Following a car accident a 33-year-old man is admitted to the hospital with a fracture of the tenth rib on the left side. He is noted to be pale, restless, and sweating, and his blood pressure is low. On examination there is pronounced guarding in the left upper quadrant of the abdomen.
Which one of the following viscera is most likely damaged?
Correct Answer E: Significant impact (eg, motor vehicle collision) can rupture a normal spleen. Rupture of the splenic capsule produces marked hemorrhage into the peritoneal cavity. The manifestations, including hemorrhagic shock, abdominal pain, and distention, are usually clinically obvious. However, splenic trauma can also produce a subcapsular hematoma, which may not rupture until hours or even months after the injury.
Rupture is generally preceded by left upper quadrant abdominal pain. Splenic rupture should be suspected in patients with blunt abdominal trauma and hemorrhagic shock or left upper quadrant pain (which sometimes radiates to the shoulder); patients with unexplained left upper quadrant pain, particularly if there is evidence of hypovolemia or shock, should be asked about recent trauma. The diagnosis is confirmed by CT scan (in the stable patient), ultrasound, or peritoneal lavage (in the unstable patient).
Treatment has traditionally been splenectomy. However, splenectomy should be avoided if possible, particularly in children, to avoid the resulting permanent susceptibility to bacterial infections.
Which one of the following is true regarding testing the rotator cuff for injury?
Correct Answer C: The rotator cuff comprises four muscles: the infraspinatus, the subscapularis, the supraspinatus, and the teres minor. The supraspinatus is tested with abduction against resistance, with pain or weakness indicating injury.
→ The infraspinatus (choice A) may be tested with lateral rotation against resistance, while the subscapularis (choice B) may be tested with medial rotation against resistance.
→ The teres minor (choice D) can be tested with lateral rotation against resistance.
→ The teres major (choice E) is not part of the rotator cuff.
A 53-year-old Hispanic male presents with a 3-day history of right shoulder pain. The pain started shortly after he caught himself when he fell coming down his front steps. Radiographs of the shoulder are normal.
Which one of the following, if present, would be most suggestive of a rotator cuff tear?
Correct Answer D: Shoulder pain after a fall may result from a strained muscle or ligament, an exacerbation of a smoldering subacromial bursitis or tendinitis, or a tear of the rotator cuff. Often there is a combination of two or three of these conditions. If the rotator cuff tear is small, treatment is similar to that recommended for the other conditions. However, if a significant rupture has occurred, immobilization and/or surgical consultation is appropriate. On physical examination, a painful arc of abduction above 90° and weakness in external rotation would be expected with a torn rotator cuff. Of these two, weakness in external rotation is much more specific.
A 22-year-old professional male hockey player with no previous history of shoulder problems is injured in a fall. He has immediate pain and is unable to abduct his arm. He goes to the emergency department and an MRI reveals an acute tear of the rotator cuff. He needs to 'get back in the game' as soon as possible.
Which one of the following is the best initial treatment for this injury?
Correct Answer B: Pain control and inflammation reduction are initially required to allow progression of healing and initiation of an active rehabilitation program in patients with a rotator cuff injury. This can be accomplished with a combination of relative rest, icing (20 min, 3-4 times per d) (choice B), and acetaminophen or an NSAID.
→ Indications for operative treatment (choice E) of rotator cuff disease include partial-thickness or full-thickness tears in an active individual who does not have improved pain and/or function within 2 months with a supervised rehabilitation program. Immediate surgical repair in cases of acute, full thickness rotator cuff tears in otherwise healthy individuals. In surgical candidates, early repair (within 6 weeks) is useful to avoid fatty degeneration and retraction of the remnant rotator cuff musculature. Surgery may be necessary in patients whose symptoms and function fail to improve despite at least six weeks of appropriate physical therapy (choice C) and two glucocorticoid injections.
→ Corticosteroids (choice D) delivered directly to the site via injection can be considered to allow further progression of the rehabilitation program.
→ Observing (choice A) for an extended period will likely lead to retraction of the detached tendon, possible resorption of tissue, and muscle atrophy.
A 27 year old carpenter dropped his circular saw and severed his lower leg.
Which one of the following would be indicative of a severed tibial nerve?
Correct Answer A: Tibial nerve passes through the popliteal fossa to pass below the arch of soleus. The nerve passes into the foot running posterior to the medial malleolus.
posterior to the medial malleolus. The tibial nerve provides motor innervation to the muscles of the posterior compartment of the leg (both superficial and deep) and sensory innervation to the posterior aspect of the leg (via its contribution to the sural nerve) and the sole of the foot. It terminates by bifurcating into the medial and lateral plantar nerves in the sole of the foot.
Injury to the tibial nerve typically produces: loss of plantarflexion of the foot, loss of flexion of the toes and weakened inversion of the foot; sensory loss over the territories described above.
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