (Monteggia
fracture) or radius (Galeazzi fracture)
results in a combination of diaphyseal
fracture and displaced dislocation of the
nearby joint. Open reduction and
internal fixation is needed for the
diaphyseal fracture, and closed reduction
for the dislocated joint.
Fall on an outstretched hand with
persistent pain in the anatomical snuffbox
is a scaphoid fracture until proven
otherwise (takes > 3 weeks to be seen on
x-ray). Place thumb spica cast to help
Consider the possibility of a hip fracture
in any elderly patient who sustains a fall.
Look for externally rotated and shortened
Femoral neck fractures are at high risk
of avascular necrosis (tenuous blood
supply) and are best treated with
femoral head replacement.
Intertrochanteric fractures are treated
with open reduction and pinning.
Femoral shaft fractures are treated
with intramedullary rod fixation. Be
aware of a high risk for fat emboli.
y rod fixation
Posterior dislocation of the hip
(history of head-on car collision where
the knees hit the dashboard) is an
orthopedic emergency. Differentiate it
from hip fracture by an internally
rotated leg (the leg is also shortened).
Emergency reduction is needed to
avoid avascular necrosis
Emergency reduction for
posterior hip dislocation
Medial/lateral collateral ligament injury (caused
by a direct blow to the opposite side of the joint):
Casting if isolated ligament injury; surgical repair if
multiple ligaments injured.
Anterior/posterior cruciate ligament injuries
(swelling pain and anterior/ posterior drawer sign):
Young athletes need arthroscopic repair. Older
patients may be treated with immobilization and
Meniscal injury (prolonged pain and swelling with
“catching” and “locking”,during ambulation). Treat
with arthroscopic repair.
A 19-year-old man takes a hard blow from the
oncoming defense during his second college
football game. He complains of severe
progressive pain in his knee and has difficulty
ambulating. He is seen by the team doctor, who
tells him to ice the knee. A week later the pain
and swelling are still present. His family doctor
orders an MRI that shows a torn ACL.
What is the best therapy?
a. Total knee replacement
d. Arthroscopic repair
Answer: D. Arthroscopic repair is the
most definitive therapy, followed by
The risk factor that should be
considered is that he had direct
trauma to the front of his knee. The
mechanism of injury can give some
insight into the type of problem that
may subsequently arise.
(e.g., history of military or cadet
marches): x-ray may be negative
initially. Treat with cast, order the
patient not to bear weight, and repeat
films in 2 weeks.
Tibial stress injury
Rupture of the Achilles tendon
(middle-aged man “overdoes it” at tennis
or basketball, or patient with history of
fluoroquinolone use, complaining of
sudden “popping” and limping): Treat
with casting in equinus position or
Carpal tunnel syndrome (CTS) is
entrapment of the median nerve that
causes pain and paresthesias. The most
common causes are idiopathic:
rheumatoid arthritis, acromegaly, and
hypothyroidism are conditions that
predispose one to CTS.
The best initial test is the history and physical.
Phalen’s test causes symptoms by flexing the
wrist gently and holding the position. Tinel’s sign
causes symptoms by tapping the nerve over the
flexor retinaculum and awaiting paresthesias.
The best initial therapy is NSAIDs and splinting
If this does not alleviate symptoms, local steroid
injections have been shown to help in some
Surgical release is recommended when splinting
no longer controls the patient’s symptoms.
Trigger finger (woman who awakens at
night with an acutely flexed finger that
“snaps” when forcibly extended) and De
Quervain tenosynovitis (young mother
carrying baby with flexed wrist and
extended thumb to stabilize the baby’s
head): Steroid injection is the best initial
A 39-year-old woman awoke from a nap with
severe pain in her index finger and found it to be
flexed while all other fingers were extended. When
she tried to pull it free she heard a loud popping
sound and the pain subsided. The following day she
comes to her doctor's office concerned about the
sound and pain.
What is the most appropriate next stop in the
management of this patient?
a. Amputate the finger
b. Steroid injection
d. Admit to the hospital
e. NSAID therapy
Answer: B. Trigger finger is an acutely flexed
and painful finger. Steroid injections have
been shown to decrease pain and
recurrence of trigger finger. It is the most
cost effective treatment, and studies have
shown a trial of steroids should be
attempted prior to surgery. Trigger finger is
caused by a stenosis of the tendon sheath
leading to the finger in question. If steroids
fail, surgery to cut the sheath that is
restricting the tendon is the definitive
a condition in which there is fixed forward curvature of
one or more fingers, caused by the development of a
fibrous connection between the finger tendons and
the skin of the palm.
palm with palmar fascial nodules
Surgery is the treatment if collagenase fails.
Do not confuse trigger finger with Dupuytren
contracture, a condition more common In men
over the age of 40.
Dupuytren contracture is when the palmar fascia
becomes constricted and the hand can no longer
be properly extended open. Surgery is the only
A 19-year-old woman broke her femur 3
days ago during a college soccer try out.
This morning her mother brought her to the
ED because she was short of breath.
Physical examination reveals a confused
patient who is awake but not alert or oriented
and a splotchy magenta rash around the
base of the neck and back.
ABG reveals a P02 under 60 mm Hg.
What is the most likely diagnosis?
a. Fat embolism
b. Myocardial infarction
Answer: A. Fat embolism syndrome is
characterized by a combination of
confusion, petechial rash, and dyspnea. It
is caused by fracture of long bones.
Myocardial infarction may have shortness
of breath, but is unlikely in a 19-year-old
would present with severe abdominal pain.
