LMCC Orthopedic Review Lecture

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LMCC Orthopedic Review Lecture

• April, 2009
• Back to Basics
• Dr. P.R. Thurston

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• Fractures

Dislocations
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Definitions

• Fracture- A discontinuity in the structural
  integrity of a bone.
• Infraction- An incomplete fracture.
• Dislocation- Complete loss of contact of the
  articular surfaces of a joint.
• Subluxation- Non-concentric joint surfaces.
• Reduction- Returning a fracture or dislocation
  to an anatomical alignment.
• Comminution- Multiple fragments.

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Fractures
A discontinuity in the structural integrity of a
bone.
Definition -

A fracture occurs because the force
applied exceeds the breaking strength of the bone
so that the Load can no longer be transferred
across that zone of the bone.

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Fractures

• All fractures ultimately begin with kinetic
  energy, released by misadventure and applied to
  the human body.
• Some of that energy is absorbed and some is
  transmitted to the surroundings.
• Absorbed energy must be dissipated, ie.
  distributed, through the soft tissues and bones.
• Fractures occur when the bone can not dissipate
  all of the energy absorbed.

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Fractures
Mechanical Properties of Bone

• Bone is a two-phase material -
• Calcium HydroxyApatite Ca10(PO4)6(OH)2
  mineral
• Osteoid Collagen type I and III
  fibrous
• Calcium is strong in compression, but weak in
  tension.
• Osteoid is strong in tension, but weak in
  compression.

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Fractures

• BUT - (for adult bone)
• Calcium is stronger in compression than
  Osteoid is in tension
• And therefore -
• Bone always fails first in tension

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Fractures

• A bone consists of three areas -
• the Diaphysis
• the Metaphysis
• the Epiphysis.

Each region has its own fracture characteristics.
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Fractures

• Bending
• Torque
• Direct
• Traction
• Compression
• Intra-articular
• Pediatric

Oblique
Diaphyseal
Spiral
Transverse
Metaphyseal
Epiphyseal
Mixed
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Fractures
Salter-Harris Classification
I
II
III
IV
V
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Fractures
Salter-Harris Classification
1) Fractures interfering with growing
bones. 2) Worse prognosis with increasing
number. 3) Probability of surgery increases with
number.
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Fractures

• A fracture can occur in -
• normal bone subject to abnormal forces.
• Traumatic Fractures.
• abnormal bone subject to normal forces.
• Pathologic Fractures.
• normal bone subject to cyclic forces.
• Fatigue or Stress Fractures.

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Fracture Description

• This fracture is angulated laterally, since it
  points laterally.
• The distal fragment is tilted medially

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Description
Medially Displaced Closed Comminuted Short
Oblique Fracture of the Proximal Humerus Caused
by a direct fall
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Fracture Description

• 1) The distal fragment is always described with
  relation to the proximal segment.
• 2) Displacement Translation of bone ends.
• 3) Angulation Orientation of bone ends.
• 4) Angulation identifies to where the fracture
  points.
• 5) For clarity, the tilt of the distal fragment
  is often used to describe angulation.

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Indications for Closed Reduction

• There is significant displacement.
• Reduction is possible.
• The reduction, if gained, can be held.
• The fracture has not been produced by a traction
  force.

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The Periosteal Bridge

• The Periosteal Bridge is intact on the concave
  side of the fracture.
• Reversal of the mechanism of the fracture
  tightens the bridge and stabilizes the fracture.

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The Periosteal Bridge

• Tightening the periosteal bridge locks the
  fracture together.
• Holding the bridge tight requires three point
  fixation.
• It takes a bent cast to produce a straight bone
• J. Charnley

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Indications for Open Reduction

• 1 ) There is a significant Displacement.
• 2 ) Open Fractures.
• 3 ) Intra-articular Fractures.
• 4 ) Un-reducible Fractures
• 5 ) Reductions that cannot be maintained in a
  cast.
• 6 ) Comminuted or Segmental Fractures.
• 7 ) Floating Joints.
• 8 ) Fractures with Neurovascular damage.

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Open Fractures

• Classification -
• 1. lt 1 cm., inside-out, little soft tissue
  damage.
• low potential for infection.
• 2. 1 cm. 10 cms., outside-in, requires
  debridement, but no flap or skin graft.
• moderate potential for infection.
• 3. gt 10 cms., outside-in, high energy,
  devitalized muscle, comminution or bone loss,
  soft tissue loss.

