State exam, 6th year
Situational tasks and questions to them in traumatology and orthopedics for certification of applicants for higher medical education of the National Medical University named after OO Bogomolets
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1. Situational task
Patient S., 65 years old, slipped on the street and fell on the palm of a straightened left hand, after which there was a sharp pain in the radial wrist. At inspection deformation of the lower third of the left radial bone in the form of a step, considerable hypostasis, a hypodermic hematoma is defined. At axial loading feels sharp pain. Active and passive movements in the left radial-carpal joint are significantly limited, painful.
What damage does the patient have?
What is the mechanism of injury and why the damage most often occurs in this area?
What treatment tactics are shown in this case?
Additional questions:
Types of fractures and terms of fusion.
Complications are possible in the early, middle and long periods after the injury.
Features of the rehabilitation period.
2. Situational task
Patient M., 40 years old, was clinically and radiologically diagnosed with a closed oblique fracture of the humerus with a displacement of fragments along the length by 1 cm and at an angle. The brush hangs down, the patient cannot fully unbend it and withdraw the first finger.
What fracture occurs in this case, and what do the symptoms described in the patient indicate?
What treatment tactics are needed in this case?
Additional questions:
Classification of humeral fractures.
Early and late complications are possible.
Indications for different types of osteosynthesis.
Fusion time and what it depends on.
3. Situational task
Patient M., 64 years old, after hip arthroplasty on the third day had the following symptoms: sudden deterioration of general condition, a sharp drop in blood pressure, shortness of breath, a feeling of pressure behind the chest, shortness of breath, nasal wings are involved in breathing. Objectively: the face is pale, the presence of pale cyanotic skin purple papules on the cheeks, lateral surfaces of the abdomen, chest. Auscultatory: wet rales. The temperature is elevated. Radiologically: heaviness and compaction along the bronchial tree.
Make and justify the diagnosis in this patient?
With what pathological processes it is necessary to carry out differential diagnosis?
Justify the tactics of treatment taking into account the diagnosis and age of the patient.
Additional questions.
Measures to prevent fat embolism in endoprosthesis and osteosynthesis of long bones?
Indications and contraindications to hip arthroplasty.
4. Situational task
A 66-year-old patient complains of pain in the right humerus, limb dysfunction. Eight months ago he was treated conservatively for a transverse fracture of the right humerus. Closed repositioning and plaster immobilization were performed. Objectively, there is painless mobility in the middle third of the right humerus. X-rays determine the gap at the level of the middle third of the right humerus, the edge of the bone ends is determined by osteosclerosis, the presence of closing plates and the closure of the bone marrow canal.
What do the described clinical and radiological symptoms indicate?
As a result, such pathological processes can occur?
What treatment tactics are used in such situations, why?
Additional questions:
Stages of bone regeneration.
Types of fractures and timing of humeral fusion.
5. Situational task
Patient K., 2 years old. Complaints of rapid fatigue when walking (the child asks for hands), instability and gait disturbance of the "diving" type. From the anamnesis it is known that the child began to walk at 1 year and 6 months, and often fell. The last time she fell the day before. Examination shows malnutrition of the muscles of the right thigh, removal of the right thigh to 70 degrees. X-ray on the right side revealed an increase in the acetabular angle to 45 degrees, the shape of the roof of the acetabulum is flattened. The head of the femur is reduced in size, its shape is changed, the neck of the femur is shortened. The gap along the line of Calve and Shenton on the right is determined.
What diagnosis will you make for the patient?
On the basis of what radiological signs will you differentiate the diagnosis?
What treatment plan will you determine for this patient, taking into account the established diagnosis and age?
Additional questions.
Clinical symptoms of dysplasia and congenital hip dislocation in children under 1 year, after 1 year.
X-ray diagnosis of dysplasia, congenital hip dislocation, Putti triad, Hilgenreiner scheme.
Treatment of children with hip dysplasia depending on age.
