Master the board step 3

Surgery
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Rupture of the Achilles tendon (middle-aged man “overdoes it” at tennis
or basketball, or patient with history of fluoroquinolone use, complaining of
sudden “popping” and limping): Treat with casting in equinus position or
surgical repair.
Wrist Injuries
Carpal tunnel syndrome (CTS) is entrapment of the median nerve that causes
pain and paresthesias. The most common causes are idiopathic: rheumatoid
arthritis, acromegaly, and hypothyroidism are conditions that predispose
one to CTS.
Diagnostic Testing
The best initial test is the history and physical. Phalen’s test causes symptoms by
flexing the wrist gently and holding the position. Tinel’s sign causes symptoms
by tapping the nerve over the flexor retinaculum and awaiting paresthesias.
Treatment
The best initial therapy is NSAIDs and splinting. If this does not alleviate
symptoms, local steroid injections have been shown to help in some cases.
Surgical release is recommended when splinting no longer controls the
patient’s symptoms.
Compartment Syndrome
This is most frequent in the forearm or lower leg. Look for a history of prolonged
ischemia followed by reperfusion, crushing injuries, or other types
of trauma. There is pain, and the affected area feels tight and tender to palpation.
The classic sign is excruciating pain with passive extension. Pulses may
be normal.
When a patient complains
of pain at the site of a cast,
always remove the cast and
examine for compartment
syndrome.
The first step in management is emergency fasciotomy.
Neurovascular Injuries
The table below summarizes injuries that involve neurovascular complications.
Primary Injury
Neurovascular
Complication Signs/Symptoms Next Step in Management
Oblique distal
humerus
Radial nerve
Unable to dorsiflex
(extend) the wrist
Function regained after
reduction
Surgery is indicated if paralysis
persists after reduction
Posterior
dislocation of
the knee
Popliteal artery injuries Decreased distal pulses Doppler studies or arteriogram
Prophylactic fasciotomy if reduction
is delayed
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