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Open Fractures

• Classification -
• 3A. No loss of soft tissue cover, no flap
  required.
• 3B. Flap required due to soft tissue stripping.
• 3C. Associated vascular injury.

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Type 1. Open Fracture 6 mm, extend debride
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Degloving Mechanism
Degloving Mechanism
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Type III C Injuries Vascular Injury
Note pallor of the ankle No pulses
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Fracture Complications

• 1. Pulmonary Fat Emboli
• 2. Compartment Syndromes
• 3. Stress Fractures
• 4. Pathologic Fractures

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Pulmonary Fat Emboli - A.R.D.S.

• - Long bone fractures, burns, contusions.
• - Interstitial pneumonitis due to free fatty
  acids
• - S.O.B. confusion in young adults.
• - Axillary Subconjunctival Petechiae.
• - Serum lipase elevated.
• - pAO2 reduced if lt 50 20 mortality.
• - Ventillatory support
• - Dexamethazone.
• - 5 day course.

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Compartment Syndromes

• - increased interstitial tissue pressure.
• - fractures, burns, tight dressings.
• normal pressure lt 25 mm. Hg.
• when the tissue pressure gt venous capillary
  pressure, but less than the arteriolar pressure.
• 5 Ps
• - pain.
• - pallor.
• - pulselessness.
• - paresthesias.
• - paralysis.

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Compartment Syndrome
Symptom Pain out of proportion to that
expected for the injury. Signs 1. Loss of
function of muscle due to ischemia within
the compartment. 2. Pain with passive
stretch 3. Numbness etc. are LATE findings! 4.
If neuro symptoms present, potential
for full neuro recovery is only 10
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Rx Compartment Syndrome
Release all compressive dressings / plaster.
Elevate extremity to heart level.
Fasciotomies.
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4 compartment fasciotomy
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Compartment Syndrome
Careful monitoring. Recognise it - 5 Ps
Call Orthopaedic Surgeon Pressure measurements

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Stress or Fatigue Fracture

• Repeated loading below acute
• failure threshold.
• Eventual fatigue failure.
• Military recruits, runners, aerobics.
• Tibia, metatarsals, femoral neck.
• Initial x-ray can be negative.
• Bone tenderness Bone scan.

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Pathologic Fractures

• Failure through abnormally
• weakened bone
• Minimal trauma BEWARE
• Osteoporosis
• Metastasis
• Tumour- Benign, Malignant
  (Myeloma).
• Metabolic Bone Disease

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Pathologic Fractures

• Metastases
• Lytic - Lung
• Colon
• Thyroid
• Renal
• Breast
• Blastic - Prostate

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Pathologic Fractures

• Metastases
• - require fixation to prevent fracture if they
  are gt 1/3.
• - produce pain on weight bearing in the lower
  limb.
• - survival gt 3 months.
• - cannot be managed by medical therapy.
• - radiotherapy after fixation (2 weeks)
• (radiotherapy induced osteonecrotic
  fractures)

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Pathologic Fractures
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Dislocations

• The articular surfaces are no longer in contact.
• Commonly affects -
• Shoulders gt PIP joints gt Elbows gt Ankles.
• Often associated with fractures.
• Often associated with neurologic injuries

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Shoulder Dislocations

• 95 anterior
• 1 posterior
• Luxatio erecta
• Medial
• Axillary nerve injury
• Rapid reduction

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Shoulder Dislocations

• Conscious sedation.
• Traction reduction.
• Immobilization.
• Recurrent.
• Voluntary
• Habitual.
• Multiaxial instability.

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Elbow Dislocation

• Posterolateral.
• Median nerve injury.
• Ulnar nerve injury.
• Rapid reduction.
• Early mobilization.

