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Kaplan Test USMLE Step 2 CK Lecture Notes Surgery .. Historically, all penetrating injuries to zone 2 mandated surgical exploration, with a recent trend . USMLE Step 2 CK Lecture Notes 5-book set (Kaplan Test Prep) 1st Edition Organized as a perfect complement to First Aid for the USMLE Step 2 CK To continue to Epidemiology & Ethics. Lecture Notes. KAPLAN medical. *USMLE.

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+ 44 (0) 20 | | [email protected] Try the USMLE Step 2 CK questions below, pick one best answer from the. Kaplan Step 2 CK LN Psychiatry Epidemiology - Ebook download as PDF File .pdf) or read book online. The only official Kaplan Lecture Notes for USMLE Step 2 CK cover the comprehensive information you need to ace the USMLE Step 2 and match into the.

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Amazon education Mastercard with Instant Spend. Differential diagnosis is essential, because additional fluid and blood administration in this setting could be lethal, as the failing heart becomes easily overloaded. It can also result in circulatory collapse.

USMLE Step 2 CK Lecture Notes 2019: Internal Medicine Pdf

Treatment with phenylephrine and fluids is aimed at filling dilated veins and restoring peripheral resistance. Key points include assessing for the patient's ability to move all extremities, looking for gross defects. Check for signs of trauma, bleeding, skin irritations, needle marks, and warm body temperature. The secondary survey may be augmented with further imaging studies depending on the mechanism of injury and findings on examination. Any change that occurs requires complete re-evaluation, including rechecking that there has not been a change in the ABCs.

Linear skull fractures are left alone if they are closed no overlying wound. Open fractures require wound closure. If comminuted or depressed, treat in the OR. The threshold for obtaining a brain CT should be very low.

Basilar skull fractures can be difficult to diagnose. CT scan of the head is required to rule out intracranial bleeding and should be extended to include the neck with reconstruction to evaluate for a cervical spinal injury.

Expectant management is the rule and antibiotics are not usually indicated. Traumatic brain injury TBI from trauma can be caused by 3 components: CT scan shows a biconvex, lens-shaped hematoma, typically in the fronto-temporal area. Emergency craniotomy produces a dramatic cure. Because most patients with a history of having been unconscious get a CT scan, the full- blown picture with a fixed pupil and contralateral hemiparesis is seldom seen.

Acute subdural hematoma SDH also arises from a blow to the head, but the force of the trauma is typically much larger and the patient is usually much sicker not fully awake and asymptomatic at any point , due to more severe neurologic damage. CT scan will show semilunar, crescent-shaped hematoma. If midline structures are deviated, craniotomy to evacuate the blood is indicated, but the prognosis is frequently poor.

Kaplan Step 2 ck 2008-2009 - Obstetrics and gynecology Notes

If there is no deviation, therapy is centered on preventing further damage from subsequent increased ICP. Invasive ICP monitoring, head elevation, modest hyperventilation, avoidance of fluid overload, and diuretics such as mannitol or furosemide can decrease ICP.

Sedation is used to decrease brain activity and oxygen demand. Moderate hypothermia is currently recommended to further reduce cerebral oxygen demand. Diffuse axonal injury occurs in more severe trauma secondary to anoxia or decreased cerebral perfusion.

CT scan shows diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages. Since there is not a discrete hematoma, there is no role for surgery.

Therapy is directed at preventing further damage from increased ICP. Chronic subdural hematoma SDH may be seen in the setting of unrecognized subdural or expansion of acute SDH that was not drained.

Chronic subdural hematoma may develop from minor trauma, often in older individuals with underlying brain atrophy, from a tear of the venous sinuses.