Rhabdomyolysis has high CPK from
breakdown with a urine analysis and
dipstick that shows positive blood with
Fracture of the long bone allows for fat to
escape as little vesicles and cause occlusion of
vasculature throughout the body. The most
common bone is the femur. Onset of symptoms
is within 5 days of the fracture. The patient will
• Petechial rash on the upper extremity and trunk
• Shortness of breath and tachypnea with
• ABG will show P02 under 60 mm
• Chest x-ray will show infiltrates.
• Urine analysis may show fat
Treatment for fat embolism requires
oxygen to keep P02 over 95%. If the
patient becomes severely hypoxic,
intubation followed by mechanical
ventilation is necessary.
Compartment syndrome is due to the
compression of nerves, blood vessels, and
muscle inside a closed space. This can also be
within a cast after setting a fracture. The 6 signs
of compartment syndrome are: “6P”
Compartement syndrome 6P
1. Pain: most commonly the first
2. Pallor: lack of blood flow causes pale
3. Paresthesia: "pins and needles"
4. Paralysis: inability to move the limb
5. Pulselessness: lack of distal pulses
6. Poikilothermia: cold to the touch
Compartment syndrome is a medical
emergency and immediate fasciotomy
must be completed in order to relieve
pressure before necrosis occurs.
When a patient complains of pain at the
site of a cast, always remove the cast and
examine for compartment syndrome.
Look for a history of prolonged ischemia
followed by reperfusion, crushing
injuries, or other types of trauma.
Back Pain-Disc Herniation
A 45-year-old man with a history of back pain for several
months presents with sudden-onset severe back pain
that came on when he was moving a television.
He describes an “electrical shock” that shoots down his
leg, which is worse when he coughs or strains and is
partially relieved by flexing his legs. The pain has
prevented him from ambulating. Straight leg raising
gives excruciating pain. What is the next step in
a. CT of the spine
c. Immediate surgery
d. Ibuprofen and brief bed rest
e. MRI of the spine
Answer: D. This is the classic presentation of
lumbar disc herniation. It occurs almost
exclusively at L4–L5 or L5–S1. Peak age is 43–
46. Anti-inflammatories and a brief period
of bed rest is all that is needed at this stage.
Immediate surgical compression is needed if
the history suggests cauda equina syndrome
(look for bowel/bladder incontinence, flaccid
anal sphincter, and saddle anesthesia). MRI
can confirm both disc herniation and
cauda equina, but do not answer MRI in classic
cases of disc herniation. Trial of
antiinflammatories is also the first step in
A sluggish ankle jerk reflex is suggestive of
pathology at S1/S2. A sluggish patellar reflex
is suggestive of pathology at L4/L5.
A 41 -year-old man presents to the ED after
acute onset of lower back pain that began
after he tried to lift an engine block at his
job. He says he feels like lightning bolts are
shooting down his legs and he is unable to
move. Physical exam reveals a positive
straight leg raise test and positive anal
What is the most appropriate next
a. X-ray of the cervical spine
b. MRI of the spine
e. Lumbar puncture
A patient who presents with acute onset
of back pain and is under the age of 50
should have an MRI to rule out spinal
cord compression due to a slipped disc or
lumbar disc herniation. If asked for the
most appropriate next step in
management, answer antiinflammatory
agents. The most common sites of lumbar
disc herniation are L4-L5 and L5-Sl. The
other choices are applicable but the most
appropriate next step is an MRI. Lumbar
puncture, however, has no role in the
treatment of slipped disc.
This presents in men in their 30s or early
40s with chronic back pain and morning
stiffness that improve with activity. X-rays
eventually show a “bamboo spine.”
It is associated with the HLA B-27
antigen; screen for uveitis and
inflammatory bowel disease, which are
also associated with HLA-B27.
Management involves anti-
inflammatory agents and physical
In cases of ankylosing spondylitis, do not
answer HLA-B27 antigen testing in first-
degree relatives. Risk of developing
ankylosing spondylitis based on HLA-B27
positivity is low, and it is not indicated for
Suspect metastatic malignancy in an
elderly patient with progressive and
constant back pain that is worse at
night and unrelieved by rest. There will
be a history of weight loss.
X-rays will show the lytic (also look for
hypercalcemia and/or elevated alkaline
phosphatase) or blastic lesions. Always
include a workup for the most likely
malignancy based on history and type of
Perform the following imaging:
First order plain radiographs
(especially important in multiple
Bone scan is most sensitive in early
MRI shows the greatest amount of
detail and is the diagnostic test of
choice if there are any neurologic
symptoms (to rule out cord
Bone scans will not be helpful in
purely lytic lesions (e.g., multiple
myeloma). Instead order plain
radiographs or MRI.
Lytic lesions can be caused by
multiple myeloma and kidney and
thyroid metastasis, while blastic
lesions are caused by metastatic
Foot Pain-Plantar Fasciitis
Plantar fasciitis commonly presents in older,
overweight patients with sharp heel pain
every time their foot strikes the ground. Pain
is worse in the mornings.
X-rays may show a bony spur matching the
location of the pain, and there is exquisite
tenderness to palpation over the spur.
However, surgical resection of the bony spur is
not indicated, so x-ray makes no difference.
Give symptomatic treatment; resolution
occurs spontaneously in 12–18 months.
The pain in plantar fasciitis
feels like a tack in the
bottom of the foot and
resolves quickly after
Morton neuroma is inflammation of
the common digital nerve at the 3rd
interspace, between the 3rd and 4th
toes, caused by wearing pointy-toed
shoes. The neuroma is palpable, and
there is very tender spot there.
Management is analgesics and
appropriate footwear. If this does not
work, follow with surgical excision.