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Back Pain
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Classification Mechanical (MacKenzie)

• Postural syndrome
• normal tissues become painful by the application
  of prolonged stresses (sitting, bending etc)
• Dysfunction syndrome
• soft tissues are shortened and stiff. Usually gt30
  year old, poor posture, under exercised, reduced
  mobility
• Derangement syndrome
• Disc derangement (tears and herniation)

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Causes and Classification of Back Pain McNab

• Viscerogenic
• Vasculogenic
• Neurogenic
• Psychogenic
• Spondylogenic

• Spondylogenic
• Osseus
• Trauma
• Infection
• Neoplasms
• Inflammatory
• Metabolic (eg.Pagets)
• Deformities
• Soft tissues
• Muscles
• SI joints
• Disc
• Facets

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Non operative Treatment of Back Pain

• Do nothing
• Activity modification
• Medications
• Exercise and physiotherapy
• Braces
• Manipulation
• Massage therapy
• Traction/inversion therapy
• Vitamins/Supplements/Diets
• Weight control
• Every Suzanne Summers sponsored abs exerciser

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Anatomy
Extension
Flexion
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Three joint complex(Kirkaldy Willis, Farfan)
Instability
Lateral n. ent
Central stenosis
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Disc herniation
Ms J.H. 25 y.o. female presented with cauda
equina syndrome
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Spinal stenosis

• Symptoms
• unilateral radicular pain
• bilateral claudication
• better with forward flexion of trunk
• better walking uphill
• rare bowel/bladder involvement

• Signs
• usually no neuro signs
• look for pulses
• stress test
• Investigations
• XR
• CT
• Myelo-CT
• MRI

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Cauda Equina Syndrome

• Sciatica associated with bowel or bladder
  dysfunction.
• Perineal numbness.
• Low or Sequestrated Lumbar Disc.
• Pressure on S1, S2 and/or S3 nerve roots.
• Requires immediate Decompression to avoid
  permanent disability.

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Time for a 10 minute break!
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1. Talipes Equinovarus is the proper name for -

1. Flat feet
2. In-toeing
3. Club feet
4. Knock knees
5. Wry neck

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Talipes Equinovarus is the proper name for -

• c. Club feet

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1. Talipes Equinovarus is the proper name for -

• Flat feet
• In-toeing
• Club feet
• Knock knees
• Wry neck

Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis
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Talipes Equinovarus

• congenital deformity of the foot
• Equinus, Inversion, Adduction, Supination
• 2 per 1000 live births
• 50 bilateral
• M gtF 21
• Serial corrective casts at birth
• Surgery if resistant
• EARLY TREATMENT IS ESSENTIAL

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2. Trendelenburg refers to -

1. Leg length discrepancy
2. Gait abnormality
3. Knee recurvatum
4. Scoliosis
5. Hip Contracture

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2. Trendelenburg refers to -

• b. Gait abnormality

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3. All of these are signs of D.D.H. except -

1. Limited Abduction
2. Ortolani Sign
3. Asymmetric Skin Folds
4. Galeazzis Sign
5. McMurray Sign

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3. All of these are signs of D.D.H. except -

• e. McMurray Sign

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3. All of these are signs of D.D.H. except -

1. Limited Abduction
2. Ortolani Sign
3. Asymmetric Skin Folds
4. Galeazzis Sign
5. McMurray Sign

Dislocated
Reducible
Dislocated
Knee height
Torn Meniscus
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Developmental Dysplasia of the Hip

• Acetabular dysplasia
• Femoral anteversion
• Adduction Contracture
• 50 bilateral, F gt M 81
• Test ALL newborns at birth
• Conservative Rx at birth Pavlik, D.diaper
• Surgical Rx if resistant

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4. The most common congenital Spinal abnormality
is -

1. Scoliosis
2. Spina Bifida
3. Torticolis
4. Klippel Feil Syndrome
5. Multiple Hereditary Osteochondroma

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4. The most common congenital Spinal abnormality
is -

• b. Spina Bifida

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Spinal Bifida

• defect of neural tube closure
• Lumbar spine, commonly low
• 2 per 1000
• myelodysplasia
• Mild to complete paraplegia
• Occulta, meningocoele, Myelomeningocoele
• Bowel and bladder dysfunction

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Polydactyly
5.
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Syndactyly
6.
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7.
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Sprengels Deformity
Omovertebral Bone
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8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -

• a. Physical Abuse
• b. Ehlers Danlos Syndrome
• c. Osteogenesis Imperfecta
• d. Multiple Hereditary Exostoses
• e. Myositis Ossificans

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8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -

• c. Osteogenesis Imperfecta

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9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from -

• a. Physical Abuse
• b. Rickets
• c. Scurvy
• d. Osteitis Deformans
• e. Myositis Ossificans