6. Situational task
Patient L., 64 years old, complains of pain in the lumbar spine, with irradiation to the lower extremities more on the left, pain in the sacroiliac and hip joints, restriction of active and passive movements in the spine. Examination reveals the gait of the "rope walker", weakness, hypoaesthesia and paresthesia of the lower extremities, lumbar lordosis is increased, palpation reveals a step between the spinous processes - L5 vertebrae. Radiographs showed a 40% displacement of the L4 vertebra to the anterior. The results of CT examination determine the signs of spondylolysis of the L4 vertebrae.
Make and justify the diagnosis in this patient?
With what diseases it is necessary to carry out differential diagnosis?
Justify the tactics of treatment taking into account the diagnosis (with the degree and / or stage of the lesion), the presence of complications, the patient's age.
Additional questions.
Classification of spondylolisthesis.
Typical clinical and radiological manifestations.
Indications for surgical treatment and its content.
7. Situational task
The 28-year-old patient received a penetrating gunshot wound to the middle third of the left leg, a gunshot fracture of the tibia and fibula in the middle third. He was injured about 1-2 hours ago. The limb is immobilized with an improvised splint, the bandage is soaked with blood, but no bleeding is detected. The patient is semi-conscious, constantly complaining of pain in the injured limb.
What immediate actions should you take when assisting a patient?
What will be the step-by-step tactics of your actions?
What complications need to be anticipated and why?
What sutures should be applied to the wound in this patient?
Additional questions.
What types of sutures do you know, in which cases and in which locations of wounds they should be applied?
Rules for applying a tourniquet?
Zones of the wound canal with a gunshot wound?
Types of surgical treatment of gunshot wounds, their purpose and essence?
8. Situational task
A 12-year-old girl complains of morning stiffness in the joints, pain and restriction of movements in the right knee joint, fever 37.3 ° C - 37.6 ° C for 3 weeks. During the last 2 months he was treated by an ophthalmologist for keratitis that developed after ARI. Palpation of the knee joint is sensitive and painful, flexion contracture in this joint is determined. Ultrasonographically, exudative-proliferative synovitis, proliferation of the synovial membrane up to 7 mm, thickening of the joint capsule were determined in the joint. General blood test: erythrocytes 3.6 x1012 / l, Hb 116 g / l, leukocytes 9.8x109 / l, ESR 50 mm / hour. SRB ++++.
Make and justify the previous diagnosis of this patient, taking into account the history and age?
With what diseases it is necessary to carry out differential diagnosis?
Justify the tactics of treatment taking into account the diagnosis (with the degree and / or stage of the lesion), the presence of complications, the patient's age.
Additional questions.
Modern diagnostics of JRA: anti-SSR, anti-MCV, ultrasonography, MRI.
Modern approaches to the basic therapy of JRA: biological agents, minimally invasive organ-preserving surgical interventions.
9. Situational task
A 38-year-old patient fell from the 5th floor while working on a construction site. The patient at the examination is excited, disoriented, systolic blood pressure - 90 mm Hg, Algover index - 0.9. Complains of pain in the pelvis and abdomen. Examination shows tension in the muscles of the anterior abdominal wall, with the upper half of the abdomen involved in the act of breathing, and the lower half is immobile ("two-story abdomen"). 3-4 minutes after Selivanov's intra-pelvic blockade on both sides, the tension in the muscles of the anterior abdominal wall disappeared.
Given the mechanism of injury, clinical symptoms and examination results, establish and justify a preliminary diagnosis?
Justify consistent tactics of care depending on the type of injury and the patient's condition?
Additional questions.
Phases and stages of traumatic shock.
Classification of pelvic fractures.
Complications of pelvic fractures (early, late, distant).
Indications for surgical treatment of pelvic fractures.
10. Situational task
The patient complains of sharp pain in the left knee joint, numbness of the foot, which appeared as a result of an accident 3 hours ago. The foot is pale, cold. Pulse on a. dorsalis pedis is absent. The knee joint is thickened, deformed, the limb is shortened by 5 cm. Passive and active movements in the knee joint are sharply painful, limited, there is an elastic deformation.
