CPEN CPEN Orthopedic and Musculoskeletal Emergencies 5 — Questions and Answers
Question 1: A 3-year-old presents with a mid-shaft tibia fracture and no history of trauma. Physical exam reveals bruising in multiple stages of healing. The nurse's most important action is to:
- Splint the fracture and discharge with orthopedic referral
- Initiate a child abuse evaluation and notify social work (Correct answer)
- Reassure the parents and attribute the injury to toddler activity
- Order a bone density scan immediately
Correct answer: Initiate a child abuse evaluation and notify social work
A tibia fracture in a non-ambulatory or very young child with unexplained or inconsistent history and multiple bruises is a red flag for non-accidental trauma requiring mandatory reporting and multidisciplinary evaluation.
Question 2: A 16-year-old presents with acute knee pain and swelling after pivoting during soccer. The Lachman test is positive. The nurse anticipates which diagnosis?
- Patellar dislocation
- Anterior cruciate ligament (ACL) tear (Correct answer)
- Medial collateral ligament sprain
- Posterior cruciate ligament tear
Correct answer: Anterior cruciate ligament (ACL) tear
A positive Lachman test (anterior tibial translation at 20–30° flexion) is the most sensitive clinical test for ACL tear.
Question 3: A 6-year-old with a displaced supracondylar humerus fracture has absent radial pulse but a warm, pink hand with good capillary refill. The nurse should prepare for:
- Emergent vascular surgery consultation only
- Closed reduction and percutaneous pinning in the OR (Correct answer)
- Discharge with neurovascular checks
- Non-operative management with a long arm cast
Correct answer: Closed reduction and percutaneous pinning in the OR
A pulseless but perfused hand ('pink pulseless') in a supracondylar fracture is managed with emergent closed reduction and percutaneous pinning, which typically restores perfusion.
Question 4: A 13-year-old runner presents with anterior knee pain that worsens with stair climbing and kneeling. There is tenderness over the tibial tubercle apophysis. Which condition is most likely?
- Osgood-Schlatter disease (Correct answer)
- Patellar tendinopathy
- Chondromalacia patellae
- Prepatellar bursitis
Correct answer: Osgood-Schlatter disease
Osgood-Schlatter disease is traction apophysitis of the tibial tubercle caused by repetitive quadriceps stress during adolescent growth spurts.
Question 5: A 2-year-old is found with a spiral femur fracture after a reported short fall. Which additional assessment is most important for the nurse to perform?
- Bone scan to assess fracture age
- Full skeletal survey to evaluate for other fractures (Correct answer)
- MRI of the femur for soft tissue injury
- Compartment pressure measurement
Correct answer: Full skeletal survey to evaluate for other fractures
A skeletal survey is the standard workup when non-accidental trauma is suspected, as it can reveal occult fractures in various healing stages.
Question 6: A 9-year-old presents with fever, hip pain, and refusal to bear weight. ESR and CRP are elevated. Ultrasound shows joint effusion. To differentiate septic arthritis from transient synovitis, the nurse anticipates which intervention?
- Empiric IV antibiotics without joint aspiration
- Hip joint aspiration for synovial fluid analysis and culture (Correct answer)
- Repeat ultrasound in 48 hours
- Oral ibuprofen and discharge with close follow-up
Correct answer: Hip joint aspiration for synovial fluid analysis and culture
Joint aspiration with synovial fluid analysis (cell count, culture, Gram stain) is required to definitively distinguish septic arthritis from transient synovitis; septic arthritis requires urgent surgical washout.
Question 7: A 15-year-old fell directly onto the lateral shoulder and now holds the arm adducted. X-ray shows the humeral head displaced inferiorly. Which neurovascular structure is most at risk in this injury?
- Radial nerve
- Axillary nerve (Correct answer)
- Ulnar nerve
- Brachial artery
Correct answer: Axillary nerve
Anterior shoulder dislocation most commonly injures the axillary nerve, leading to decreased sensation over the deltoid (regimental badge area) and possible deltoid weakness.
CPEN CPEN Orthopedic and Musculoskeletal Emergencies 5
A 3-year-old presents with a mid-shaft tibia fracture and no history of trauma.
Physical exam reveals bruising in multiple stages of healing.
The nurse's most important action is to: