Bone Or Joint Injury

Introduction to Orthopedic Trauma for MCCQE1

For the MCCQE1, understanding the management of bone and joint injuries is paramount. This topic falls under the Surgery and Emergency Medicine categories but requires a multidisciplinary approach involving Family Medicine and Rehabilitation.

As a Canadian medical graduate, you are expected to apply the CanMEDS framework, particularly the roles of Medical Expert (diagnosing and managing trauma) and Health Advocate (injury prevention and return-to-work strategies).

Initial Assessment and Management

The initial approach to any patient with significant bone or joint injury follows the Advanced Trauma Life Support (ATLS) principles.

Diagnostic Imaging: The Ottawa Rules

In the Canadian healthcare system, resource stewardship is vital. The Ottawa Rules are highly sensitive clinical decision rules developed in Canada to exclude fractures and reduce unnecessary X-rays.

Classification of Fractures

Describing a Fracture

When presenting a case or answering a descriptive question, use the following framework:

1. Site: Bone involved and location (proximal, diaphysis, distal).
2. Type: Transverse, oblique, spiral, comminuted.
3. Displacement: Translation (%), Angulation (degrees/direction), Rotation, Shortening.
4. Articular involvement: Intra-articular vs. Extra-articular.
5. Skin integrity: Open vs. Closed.

Salter-Harris Classification (Pediatric)

Pediatric bones have growth plates (physes). Injury here can cause growth arrest.

Gustilo-Anderson Classification (Open Fractures)

Used to determine antibiotic prophylaxis and surgical urgency.

• Type I: Wound <1 cm, clean.
• Type II: Wound 1–10 cm, moderate soft tissue damage.
• Type III: Wound >10 cm, extensive soft tissue damage/contamination (High energy).

Common High-Yield Injuries for MCCQE1

1. Scaphoid Fracture

• Mechanism: Fall On Outstretched Hand (FOOSH).
• Presentation: Tenderness in the anatomical snuffbox.
• Imaging: X-rays may be negative initially.
• Management:
  • If clinical suspicion is high but X-ray is negative: Immobilize in Thumb Spica Splint and repeat imaging in 10-14 days OR order CT/MRI (preferred in some centers for earlier return to work).
• Complication: Avascular Necrosis (AVN) due to retrograde blood supply.

2. Hip Fracture

• Demographics: Elderly, osteoporotic.
• Presentation: Leg is Shortened and Externally Rotated.
• Types: Intracapsular (Subcapital, Neck) vs. Extracapsular (Intertrochanteric).
• Risk: Intracapsular fractures have a high risk of AVN.
• Canadian Guideline: Surgery should be performed within 48 hours to reduce mortality.

3. Anterior Shoulder Dislocation

• Mechanism: Abduction and external rotation.
• Presentation: “Squared off” shoulder, patient holds arm close to body.
• Nerve at Risk: Axillary nerve (check sensation over “regimental badge” area/deltoid).
• Imaging: AP and Trans-scapular (Y-view) or Axillary view.
• Management: Reduction followed by immobilization.

4. Colles Fracture

• Definition: Distal radius fracture with dorsal angulation (dinner fork deformity).
• Mechanism: FOOSH.
• Nerve at Risk: Median nerve (Acute Carpal Tunnel Syndrome).

Orthopedic Emergencies

Compartment Syndrome

Increased pressure within a confined fascial space reducing capillary perfusion.

Septic Arthritis

• Presentation: Hot, swollen, painful joint, decreased ROM, fever.
• Diagnosis: Joint aspiration (Synovial fluid WBC >50,000/mm³, >90% neutrophils).
• Organism: Staph aureus (most common), Neisseria gonorrhoeae (sexually active young adults).
• Treatment: IV antibiotics + Surgical washout (Arthrotomy/Arthroscopy).

Canadian Guidelines & Choosing Wisely

• Imaging for Low Back Pain: Do not image for lower back pain within the first 6 weeks unless red flags are present (Choosing Wisely Canada).
• Opioid Stewardship: Prescribe the lowest effective dose for the shortest duration for acute pain. Optimize non-opioid analgesia (Acetaminophen, NSAIDs) first.
• Osteoporosis Screening: All Canadians ≥ 65 years should be screened with DEXA. Those < 65 with risk factors (e.g., fragility fracture) should also be screened.

Key Points to Remember for MCCQE1

• Neurovascular status documentation is mandatory before and after splinting.
• Scaphoid fractures are notorious for being X-ray negative; treat clinically.
• Open fractures require immediate antibiotics and tetanus prophylaxis.
• Compartment syndrome is a clinical diagnosis; do not wait for pressure measurements if signs are overt.
• Child abuse (Non-accidental injury) should be suspected in spiral fractures of long bones in non-ambulatory children or multiple fractures at different stages of healing.

Sample Question

Clinical Scenario

A 24-year-old male presents to the Emergency Department after falling forward onto his hands while playing soccer. He complains of pain in his right wrist. On physical examination, there is no obvious deformity, but he has distinct tenderness in the anatomical snuffbox. He has full range of motion of the fingers and the neurovascular status of the hand is intact. An X-ray of the wrist (scaphoid views) reveals no evidence of a fracture.

Question

Which one of the following is the most appropriate next step in management?

• A. Reassure the patient and discharge with advice to take NSAIDs.
• B. Apply a tensor bandage and refer to physiotherapy.
• C. Perform a closed reduction under conscious sedation.
• D. Immobilize in a thumb spica splint and arrange follow-up imaging in 2 weeks.
• E. Immediate surgical fixation with a compression screw.

Explanation

The correct answer is:

• D. Immobilize in a thumb spica splint and arrange follow-up imaging in 2 weeks.

Detailed Analysis

• Why D is correct: This patient has a classic presentation for a scaphoid fracture (FOOSH mechanism, anatomical snuffbox tenderness). Scaphoid fractures are unique because initial X-rays are often negative (occult fracture) in up to 15-20% of cases. Due to the tenuous retrograde blood supply of the scaphoid (branch of the radial nerve), missed fractures have a high risk of avascular necrosis and non-union. Therefore, the standard of care is to treat clinically: immobilize (thumb spica cast or splint) and repeat imaging (X-ray, or increasingly CT/MRI) in 10-14 days to confirm or rule out the fracture.
• Why A and B are incorrect: Discharging without immobilization risks fracture displacement and non-union. A tensor bandage provides insufficient immobilization for a scaphoid fracture.
• Why C is incorrect: Closed reduction is used for displaced fractures or dislocations. Since there is no deformity and X-rays are normal, there is nothing to reduce.
• Why E is incorrect: Immediate surgery is not indicated for a non-displaced, occult fracture. Surgery is reserved for displaced fractures, non-unions, or specific high-demand patients (e.g., professional athletes) after confirmed diagnosis.

References

1. Medical Council of Canada. (n.d.). MCCQE Part I Clinical Decision-Making and Multiple-Choice Questions Objectives.
2. Stiell, I. G., et al. (1992). “Implementation of the Ottawa Ankle Rules.” JAMA.
3. Choosing Wisely Canada. (n.d.). Emergency Medicine: Ten Things Physicians and Patients Should Question.
4. American College of Surgeons. (2018). Advanced Trauma Life Support (ATLS) Student Course Manual. 10th Edition.
5. Toronto Notes. (2023). Orthopedics Chapter. Toronto Notes for Medical Students, Inc.
6. Osteoporosis Canada. (2023). Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada.