Master the board step 3

Surgery
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Closed reduction is the answer for fractures that are not badly displaced or
angulated.
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Open reduction and internal fixation is the answer when the fracture is
severely displaced or angulated or cannot be aligned.
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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.
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Always perform cervical spine films in any patient with facial injuries.
Fracture Management
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.
• Anterior dislocation:
This is the most common
shoulder dislocation.
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 forearm
is internally rotated.
Anterior Dislocation of the Shoulder
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