Over several days or weeks, mental function deteriorates as hematoma forms. Neurologic symptoms may arise from a sub-clinical hematoma as the red blood cells lyse leading to osmotic expansion of the fluid collection. CT scan is diagnostic, and surgical evacuation provides dramatic improvement. Hypovolemic shock cannot happen from intracranial bleeding: Look for another source. Zone 1 begins at the clavicles and extends to the level of the cricoid cartilage Zone 2 is located between the cricoid cartilage and the angle of the mandible Zone 3 runs from the angle of the mandible to the base of the skull Surgical exploration for penetrating trauma to the neck is indicated in cases where there is an expanding hematoma, deteriorating vital signs, and signs of esophageal or tracheal injury such as coughing or spitting up blood.

For injuries to zone 1, evaluate with CTA and neck CT esophagogram water- soluble, followed by barium if negative , esophagoscopy, and bronchoscopy to help decide if surgical exploration is indicated and to determine the ideal surgical approach.

Historically, all penetrating injuries to zone 2 mandated surgical exploration, with a recent trend toward selective exploration based on physical exam and imaging studies.

If the patient is stable with low index of suspicion of a significant injury, use CTA and neck CT to potentially avoid unnecessary surgical exploration.

For injuries to zone 3, evaluate with CT angiography to identify any vascular injury. In all patients with severe blunt trauma to the neck, the integrity of the cervical spine has to be ascertained. Unconscious patients and conscious patients with midline tenderness to palpation should be evaluated initially with CT scan, potentially followed with MRI depending on findings.

Transection of the spinal cord results in irreversible complete loss of motor and sensory neurologic function below the level of the injury. Spinal shock should be considered in the acute trauma setting if there is hypotension and paralysis, often accompanied by bradycardia. A few specific conditions related to spinal cord injury follow. Complete transection is unlikely to be on the exam because it is too easy: Hemisection Brown-Sequard is typically caused by a clean-cut injury such as a knife blade, and results in ipsilateral paralysis and loss of proprioception along with contralateral loss of pain perception below the level of the injury.

Anterior cord syndrome is typically seen with burst fractures of the vertebral bodies. There is loss of motor function, pain and temperature sensation bilaterally below the injury, but vibratory and positional sense are preserved. Central cord syndrome occurs in the elderly with forced hyperextension of the neck, such as a rear-end collision. There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.

Management necessitates precise diagnosis of a cord injury, best done with MRI. There is some evidence that high-dose corticosteroids immediately after the injury may help, but that concept is still controversial. Further surgical management is too specialized for the exam.

To avoid this cycle, treat pain from rib fractures with a local nerve block or epidural catheter, in addition to oral and IV analgesics. Figure I All rights reserved. Simple pneumothorax results from collapse of the lung. Mechanisms include penetrating injury, rib fracture with puncture of lung, and secondary iatrogenic causes e. There is typically moderate shortness of breath with absence of unilateral breath sounds and hyperresonance to percussion.

Diagnosis is confirmed with chest x-ray, and management consists of chest tube placement. Hemothorax occurs when blunt or penetrating injury results in bleeding into the chest cavity.

The blood can originate directly from the lung parenchyma or from the chest wall, such as an intercostal artery. Physical examination reveals decreased breath sounds on the affected side, accompanied by dullness to percussion. Diagnosis is confirmed with chest x-ray. Chest tube placement is necessary to enable evacuation of the accumulated blood to prevent late development of a fibrothorax or empyema, but surgery to stop the bleeding is sometimes required. If the lung is the source of bleeding, it usually stops spontaneously as it is a low pressure system.

In some cases where a systemic vessel such as an intercostal artery is the source of bleeding, thoracotomy is needed to stop the hemorrhage. Indications for thoracotomy include: Sucking chest wounds are obvious from physical exam. If there is a flap that sucks air with inspiration and closes during expiration it could lead to a tension pneumothorax.

A sucking chest wound can also arise from an open pneumothorax, where a larger open wound leads to the inability to exchange air on the side of the injury. Initial management is with a partially occlusive dressing secured on 3 sides, with one open side acting as a one-way valve.