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9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from -

• b. Rickets

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9.
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9.
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Etiology Alkaline
Calcium Phosphate Urea
Phosphatase Vita
min D Up Down Normal
NormalDeficiency Rickets
Renal Up
Down Up UpInsufficiency (Renal
Rickets) Renal Up
Down Down NormalTubular
Insufficiency (HypoPhosphatemia)
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10. This is -

• a. Osteomyelitis
• b. Osteomalacia
• c. Osteoporosis
• d. Osteitis Deformans
• e. Leprosy

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10. This is -

• d. Osteitis Deformans

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Osteitis DeformansPagets Disease

• 4 of pop. Over 40 yrs.
• accelerated bone turnover
• often assymptomatic
• monostotic gt polyostotic
• loss of stature
• AV shunting
• pathologic bone

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11. A child with knee pain has a ____ problem
until proven otherwise.

• a. Knee
• b. Femoral
• c. Tibial
• d. Hip
• e. Patella

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11. A child with knee pain has a ____ problem
until proven otherwise.

• d. Hip

Obdurator Nerve
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11. All of the following are part of the
differential of hip pain in a 6 year old, except
-

• a. Femoral Osteomyelitis
• b. Septic Hip
• c. Transient Synovitis
• d. Legg-Perthes Osteochondritis
• e. Slipped Capital Femoral Epiphysis

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11. All of the following are part of the
differential of hip pain in a 6 year old, except
-

• e. Slipped Capital Femoral Epiphysis

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Ages for Hip Disease

• D.D.H. Birth
• Septic Hip Birth 11
• Legg-Perthes 3 11
• Transient Synovitis 3 11
• S.C.F.E. 11 - 16

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12. Osteomyelitis in children is produced by
what route of infection?

• a. Direct extension from another focus
• b. Hematogenous spread
• c. Perforating wounds
• d. Lymphatic spread
• e. Septic hip

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12. Osteomyelitis in children is produced by
what route of infection?

• b. Hematogenous spread

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Osteomyelitis

• Acute infection,metaphyseal
• 90 Staph.,20 mortality
• 100 growth abnormality
• Periosteal elevation, osteolysis
• Sequestrum, Involucrum

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13.
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13.
Paronychia
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14.
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14.
Felon
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15. All of these are findings of a Herniated
L5-S1 disc, except -

• a. Absent Achilles reflex
• b. Lateral foot numbness
• c. Sciatica
• d. Low back pain
• e. Extensor Hallucis Longus weakness

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15. All of these are findings of a Herniated
L5-S1 disc, except -

• e. Extensor Hallucis Longus weakness

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15. All of these are findings of a Herniated
L5-S1 disc, except -

• a. Absent Achilles reflex S1
• b. Lateral foot numbness S1
• c. Sciatica S1
• d. Low back pain
• e. Extensor Hallucis Longus weakness L5
• f. Knee jerk L4

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16. Avascular necrosis of the femoral head is
associated with all of the following except -

• a. Steroid use
• b. Alcohol
• c. Deep sea diving
• d. Lipid storage disease
• e. Diabetes

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16. Avascular necrosis of the femoral head is
associated with all of the following except -

• e. Diabetes

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17.
8 year old boy
What is the Diagnosis?
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17.
8 year old boy
Legg Perthes Osteochondosis
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Legg-Perthes Disease

• Osteochondrosis (avascular necrosis)
• Proximal Femoral Epiphysis
• Necrosis, revascularization, fragmentation,
  healing
• 3 11 yrs., M gt F 41, 15 bilat.
• Subluxation laterally, Coxa plana, Coxa magna
• Osteoarthritis 50 yrs.

