ABEM Orthopedic & Musculoskeletal Emergencies 2 — Questions and Answers
Question 1: A 30-year-old falls on an outstretched hand and has anatomical snuffbox tenderness. Initial X-rays are negative. What is the most appropriate management?
- Discharge with wrist splint and routine follow-up in 2 weeks
- Thumb spica splint with MRI or repeat X-ray in 1-2 weeks (Correct answer)
- CT scan of the wrist immediately
- Apply cast for 6 weeks without further imaging
Correct answer: Thumb spica splint with MRI or repeat X-ray in 1-2 weeks
Anatomical snuffbox tenderness after a FOOSH injury warrants presumptive treatment for occult scaphoid fracture with thumb spica splinting and early MRI or repeat X-ray due to avascular necrosis risk.
Question 2: A patient presents with a Gustilo type IIIB open tibia fracture with significant soft tissue loss. After hemorrhage control and wound assessment, what is the highest priority in the ED?
- Immediate IV antibiotics and urgent surgical debridement in the OR (Correct answer)
- Wound irrigation with saline followed by primary closure in the ED
- Splinting and outpatient orthopedic follow-up within 24 hours
- ORIF in the ED procedure room
Correct answer: Immediate IV antibiotics and urgent surgical debridement in the OR
Open fractures require immediate IV antibiotics (cephalosporin plus aminoglycoside for type III) and urgent operative debridement to prevent osteomyelitis and sepsis.
Question 3: A 35-year-old is restrained in a head-on collision. He presents with his right hip in flexion, adduction, and internal rotation with severe pain. What is the most likely diagnosis?
- Anterior hip dislocation
- Posterior hip dislocation (Correct answer)
- Intertrochanteric hip fracture
- Central acetabular fracture-dislocation
Correct answer: Posterior hip dislocation
Posterior hip dislocation, the most common type, presents with the hip flexed, adducted, and internally rotated — the classic 'dashboard injury' pattern.
Question 4: A 40-year-old squash player hears a 'pop' and feels as if he was kicked in the back of his leg. He cannot plantar flex against resistance. Which test confirms the diagnosis?
- Anterior drawer test of the ankle
- Thompson test (calf squeeze test) (Correct answer)
- Tinel sign at the heel
- Peroneal provocation test
Correct answer: Thompson test (calf squeeze test)
A positive Thompson test — absence of plantar flexion when the calf is squeezed with the patient prone — confirms complete Achilles tendon rupture.
Question 5: A 7-year-old presents with 3 days of fever, hip pain, and refusal to bear weight. WBC is 18,500, ESR 60, CRP 4.8 mg/dL, and temperature 38.9°C — meeting all 4 Kocher criteria. Ultrasound shows an effusion. What is the definitive treatment?
- IV antibiotics alone for 6 weeks
- Emergent surgical joint irrigation and debridement (Correct answer)
- Joint aspiration alone with IV antibiotics
- NSAIDs and bed rest with repeat labs in 48 hours
Correct answer: Emergent surgical joint irrigation and debridement
Septic arthritis of the hip requires emergent surgical irrigation and debridement plus antibiotics to prevent articular cartilage destruction and avascular necrosis.
Question 6: A patient sustains a closed mid-shaft femur fracture after a motor vehicle collision. Approximately how much blood can accumulate in the thigh from this injury?
- 250-500 mL
- 500-750 mL
- 1000-1500 mL (Correct answer)
- 2500-3000 mL
Correct answer: 1000-1500 mL
A closed femur fracture can cause 1,000-1,500 mL of blood loss into the thigh, enough to precipitate hemorrhagic shock even without external bleeding.
Question 7: A 25-year-old jams her finger and cannot actively extend the distal interphalangeal (DIP) joint; there is a slight flexion deformity. X-ray shows no bony avulsion. What is the correct diagnosis and treatment?
- Boutonniere deformity; PIP extension splinting
- Mallet finger; continuous DIP extension splinting for 6-8 weeks (Correct answer)
- Jersey finger; urgent surgical tendon repair
- Swan neck deformity; hand therapy referral
Correct answer: Mallet finger; continuous DIP extension splinting for 6-8 weeks
Mallet finger results from disruption of the terminal extensor tendon at the DIP joint and is treated with uninterrupted DIP extension splinting for 6-8 weeks.
ABEM Orthopedic & Musculoskeletal Emergencies 2
A 30-year-old falls on an outstretched hand and has anatomical snuffbox tenderness.
Initial X-rays are negative.
What is the most appropriate management?