This allows air to escape but not to enter the pleural cavity to prevent iatrogenic tension pneumothorax. The real problem is the underlying pulmonary contusion. A contused lung is very sensitive to fluid overload, thus treatment includes fluid restriction and aggressive pain management.

Pulmonary dysfunction may develop, thus serial chest x-rays and arterial blood gases have to be monitored. Significant force is necessary to result in a flail chest, so traumatic dissection or transection of the aorta should be evaluated for using a CT angiogram. Finally, ARDS may develop in this scenario. Blunt cardiac injury should be suspected with the presence of sternal fractures.

ECG monitoring will detect any abnormalities. Traumatic rupture of the diaphragm shows up with the bowel in the chest by physical exam and x-rays , almost always on the left side the liver protects the right hemidiaphragm. If diaphragmatic injury is suspected it should be evaluated with laparoscopy, although gas insufflation of the peritoneum may complicate anesthetic care.

Surgical repair is typically done from the abdomen. Such an injury can occur in the setting of a significant deceleration injury and may be totally asymptomatic until the hematoma contained by the adventitia ruptures resulting in rapid death.

Aortic injury should be suspected if: Mechanism of injury, high energy deceleration mechanism Widened mediastinum on chest x-ray or mediastinal hematoma on chest CT Presence of atypical fractures such as the first or second rib, scapula, or sternum, all of which require great force to fracture Diagnosis is made with CT angiogram.

Surgical repair is indicated once the patient has been stabilized and more immediate live-threatening injuries have been managed. Repair of aortic injury can be done in an open or endovascular fashion. Surgical repair is indicated. Differential diagnosis of subcutaneous emphysema also includes rupture of the esophagus and tension pneumothorax. Air embolism can produce sudden cardiovascular collapse and cardiac arrest. It should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respirator.

It also can occur in a spontaneously breathing patient if the subclavian vein is opened to the air e. Prevention of air embolism includes use of the Trendelenburg position when the great veins at the base of the neck are to be accessed. Fat embolism may also produce respiratory distress in a trauma patient who is without direct chest trauma. The typical setting is the following: Patient with multiple traumatic injuries including several long bone fractures develops petechial rashes in the axillae and neck; fever, tachycardia, and low platelet count At some point patient develops a full-blown picture of respiratory distress, with hypoxemia and bilateral patchy infiltrates on chest x-ray The mainstay of therapy for fat embolism is respiratory support.

Other therapies for this syndrome including heparin, steroids, alcohol, or low-molecular-weight dextran have been discredited. Penetrating trauma is further differentiated into gunshot wounds and stab wounds as the pattern of injury based on mechanism is quite different. Stab wounds allow a more individualized approach. In the absence of the conditions above, local wound exploration may be performed in the ED to assess whether or not the anterior rectus fascia has been penetrated. If the fascia is not violated, the intra-abdominal cavity likely has not been penetrated and no further intervention is necessary.

If the fascia has been violated, surgical exploration is indicated to evaluate for bowel or vascular injury, even in the setting of hemodynamic stability and lack of peritoneal findings on physical examination. If there is any question, perform CT. Blunt trauma to the abdomen with obvious signs of peritonitis or suspected intra-abdominal hemorrhage requires emergent surgical evaluation via exploratory laparotomy. Signs of internal injury include abdominal distention and significant abdominal pain with guarding or rigidity on physical examination consistent with peritonitis.

The occurrence of blunt trauma even without obvious signs of internal injury requires further evaluation because internal hemorrhage or bowel injury can be slow and therefore present in a delayed fashion. Patients tend to be cold, pale, anxious, shivering, thirsty, and perspiring profusely.

There are few places in the body that this volume of blood can be lost without being obvious on physical or radiographic exam. The head is too small without causing a lethal degree of intracranial pressure. The pleural cavities could easily accommodate several liters of blood, with relatively few local symptoms, but such a large hemothorax would be obvious on chest x-ray, which is routinely obtained as part of the primary survey in a trauma patient.

The femurs and pelvis are always checked for fractures in the initial survey of the trauma patient by physical exam and pelvic x-ray. So any patient who is hemodynamically unstable with normal chest and pelvic x-rays likely has intra-abdominal bleeding. Ultrasound is an important, readily available, adjunct to identify intra-abdominal and pericardial fluid.

The Focused Abdominal Sonography for Trauma FAST is a bedside ultrasound study that Bedside evaluates the perihepatic space, perisplenic space, pelvis, and pericardium for free fluid.

Fluid is not typically present in these locations, so if there is a clinical suspicion such as hypotension following blunt trauma, consider an internal injury. A stable patient in whom the diagnosis is less definite should undergo a more definitive study, i.

CT will show the presence of intra-abdominal fluid and can accurately delineate the source, typically the liver or spleen. Additionally, grading scores exist for the extent of solid organ injury, with specific guidelines as to when a surgical intervention is indicated versus observation. The details of these guidelines are outside the scope of the exam.

Generally speaking, a patient with intra-abdominal bleeding injury from the liver or spleen can be observed as long as they are hemodynamically stable or respond to fluid and blood product administration; the moment instability is mentioned in a vignette, surgical exploration is indicated. If surgical exploration is indicated for penetrating or blunt trauma, certain principles must be employed. The longer a patient is open, the worse these components get, and they can interact in a vicious cycle ultimately leading to death.

The over-arching principle is to control bleeding. Once bleeding is controlled, the next priority is control of contamination from injury to the GI tract. If a bowel resection is necessary, reconstruction can be delayed as only the contamination is life-threatening, not the inability to digest food.

If hypothermia, coagulopathy, or acidosis is setting in and injuries have been controlled, the operation is terminated and the abdomen is closed with a temporary closure. The patient is resuscitated in the ICU, and returns to the OR at a later date when warm, not coagulopathic, and not acidotic for definitive reconstruction and abdominal closure.

If coagulopathy does develop during surgical exploration, it is best treated with transfusion of RBCs, fresh frozen plasma, and platelets in equal quantities 1: This most realistically mimics the replacement of whole blood and provides not only hemoglobin, but also adequate clotting factors to reverse the developing coagulopathy and enable control of hemorrhage.

Abdominal compartment syndrome is when the pressure in the peritoneal cavity is elevated and and exceeds the capillary perfusion pressure leading to end-organ injury. This occurs when a significant amount of fluid is administered in an effort to resuscitate a patient in hypovolemic shock. Bowel edema develops, increasing intra-abdominal pressure IAP , which is detrimental for several reasons. First, the elevated pressure leads to decreased perfusion pressure to the viscera, contributing to acute kidney injury and possibly bowel and hepatic ischemia.

Second, increased IAP leads to upward displacement of the diaphragm preventing adequate expansion of the lungs and ventilation, contributing to respiratory failure. Similarly, if a patient is not surgically explored but undergoes a significant volume resuscitation and abdominal compartment syndrome develops, a decompressive laparotomy may be indicated.

Incidentally, this can occur in non-trauma scenarios requiring massive fluid resuscitation, most notably severe pancreatitis. A ruptured spleen is the most common source of significant intra-abdominal bleeding in blunt abdominal trauma. Often there are additional diagnostic hints, such as fractures of lower ribs on the left side. Given the limited function of the spleen in the adult, a splenic injury resulting in hemodynamic instability or requiring significant blood product transfusion is an indication for splenectomy.

Post-operative immunization against encapsulated bacteria is mandatory Pneumococcus, Haemophilus influenza B, and Meningococcus. However, lesser injuries to the spleen which can be repaired easily are attempted. These can range from minor to life-threatening. Minor fractures with small pelvic hematomas incidentally identified on CT scan are typically monitored. In pelvic fracture with ongoing significant bleeding causing hemodynamic instability, management is complex.