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19. Diagnosis?
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19. Gout
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Gout

• Urate crystalopathic arthritis
• Crystals in periarticular tissues
• Inconsistant elevated serum urate
• Allopurinol and colchicine
• Tophi in periarticular soft tissues
• Deposits in non-articular cartilage
• Juxta-articular erosions

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20.
L4
L5
Spondylolytic Spondylolisthesis
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Spondylolisthesis

• Lumbosacral junction defect
• Spondylolysis of Pars Interarticularis
• Traumatic or congenital
• Acute immobilize
• Chronic - surgery

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21. The Salter- Harris Classification is used
to assess the severity of -

• a. Epiphyseal Fractures
• b. Developmental Dysplasia of the Hip
• c. Legg Perthes Disease
• d. Club Foot
• e. Osteomyelitis

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21. The Salter- Harris Classification is used
to assess the severity of -

• a. Epiphyseal Fractures

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22. What is this deformity?
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22. A Diner Fork Deformity
Probable Diagnosis?
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1. Colles Fracture

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22. Colles Fracture

• distal radial fracture
• FOOSH
• occurs at all ages
• commonly 60 yrs.
• osteoporosis
• intra-articular

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CR K-Wires
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External vs Internal Fixation
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23. The common complication of this fracture
is -
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23. Proximal pole Avascular Necrosis
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24. This is a -
a. Buckle Fracture b. Greenstick Fracture c.
Stress Fracture d. Pathologic Fracture e. Growth
Arrest line
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24. This is a -
a. Buckle Fracture
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24.
This is a -
a. Buckle Fracture b. Greenstick Fracture c.
Stress Fracture d. Pathologic Fracture e. Growth
Arrest line
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24.
Greenstick Fractures
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25. Is this fracture treated by Closed or Open
Reduction?
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ORIF
25.
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25. Fractures of Necessity
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26. What is the Diagnosis?
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26. Posterolateral Dislocation of the Elbow
127
26. Reduction by traction.
TRACTION
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27. What is the Diagnosis?
129
27. Anterior Dislocation of the Shoulder
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27. Reduction by traction
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28.
This is a -
a. Supracondylar b. Olecranon c.
Dislocation d. Forearm e. Radial Head
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28.
This is a -
a. Supracondylar
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28. Supracondylar Fracture
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29. The complications of a Supracondylar
fracture in children include all of the
following except -

• a. Malunion
• b. Volkmanns Ischemic Contracture
• c. Compartment Syndrome
• d. Cubitus Varus
• e. Peripheral Nerve Injuries
• f. Pulmonary Fat Embolus

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29. The complications of a Supracondylar
fracture in children include all of the
following except -

• f. Pulmonary Fat Embolus

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30. The only sign of a Compartment Syndrome
that is always present is -

• a. Pain
• b. Pallor
• c. Pulselessness
• d. Paresthesias
• e. Paralysis

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30. The only sign of a Compartment Syndrome
that is always present is -

• a. Pain

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31. Compartment pressures indicating the need
for fasciotomy -

• a. 0 15 mms. Hg
• b. 15 25 mms. Hg
• c. gt 25 mms. Hg
• d. gt 50 mms. Hg
• e. gt 75 mms. Hg

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31. Compartment pressures indicating the need
for fasciotomy -

• c. gt 25 mms. Hg

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32. A 20 yr. old male with a fractured femur
has findings of confusion, tachypnea and
conjunctival petechia. The most likely diagnosis
is -

• a. Pneumonia
• b. Pulmonary Fat Emboli
• c. Cerebral Contusion
• d. Cardiac Contusion
• e. Transient Stress Reaction

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32. A 20 yr. old male with a fractured femur
has findings of confusion, tachypnea and
conjunctival petechia. The most likely diagnosis
is -

• b. Pulmonary Fat Emboli

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35. The commonest complication of this
fracture is -
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35. A Radial Nerve Palsy
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36. Does this fracture require surgery?
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36. Does this fracture require surgery?
Yes
146
37. Does this fracture require surgery?
147
37. Does this fracture require surgery?
No
148
38. This patient most likely has a fracture
of the --------.
149
38. This patient most likely has a fracture
of the --------.
Hip
150
38. This patient most likely has a fracture
of the hip.
External Rotation Shortening Hip Flexion
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38.
152
39. Whats the Diagnosis?
153
39. Sub-Capital Hip Fracture.
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40. All of the following are complications of
this fracture except -
a. Malunion b. Avascular necrosis c. Fat
emboli d. Non-union e. Thrombophlebitis
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40. All of the following are complications of
this fracture except -
c. Fat emboli
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40. Blood Supply of Femoral Head
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40. Save Head versus Replacement
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40. Subcapital Hip Fractures
Properties
1. Avascular Necrosis - 30 2. Malunion -
30 3. Non-union - 30 4. Surgery required 5.
Older population 6. Pathologic - Osteoporotic

