A high-school baseball player has severe wrist pain after check-swinging at a pitch.
The most likely injury is:
Correct Answer E: Fractures of the hook of the hamate occur with a direct blow against the hamate by the handle of a tennis racket, golf club, or bat during an unbalanced swing. Radial head subluxation (nursemaid’s elbow) occurs with sudden traction of the extended arm. Lunate subluxation, Colles’ fracture, and scaphoid fracture occur with sudden forceful hyper-extension.
Which one of the following is true regarding gamekeeper’s thumb (skier’s thumb)?
Correct Answer A: Gamekeeper’s thumb results from avulsion of the attachment of the ulnar collateral ligament and can be associated with a bony avulsion fracture.
→ It is not associated with boxer’s fracture (choice B), which is a fracture of the fifth metacarpal bone.
→ Stress radiographs (choice C) are not recommended, as they can aggravate the injury. Ultrasonography should confirm the diagnosis.
→ Transient splinting (choice D) is often inadequate and surgical repair must frequently be undertaken.
→ Mallet finger (baseball finger) (choice E) is often caused by a direct blow to the extended digit - there is an avulsion of the extensor tendon at its insertion to the base of the distal phalanx.
A 40-year-old male comes to the urgent care center with severe pain in his right knee. The pain began suddenly when he pivoted on the knee while playing touch football at a family Thanksgiving gathering. You perform the following: the knee is placed in 30° of flexion, with the patient lying supine. You place one hand behind the tibia (with your thumb being on the tibial tuberosity) and the other on the patient's thigh. On pulling anteriorly on the tibia, you remark about 1cm of tibial anterior translation.
This is best described as:
Correct Answer A: A positive Lachman test is strong evidence of an anterior cruciate ligament (ACL) tear.
How to perform Lachman test:
The normal response: There should be a firm restraint to anterior translation. The tibia should not move forward much (the same amount as found on the other side) and it should come to a strong stop, the so-called "good end point" as the ACL reaches its maximum length Again, this end point on the injured leg should be comparable to the normal side.
What it means if not normal --> ACL deficiency is suggested.
Grades of laxity defined by amount of anterior tibial translation relative to contralateral knee:
→ The Lachman test is recognized by most authorities as the most reliable and sensitive clinical test for the determination of anterior cruciate ligament integrity, superior to the anterior drawer test commonly used in the past.
→ Joint line tenderness is not very helpful for either confirming or ruling out meniscal injury.
→ The five criteria in the Ottawa Knee Rule include “inability to flex (not extend) the knee to 90˚” and “inability to bear weight for four steps both immediately and in the examination room regardless of limping”.
A 25-year-old male presents with a history of a forceful blow to the tip of the extended middle finger of his right hand during a neighborhood volleyball game last evening. You diagnose mallet finger.
Which one of the following findings would lead you to consider referring this patient for surgical consultation?
Correct Answer B: Injury to the extensor tendon at the distal interphalangeal (DIP) joint, also known as mallet finger, is the most common closed tendon injury of the finger. Mallet finger is usually caused by an object (e.g., a ball) striking the finger, forcefully flexing an extended DIP. The extensor tendon may be stretched, partially torn, completely ruptured, or separated by a distal phalanx avulsion fracture. Patients with mallet finger present with pain at the dorsal DIP joint, the inability to actively extend the joint, and often a characteristic flexion deformity. It is important to isolate the DIP joint during the evaluation to ensure extension from the extensor tendon and not the central slip. The absence of full passive extension may indicate bony or soft-tissue entrapment requiring surgical intervention.
Bony avulsion fractures are present in one-third of patients with mallet finger. Conservative treatment is successful for up to 3 months, even with delayed presentation. Referral criteria include bony avulsions involving over 30% of the joint space or the inability to achieve full passive extension.
A 16-year-old high-school basketball player is struck on the end of her long finger by the ball. Her finger was fully extended and the result was a forced flexion injury of the proximal interphalangeal (PIP) joint. She is unable to actively extend the PIP joint, although passive extension is possible. She is tender over the dorsal aspect of the middle phalanx. Radiographs are negative.
Which one of the following is true regarding this injury?
Correct Answer E: An injury to the central extensor slip can occur when the proximal interphalangeal (PIP) joint is forcibly flexed while the digit is actively extended. The injury is evaluated by holding the joint in a position of 15°-30° of flexion. The patient will not be able to actively extend the joint, but passive extension should be possible. There will be tenderness over the dorsal aspect of the middle phalanx. Delay or improper treatment may result in a boutonniere deformity, which usually develops over several weeks but can occasionally develop acutely.
Treatment consists of splinting the PIP joint in full extension for 6 weeks. The stack splint should only be used to treat injuries of the distal interphalangeal joint.
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