The first step for an obvious pelvic fracture in an unstable patient is external pelvic wrapping to provide some stabilization of the pelvis, thereby limiting the potential space for ongoing blood loss. In most cases angiography, not surgical exploration , is the next step in managing hemorrhage from serious pelvic fracture. This is because it is incredibly difficult often impossible to identify the source of bleeding in the pelvis where a deep cavity contains significant organs and vessels including the complex sacral venous plexus.

However, interventional radiologists can angiographically identify an arterial source of bleeding and potentially embolize the branch vessels and control hemorrhage. If no arterial bleeding is identified, the ongoing blood loss is presumed to be venous in origin, and the internal iliac arteries are prophylactically embolized to prevent the inflow to these bleeding veins. In any pelvic fracture, associated injuries have to be ruled out. These include injuries to the rectum do a rectal exam and rigid proctoscopy , vagina in women do a manual vaginal exam ; urethra in men do a retrograde urethrogram , and bladder addressed in the next section.

Gross hematuria in that setting must be investigated with appropriate studies. Penetrating urologic injuries as a rule are surgically explored and repaired.

Blunt urologic injuries may affect the kidney, in which case the associated injuries tend to be lower rib fractures. If they affect the bladder or urethra, the usual associated injury is pelvic fracture. Urethral injuries occur almost exclusively in men. They are typically associated with a pelvic fracture and may present with blood at the meatus. The key issue in any of these is that a Foley catheter should not be inserted, as it might compound an existing injury; a retrograde urethrogram should be performed instead.

If Foley catheter placement is attempted and resistance met, this should be a clue that a urethral injury may be present and attempt should be aborted. Bladder injuries can occur in either sex, are usually associated with pelvic fracture, and are diagnosed by retrograde or CT cystogram.

The x-ray study must include post-void films to enable visualization of extraperitoneal leak that might be obscured by a bladder full of dye. Renal injuries secondary to blunt trauma are usually associated with lower rib fractures. They are assessed by CT and most of the time can be managed without surgical intervention. A rare but fascinating potential sequela of injuries affecting the renal pedicle is the development of an arteriovenous fistula leading to CHF.

Should renal artery stenosis develop after trauma, renovascular hypertension is another potential sequela. Scrotal hematomas can attain alarming size, but typically do not need specific intervention unless the testicle is ruptured. The latter can be assessed with ultrasound examination.

Penile fracture disruption of the corpora cavernosa or the tunica albuginea occurs to an erect penis, typically during vigorous intercourse more often with a partner on top. There is sudden pain and development of a penile shaft hematoma, with a normal appearing glans.

Frequently, the true history will be concealed by an embarrassed patient. Emergency surgical repair is required. If not done, impotence will ensue as either arteriovenous shunts or painful erections. Often it involves orthopedic, soft tissue, vascular, or nerve injury. Vascular injury has the potential to be immediately life-threatening and should be the initial focus in evaluation.

In penetrating injuries of the extremities, the main issue is whether a vascular injury has occurred or not. Anatomic location provides the first clue. When there are no major vessels in the vicinity of the injury, only tetanus prophylaxis and irrigation of the wound is required.

If the penetration is near a major vessel and the patient is asymptomatic, Doppler studies or CT angiogram is performed and will guide the need for a surgical intervention. If there is an obvious vascular injury absent distal pulses, expanding hematoma surgical exploration and repair are required. Simultaneous injuries of arteries and bone pose the challenge of the sequence of operative repair. One perspective is to stabilize the bone first, then do the delicate vascular repair which could otherwise be disrupted by the bony reduction and fixation.

However during the orthopedic repair, ongoing ischemia is occurring as the arterial flow is disrupted. A good solution, if proposed on the exam, is to place a vascular shunt, which allows temporary revascularization during the bony repair, with definitive vascular repair completed subsequently. A fasciotomy should usually be added because prolonged ischemia could lead to a compartment syndrome.