Based on the results of the examination, make and substantiate the previous diagnosis, determine further tactics of the examination?
Justify further tactics of treatment of the patient taking into account the type of injury and possible complications?
Additional questions.
Clinical symptoms of damage to the anterior, posterior cruciate ligaments, lateral ligaments of the knee joint.
Symptoms of damage to the menisci of the knee joint.
Tactics of treatment for injuries of the menisci of the knee joint (conservative treatment, meniscus suture, meniscus resection).
11. Situational task
The 62-year-old patient fell on his outstretched arm from the height of his height while walking. I felt a sharp pain in my shoulder joint. I tried to get up and get to my feet - I felt a crunch in my shoulder again and pain again. After injury, all active movements in the shoulder joint became impossible, the attempt to move is accompanied by pain in the deltoid region. The shoulder joint is increased in size due to edema and hemarthrosis, deformed, its contours are smoothed. Positive symptom of axial loading. Sharp pain on palpation below the projection of the head of the humerus, pain in the projection of the large tubercle. The patient is overweight, has a history of thyroid surgery, takes thyroxine.
Formulate a diagnosis? What are the reasons for the displacement of fragments? Treatment? When is a control radiograph of the damaged segment performed?
Additional questions:
For which age category are these injuries characteristic?
Classification of fractures of the proximal humerus
Causes of post-traumatic contracture of the shoulder joint
12. Situational task
Xvora, 63, fell on an outstretched arm in the radial wrist joint. Complains of pain and inability to move in the right wrist. The distal part of the forearm is bayonet-shaped deformed - deformation of the "table fork", swelling of soft tissues. Palpation is sharply painful. The radiographs determine the fracture of the radial bone in the area of the distal metaepiphysis, the fracture line runs horizontally.
Formulate a diagnosis. Name the typical displacements of fragments and medical manipulations to restore the segment.
Additional questions:
What are the possible complications in the conservative treatment of this injury?
Classification of fractures of the distal epimetaphysis of the radial bone.
13. Situational task
A 23-year-old patient was injured in an accident. He was a taxi passenger. Complains of severe pain in the left hip joint. Lying on his back, forced body position. The severity of lordosis of the lumbar spine. The left leg is bent, brought and rotated outwards. There is a shortening of the limb. Palpation - depression under the pupar ligament on the left and protrusion above the area of the acetabulum behind. Movements in the hip joint are severely limited, extremely painful, a positive symptom of "spring resistance." Impossibility to align the lower limb.
Your diagnosis? Treatment tactics? What remote complication is possible with this injury?
Additional questions:
Definition of "central hip dislocation".
14. Situational task
The patient, 35, fell on his half-bent right arm. I felt severe pain in the forearm, elbow joint, the elbow joint stopped functioning. Clinically, the forearm is somewhat shortened, deformity, swelling of soft tissues in the elbow joint. Movements in the latter are sharply limited, when trying to move - pain and a feeling of obstruction on the anterior surface of the joint. Palpation in this area is determined by protrusion. At the border of the upper and middle third of the ulna is determined by pain, abnormal mobility and crepitation.
Preliminary diagnosis? Treatment? When is the control radiography of the damaged segment performed, the conditions of performance?
Additional questions:
Possible complications of this injury?
Differential diagnosis.
15. Situational task
A 42-year-old patient of athletic build with complaints of pain in the left knee joint, moderate restriction of movement - lack of extension 100, possible flexion from 100 to 1000, gait disturbance - limping, pain increases during long gait, after exercise and disappears completely. at rest. From the anamnesis it was found out that 8 years ago he received an injury of the left knee joint during sports, did not seek help, treated himself. Over time, he began to feel insecurity (instability) in the knee joint. On examination, the knee joint is of normal shape and configuration. At a palpation temperature in the field of a joint within norm. The pain is localized along the medial ligament, the projection of the medial joint space, moderate synovitis of the knee joint, a positive symptom of the "anterior drawer", "Lachman" - the test. On the radiograph of the left knee joint in the anterior-posterior projection of the narrowing of the joint space, mainly in the medial part of the joint, the marginal bone growths more on the medial surface, subchondral sclerosis.