159
41. Whats the Diagnosis?
160
41. Intertrochanteric Hip Fracture
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41. Intertrochanteric Fractures
Properties

• 1. Varus deformity
• 2. Well - Healing
• Traumatic Osteoporosis
• Surgery required
• Mid-range Age population

162
43.Surgery or not?
163
43.Surgery or not?
Yes
164
44. Surgery or not?
165
44. Surgery or not?
Yes
166
45. What is the approach to this fracture?
23 y.o. male Basketball injury Open fracture
Numbness dorsum toes
167
45.
Reduce dislocation Sterile dressing Splint
extremity Re-check NV status IV Antibiotics
Tetanus Surgery
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48. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back
pain and right sided sciatica to his foot, after
chopping wood at the cottage. Upon arising the
following morning, he notices numbness on the
outer border of his right foot and some
weakness in the right leg. He has no bowel or
bladder problems. The most likely diagnosis
would be-

• a. Lumbar Muscular Strain.
• b. Herniated Lumbar Disc.
• c. Herniated Lumbosacral Disc.
• d. Cauda Equina Syndrome.
• e. Spinal Stenosis.

169
48. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back
pain and right sided sciatica to his foot, after
chopping wood at the cottage. Upon arising the
following morning, he notices numbness on the
outer border of his right foot and some
weakness in the right leg. He has no bowel or
bladder problems. The most likely diagnosis
would be-

• c. Herniated Lumbosacral Disc.

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49. Your initial approach to this problem would
include some or all of the following-

• a. Bedrest.
• b. Anti-inflammatories.
• c. Muscle Relaxants.
• d. Spinal X-rays.
• e. Physiotherapy.
• f. Orthopedic/Neurosurgical referral.
• g. CT-Myelogram or MRI
• h. Discectomy

171
49. Your initial approach to this problem would
include some or all of the following-

• a. Bedrest.
• b. Anti-inflammatories.
• c. Muscle Relaxants.
• d. Spinal X-rays.
• e. Physiotherapy.
• f. Orthopedic/Neurosurgical referral.
• g. CT-Myelogram or MRI
• h. Discectomy

?
172
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-

• a. Reassure the patient that this is not serious
• b. Order an urgent MRI
• c. Get an urgent referral to Neuro/Orthopedics
• d. Place the patient on immediate bedrest.

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50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-

• c. Get an urgent referral to Neuro/Orthopedics

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51. A lumberjack felling a tree is unfortunately
struck on the back by the tree, knocking him to
the ground and injuring his left lower extremity.
In the ER, his left hip is in flexion, adduction
and internal rotation. The most likely diagnosis
is-

• a. Fracture of the Hip.
• b. Fracture of the Femur.
• c. Anterior Hip Dislocation.
• d. Posterior Hip Dislocation.
• e. Fracture of Pelvis.

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51. A lumberjack felling a tree is unfortunately
struck on the back by the tree, knocking him to
the ground and injuring his left lower extremity.
In the ER, his left hip is in flexion, adduction
and internal rotation. The most likely diagnosis
is-

• d. Posterior Hip Dislocation.

176
52. Which of the following signs and symptoms
are consistent with a torn medial meniscus of
the knee-

• a. Inability to squat
• b. Pain on descending stairs
• c. Locking
• d. Recurrent effusions
• e. All of the above.

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52. Which of the following signs and symptoms
are consistent with a torn medial meniscus of
the knee-

• a. Inability to squat
• b. Pain on descending stairs
• c. Locking
• d. Recurrent effusions
• e. All of the above.

178
53. A 35 yr. old male falls jogging and sustains
an undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-

• a. Re-X-ray the ankle.
• b. Remove the cast.
• c. Measure the compartment pressures.
• d. Instruct the patient to elevate the limb
  and prescribe an anti-inflamatory.

179
53.. A 35 yr. old male falls jogging and sustains
an undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-

• b. Remove the cast.

180
54. The most common dislocations of the shoulder
are-

• a. Medial.
• b. Posterior.
• c. Luxatio Erecta.
• d. Anterior.

181
54. The most common dislocations of the shoulder
are-

• d. Anterior.

182
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-

• a. Thyroid.
• b. Pancreas.
• c. Prostate.
• d. Kidney.
• e. Lung.

183
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-

• c. Prostate.

184
Th - Tha Thats all folks!