High-velocity gunshot wounds e. Crushing injuries of the extremities resulting in myonecrosis pose the hazard of hyperkalemia and renal failure as well as potential development of compartment syndrome. Aggressive fluid administration, osmotic diuretics, and alkalinization of the urine with sodium bicarbonate are good preventive measures for the acute kidney injury, and a fasciotomy may be required to prevent or treat compartment syndrome.

Alkaline burns Liquid Plumr, Drano are worse than acid burns battery acid. Irrigation must begin as soon as possible at the site where the injury occurred tap water, shower. Do not attempt to neutralize the agent.

High-voltage electrical burns are always deeper and worse than they appear to be. Massive debridements or amputations may be required. Additional concerns include myonecrosis-induced acute kidney injury, orthopedic injuries secondary to massive muscle contractions e.

Of course cardiac electrical integrity and function must be evaluated. Respiratory burns inhalation injuries occur with flame burns in an enclosed space a burning building, car, plane and are chemical injuries caused by smoke inhalation.

Burns around the mouth or soot inside the throat are suggestive clues. Diagnosis is confirmed with fiberoptic bronchoscopy, but the key issue is whether respiratory support is necessary, guided by serial arterial blood gases.

Intubation should be initiated if there is any concern about adequacy of the airway. This can also occur in circumferential burns to the chest, with resultant limitations in ventilation.

Escharotomies of insensate full-thickness burns can be done at the bedside with no need for anesthesia to provide immediate relief. Scalding burns in children should always raise the suspicion of child abuse, particularly if the pattern of the burn does not fit the description of the event given by the parents.

A classic example is burns of both buttocks, which are typically produced by holding a small child by rbaygell arms and legs and dunking him into boiling water.

Burns differ importantly from other types of traumatic injury.

Burns result in the loss of skin integrity and increase insensible fluid losses, leading to profound hypovolemia and loss of temperature control. When in doubt consult a burn center before initiating fluid resuscitation or other interventions. In the first 24 hours after burn, fluid needs can be estimated by calculations that take into account the extent of the burn and provide an estimated amount of IV fluid that is needed.

Once fluid resuscitation has been initiated, adjust rate based on urinary output. For purposes of this calculation, only partial and full thickness previously referred to as second- and third-degree burns count. The 24 hour time window for burn resuscitation begins from the time of the burn injury!

Parkland Formula: Alternative strategy: Fluids containing glucose are avoided to prevent an osmotic diuresis that would render urine output unreliable and exacerbate hypovolemia. Fluid needs for burned babies differ from adults in several respects.

Third-degree burns in babies look deep red rather than the leathery, dry, gray appearance present in adults. Other aspects of burn care include tetanus prophylaxis, cleaning of the burn areas, and the use of topical agents. The standard topical agent is silver sulfadiazine. If a topical agent with deep penetration is necessary e.

Burns near the eyes are covered with bacitracin or triple antibiotic ointment silver sulfadiazine is irritating to the eyes. In the early period, all pain medication is given intravenously because GI absorption is unpredictable.

After 2 or 3 weeks of wound care and general support, the burned areas which have not regenerated are grafted. Rehabilitation starts on day 1. When possible, early excision and skin grafting are recommended to save costs and minimize pain, suffering, and complications.

Dog bites are considered provoked if the dog was petted while eating or otherwise teased. No rabies prophylaxis is required, other than observation of the dog for developing signs of rabies. Unprovoked dog bites or bites from wild animals raise the issue of potential rabies. If the animal is available, it can be euthanized and the brain examined for signs of rabies.

Otherwise, rabies prophylaxis with immunoglobulin plus vaccine is mandatory. The most reliable signs of envenomation are severe local pain, swelling, and discoloration developing within 30 minutes of the bite. If such signs are present, draw blood for typing and crossmatch they cannot be done later if needed , coagulation studies, and liver and renal function.