Primary diagnosis?
What is the cause of these changes in the knee joint?
3 What diseases of the knee joint need to be differentially diagnosed?
Your treatment plan?
Additional questions:
Define the concept: joint deformity, joint contracture, osteoarthritis, osteonecrosis.
16. Situational task
A 33-year-old patient went to the polyclinic (KDC KDC) with complaints of pain in the left hip joint, which worsens after prolonged walking and restricted movement. Joint pain began to progress after childbirth. From the anamnesis: in childhood the patient was treated for hip dysplasia, and in the last three years - for lumbosacral radiculitis. At inspection malnutrition of muscles of the left hip, considerable restriction of rotational movements of a joint, moderate restriction of bending, removal of the left lower extremity, pain at a palpation in a projection of a joint crack is defined. On the radiograph of the left hip joint in the anterior-posterior projection of the narrowing of the joint space, increased obliqueness of the acetabulum of the pelvis, cervical-diaphyseal angle of the femur 1400, subchondral sclerosis, moderate marginal bone growths - osteophytes of the joint.
Primary diagnosis?
What additional diagnostic examination should be used?
Justify the treatment plan taking into account the etiological factor.
Recommendations for outpatient treatment.
Prognosis for disease progression and further treatment.
Additional questions:
What are the main causes of osteoarthritis of the joints?
17. Situational task
Patient 35y. carried out repair of the car sitting squatting. At sharp rise with turn there was a sharp pain from the inside of the right knee joint, active and passive movements in it suddenly became impossible. The joint became slightly swollen. He can stand on his feet only with the help of a stick, limping. I went home, put a warming compress on my knee. In the morning he went to the clinic. Swollen joint contours it smoothed. Palpation determines the presence of free fluid in the joint, the patella is running, local pain on the medial side in the projection of the joint space. Movements - lack of extension to 200, impossible due to sharp pain and a feeling of mechanical obstruction in the joint. Bending is possible up to 900. Deviation of the lower leg to the middle increases the pain. No pathology was detected on radiographs of the knee joint.
Primary diagnosis?
Differential diagnosis of a knee injury?
What additional diagnostic examination should be used?
Justify the treatment plan.
Additional questions:
What is the function of the menisci of the knee joint.
18. Situational task
The 32-year-old patient had a sports injury of the left knee joint about 3 years ago, due to which he was treated on an outpatient basis for 2 months. Currently, periodically disturbed feeling of instability and moderate pain in the right knee joint. Periodically something jams and movements and joints become impossible. The patient eliminates these violations independently by rocking and rotational movements of a shin. According to the patient at this point, "something crunches and the joint begins to normal work ". The pain is exacerbated during the descent down the stairs. On examination, there is a moderate atrophy of the thigh muscles. Movements in the knee joint in full. in the knee joint and at the same time press on the area of the joint space on the inside there is pain.
Primary diagnosis?
Differential diagnosis of a knee injury?
What additional diagnostic examination should be used?
Justify the treatment plan
Additional questions:
What are the ligaments of the knee joint, you know what their function is for the knee joint.
19. Situational task
Patient B., 27 years old, applied to the trauma department with complaints of pain in the left upper arm and shoulder joint. He was injured 3 hours ago when he fell from a bicycle on his left shoulder. Swelling, tenderness on palpation, step-like deformation in the area of the acromioclavicular joint are determined in the area of the upper arm; when pressing on the acromial end of the clavicle - a positive symptom of the "key". The upper arm is shortened. Movements in the shoulder joint are limited due to pain.
Preliminary diagnosis, treatment tactics.
Additional questions.
What other damage can you suspect and make a differential diagnosis?
What method of treatment would you offer to a patient with an acromioclavicular joint of the Tossi type 3?
