Master the board step 3

Master the Boards: USMLE Step 3
Following are the best choices for the management of fractures:
Open femoral shaft
fractures are an orthopedic
emergency and can result
in massive blood loss and
a high rate of infection.
Immediate surgery and
cleaning within 6 hours is
needed.
Femoral shaft fractures
cause fat emboli.
Tinel’s sign has greater
specificity than Phalen’s
sign.
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Clavicular fractures: Figure-eight sling
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Colles’ fracture: Closed reduction and casting (Presents often in an elderly
woman who falls on an outstretched hand. Look for a painful wrist with a
“dinner-fork” deformity.”)
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Direct blow to the ulna (Monteggia fracture) or radius (Galeazzi fracture)
results in a combination of diaphyseal fracture and displaced dislocation of
the nearby joint. Open reduction and internal fixation is needed for the
diaphyseal fracture, and closed reduction for the dislocated joint.
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Fall on an outstretched hand with persistent pain in the anatomical snuffbox
is a scaphoid fracture until proven otherwise (takes > 3 weeks to be seen on
x-ray). Place thumb spica cast to help prevent nonunion.
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Consider the possibility of a hip fracture in any elderly patient who sustains
a fall. Look for externally rotated and shortened leg.
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Femoral neck fractures are at high risk of avascular necrosis (tenuous
blood supply) and are best treated with femoral head replacement.
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Intertrochanteric fractures are treated with open reduction and pinning.
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Femoral shaft fractures are treated with intramedullary rod fixation. Be
aware of a high risk for fat emboli.
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Trigger finger (woman who awakens at night with an acutely flexed finger
that “snaps” when forcibly extended) and De Quervain tenosynovitis
(young mother carrying baby with flexed wrist and extended thumb to stabilize
the baby’s head): Steroid injection is the best initial therapy.
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Dupuytren contracture (contracture of the palm with palmar fascial nodules):
Surgery is the treatment if collagenase fails.
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Posterior dislocation of the hip (history of head-on car collision where
the knees hit the dashboard) is an orthopedic emergency. Differentiate it
from hip fracture by an internally rotated leg (the leg is also shortened).
Emergency reduction is needed to avoid avascular necrosis.
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Knee injuries:
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Medial/lateral collateral ligament injury (caused by a direct blow to the
opposite side of the joint): Casting if isolated ligament injury; surgical
repair if multiple ligaments injured.
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Anterior/posterior cruciate ligament injuries (swelling pain and anterior/posterior
drawer sign): Young athletes need arthroscopic repair.
Older patients may be treated with immobilization and rehabilitation.
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Meniscal injury (prolonged pain and swelling with “catching” and “locking”
during ambulation). Treat with arthroscopic repair.
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Tibial stress injury (e.g., history of military or cadet marches): x-ray may be
negative initially. Treat with cast, order the patient not to bear weight, and
repeat films in 2 weeks.
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