Treatment is based on antivenin. Antivenin dosage relates to the size of the envenomation, not the size of the patient children get the same dosages as adults. Surgical excision of the bite site or fasciotomy is very rarely needed. The only valid first aid is to splint the extremity during transportation.

Do not make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet. Bee stings kill many more people in the United States than snakebites because of an anaphylactic reaction. Epinephrine is the drug of choice 0. The stingers should be removed without squeezing them. Black widow spiders have a characteristic a red hourglass on the belly.

Bitten patients experience nausea, vomiting, and severe generalized muscle cramps. The antidote is IV calcium gluconate. Muscle relaxants also help. Brown recluse spider bites are often not recognized at the time of the bite. In the next several days, a skin ulcer develops, with a necrotic center and a surrounding halo of erythema.

Surgical debridement of all necrotic tissue is needed. Skin grafting may be needed subsequently. Human bites are bacteriologically the dirtiest bite one can get. They require extensive irrigation and debridement in the OR and antibiotics. A classic human bite is the sharp cut over the knuckles on someone who punched someone else in the mouth and was cut by the teeth of the victim. They often show up in the ED with a cover story, but should be recognized because they need specialized orthopedic care.

Hip pathology in older children may present as hip or knee pain. Legg-Calve- Perthes disease is avascular necrosis of the capital femoral epiphysis and occurs around age 6, with insidious development of limping, decreased hip motion, and hip or knee pain. Diagnosis is confirmed by AP and lateral hip x-rays. Treatment is controversial, usually containing the femoral head within the acetabulum by casting and crutches.

Slipped capital femoral epiphysis SCFE is the most common hip disorder in adolescents. It is an orthopedic emergency because further slippage may compromise the blood supply and result in avascular necrosis of the femoral head. The typical patient is an overweight boy around age 13 who complains of groin or knee pain, and who ambulates with a limp.

When sitting with the legs dangling, the sole of the foot on the affected side points toward the other foot. On physical exam there is limited hip motion, and as the hip is flexed the thigh goes into external rotation and cannot be rotated internally.

X-rays are diagnostic, and surgical treatment relies on placement of pins to hold the femoral head back in place. A septic hip is an orthopedic emergency. It is seen in toddlers who have had a febrile illness, and then refuse to move the hip. They hold the leg with the hip flexed, in slight abduction and external rotation, and appear uncomfortable with passive movement of the joint e.

White blood cell count and erythrocyte sedimentation rate are elevated. Diagnosis is made by aspiration of the hip under general anesthesia, and surgical irrigation and open drainage are performed if pus is obtained. Acute hematogenous osteomyelitis is seen in small children who have had a febrile illness and presents as severe localized pain in a bone with no history of trauma to that bone. X-rays will not show anything for several weeks. MRI reveals prompt diagnosis.

Treatment is IV antibiotics. Genu varum bow-legs is normal up to age 3; no treatment is needed. Genu valgus knock-knee is normal between ages 4—8; no treatment is needed. Osgood-Schlatter disease osteochondrosis of the tibial tubercle is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps.

Physical exam shows localized pain right over the tibial tubercle in the absence of knee swelling.

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Treatment is initially with rest, ice, compression, and elevation. If conservative management fails, treatment is immobilization of the knee in an extension or cylinder cast for 4—6 weeks. Club foot talipes equinovarus is seen at birth. Both feet are turned inward, and there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia.

The most sensitive screening finding is to look at the girl from behind while she bends forward. In addition to the cosmetic deformity, severe cases develop decreased pulmonary function. Bracing is used to arrest progression; severe cases may require surgery. Early treatment is mandated. Also, the healing process is much faster than in the adult. The only areas where children have special problems include supracondylar fractures of the humerus and fractures of any bone that involve the growth plate or epiphysis.

Supracondylar fractures of the humerus occur with hyperextension of the elbow in a child who falls on the hand with the arm extended. The injuries are particularly dangerous due to the proximity of the brachial artery and ulnar nerve. Although these fractures are treated with standard casting or traction and rarely need surgery, they require careful monitoring of vascular and nerve integrity and vigilance regarding development of compartment syndrome.

Supracondylar Fracture of the Humerus Fractures that involve the growth plate or epiphysis can be treated by closed reduction if the epiphysis and growth plate are displaced laterally from the metaphysis but they are in one piece i.

If the growth plate is fractured into two pieces, open reduction and internal fixation will be required to ensure precise alignment and even growth to avoid chronic deformity of the extremity.

The Salter Harris SH classification is commonly used to grade epiphyseal fractures. Clavicular fracture is typically at the junction of middle and distal thirds. It is treated by placing the arm in a sling. Figure-of-8 bandage treatment is now less popular. Anterior dislocation of the shoulder is by far the most common shoulder dislocation.

Patients hold the arm close to their body but rotated outward as if they were going to shake hands. There may be numbness in a small area over the deltoid, from stretching of the axillary nerve. AP and lateral x-rays are diagnostic.

Some patients develop recurrent dislocations with minimal trauma. Posterior shoulder dislocation is rare and occurs after massive uncoordinated muscle contractions, such as epileptic seizure or electrical burn. The arm is held in the usual protective position close to the body, internally rotated. Regular x- rays can easily miss it; axillary views or scapular lateral views are needed.

Treatment is with close reduction and long arm cast. Monteggia fracture results from a direct blow to the ulna i. There is diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head.

Galeazzi fracture is the mirror image: In both of these, the broken bone often requires open reduction and internal fixation, whereas the dislocated one is typically handled with closed reduction. Fracture of the scaphoid carpal navicular affects a young adult who falls on an outstretched hand. Chief complaint is typically wrist pain, with physical exam revealing localized tenderness to palpation over the anatomic snuff box.

In undisplaced fractures, x-rays are usually negative, but thumb spica cast is indicated just with the history and physical findings. X-rays will show the fracture 3 weeks later. If original x-rays show displaced and angulated fracture, open reduction and internal fixation are needed.

Scaphoid fractures are notorious for a very high rate of nonunion secondary to avascular necrosis. Metacarpal neck fracture typically the fourth or fifth, or both happens when a closed fist hits a hard surface like a wall. The hand is swollen and tender, and x-rays are diagnostic. Treatment depends on the degree of angulation, displacement, or rotary malalignment: Hip fracture is a bit of a misnomer for fractures that involve the proximal femur.

These fractures typically occur in the elderly following a fall. Specific treatment depends on the specific location as shown by x-rays. Femoral neck fracture, particularly if displaced, compromises the very tenuous blood supply of the femoral head.

Faster healing and earlier mobilization can be achieved by replacing the femoral head with a prosthesis. Right Femoral Neck Fracture on X-ray Intertrochanteric fracture is less likely to lead to avascular necrosis and is usually treated with open reduction and pinning. The unavoidable immobilization that ensues poses a very high risk for deep venous thrombosis and pulmonary emboli, thus post-op anticoagulation is recommended.

Femoral shaft fracture is common and often requires operative management in adults with intramedullary rod fixation.Additionally, those with a graduation date prior to who have not passed the Step 2 CK taken on or before June 30, must pass the Step 2 CS. Challenge Questions Board style vignettes you can take by topic or mix and match to prepare for the test. Bitten patients experience nausea, vomiting, and severe generalized muscle cramps. CT scan helps assess operability.

De Quervain tenosynovitis is more common in women and is often seen after pregnancy. When possible, early excision and skin grafting are recommended to save costs and minimize pain, suffering, and complications.

The level of the pouch is determined with x-rays taken upside down so the gas in the pouch goes up , with a metal marker taped to et the anus.