20. Situational task
Patient B., 27 years old, applied to the trauma department with complaints of pain in the left upper arm. He was injured 3 hours ago when falling from a Segway on his left shoulder. In the upper arm is determined by edema, severe pain on palpation in the middle third of the clavicle; when pressing on the acromial end of the clavicle - a negative symptom of the "key", smoothing of the supraclavicular and subclavian fossae. The upper arm is shortened. Movements in the shoulder joint are limited due to pain.
Preliminary diagnosis, treatment tactics.
Additional questions.
What is a typical clavicle fracture site?
What are the indications for surgical treatment of a clavicle fracture?
21. Situational task
Patient P., 72 years old, was taken to the trauma department with complaints of pain in the right hip joint, impaired limb impotence. She was injured in her own apartment when she fell on her right side due to dizziness. At inspection: the patient in consciousness, position of the patient on a back, relative shortening of the right extremity on 2 cm is defined; external rotation of the limb, a positive symptom of a stuck heel, the tip of the great acetabulum is located above the Roser-Nelaton line, movements in the hip joint cause pain, axial load of the right limb, causes pain in the right hip joint.
Preliminary diagnosis. Doctor's tactics.
Additional questions:
What are the fractures of the proximal femur?
What are the tactics of conservative treatment in the presence of contraindications to surgical treatment?
22. Situational task
A 24-year-old patient came to see an orthopedist-traumatologist with complaints about the impossibility of complete extension of the right knee joint. In the anamnesis 2 days ago he played football, suffered an injury to the right knee joint (the mechanism of injury is rotational). On examination: relative shortening of the right lower limb, passive and active movements in the knee joint cause severe pain, right knee joint in a semi-bent position, movements in the right knee joint 0/30/60. Palpation pain along the joint slit on the inside of the knee joint.
Preliminary diagnosis. Doctor's tactics.
Additional questions.
What additional damage to the structure of the knee joint can be suspected?
Is conservative treatment possible in this case, if so, which one?
What is the function of the menisci in the knee joint?
23. Situational task
A 39-year-old patient came to see an orthopedist-traumatologist with complaints of pain in the right hip joint. Anamnestically ill for about 7 years, the pain in the right hip joint worsened after childbirth, which was 6 years ago, from the anamnesis it is also known that the patient in childhood was treated for hip dysplasia. In orthopedic examination: gentle lameness on the right lower limb, relative shortening of the right lower limb 2 cm, multiplanar contracture of the right hip joint, when trying to rotate, there is severe pain in the right hip joint.
Preliminary diagnosis. Doctor's tactics.
Additional questions.
Is dysplastic osteoarthritis of the hip joint primary or secondary osteoarthritis?
What are the radiological signs of osteoarthritis?
24. Situational task
A mother and a 6-month-old girl came to see the orthopedist of the traumatologist. The mother complains of limited abduction in the hip joints, especially the left, asymmetry of the buttocks. From the anamnesis: the first childbirth, natural childbirth, full-term child, sciatica, child development corresponds to age. In orthopedic status: abduction in the hip joints on the right to 60 degrees, on the left to 50 degrees, relative shortening of the left lower extremity, external rotation, positive c-m piston, the apex of the great acetabulum of the left femur is above the Nelaton-Roser line, Brian triangle left .
Preliminary diagnosis. Doctor's tactics.
Additional questions.
What are the radiological signs of habitual hip dislocation, what are the symptoms of the Putti triad?
What disease will develop in a patient in adulthood with untimely treatment of hip dysplasia?
25. Situational task
Patient N., 38 years old, was taken to the admission department with complaints of intense sharp pain in the area of the left forearm of a dissecting nature, which is not removed by analgesics. The anamnesis revealed that the patient had an extensor fracture of the left humerus 4 hours ago. Emergency care at the trauma center - a closed reposition was performed and a circular plaster bandage was applied from the wrist bones to the left shoulder. On examination - the fingers of the hand are pale, swollen, bent, when you try to stretch the back of the hand, the pain increases, there is a growing hypoesthesia in the area of innervation of the median and ulnar nerves.
Preliminary diagnosis. Treatment tactics.
Additional questions.
What is compartment syndrome?
What are the optimal timing of fasciotomy?
26. Situational task
A 38-year-old patient was taken to the admission department with complaints of pain in the right shoulder joint and inability of the latter to function. On examination, the right arm is bent at the elbow, removed from the torso and supported by the forearm with a healthy hand. The contours of the shoulder joint are smoothed, the resistance of the acromial process of the scapula is revealed, the deformation of the shoulder joint resembles an epaulette, under the acromial process of depression. There are no active movements, in the study of passive movements - elastic mobility
Preliminary diagnosis. Doctor's tactics.
Additional questions.
What are the treatment tactics for habitual shoulder dislocation?
What methods of shoulder dislocation do you know?
With what injuries carry out differential diagnosis of anterior dislocation of the shoulder?
27. Situational task
Patient, 68 years old. Hospitalized in the trauma department for a fracture of the femoral shaft, which occurred suddenly while walking. From the anamnesis: 5 years ago for breast cancer the patient underwent chemotherapy and mastectomy on the left. On the radiograph, a transverse fracture of the femoral shaft, the edges of the fracture are indistinct and have signs of small focal destruction of the cortical layer up to 3.5 cm in diameter.
What is the diagnosis?
What methods of examination are shown to the patient?
What are the orthopedic treatment tactics?
Additional questions.
Additional survey methods.
Prevention of complications in the early and long periods after injury.
Features of rehabilitation.
28. Situational task
Patient P. is 19 years old. Turned to an orthopedist with complaints of intense progressive pain and increased swelling in n / 3 thighs. Ill for 6 months, denies the injury. Regarding osteoarthritis of the knee joint, NSAIDs, physiotherapy, ointments without effect were prescribed. On examination, palpation: the lower third of the right thigh was club-shaped thickened, on the medial surface in the area of 8x6 cm elastic consistency, sharply painful, immobile in relation to the bone, the circumference tightened in n / 3: S / D = 38 / 46cm. Function of the knee joint: flexion 100g, extension 165g. On radiographs: in the distal metaphysis with the transition to the lower third of the femoral shaft there is an increase in soft tissue (7.8x6 cm), which has signs of intense osteosclerosis, which resembles "clouds" and continues centrally, peeling of the cortical layer in the form of a visor; bone epiphyses are not changed.
What is the diagnosis?
What are the main diagnostic methods?
Additional questions.
Additional survey methods.
Differential X-ray diagnosis of osteogenic sarcoma and benign tumors.
Further treatment tactics.
29. Situational task
Patient P. is 49 years old. She went to an orthopedist with complaints of moderate pain and increased swelling in the n / 3 thighs, which appeared about 1 year ago. Received NSAIDs, physiotherapy, ointments with a negative effect. On examination: the lower third of the right thigh was club-shaped thickened, in the area of 8.5x6 cm, elastic consistency, moderately painful, and mobile in relation to the bone, the circumference of the thigh in n / 3: S / D = 39 / 47cm. Movements in the knee joint are painful: flexion 120g, extension 180g. On radiographs: in the distal third of the thigh you can see an increase in soft tissue, in the form of a more intense oval shadow, size 8x5.5 cm, without clear contours, thinning of the cortical layer; bone epiphyses are not changed. Cytology: tumor maligna.
What is the diagnosis?
What are the main diagnostic methods?
Additional questions.
Additional survey methods.
Orthopedic regime for the patient.
Further treatment tactics.
30. Situational task
Patient P. is 65 years old. She went to an orthopedist with complaints of moderate and increasing pain in the thighs, on the outer surface, which appeared for about 4 months. therefore, the injury is denied. On examination: lame, the upper third of the thigh is not changed, local soreness in the area of the great acetabulum, inguinal fold. Movements in the hip joint are painful: bending 120g, withdrawal 35g, rotation 35g. Limbs of equal length. On radiographs: narrowing of the joint space of the hip joint; in b / 3 of the femoral shaft significant osteolytic destruction up to ½ diameter with a smooth, indistinct contour, 4x5.5 cm. In the analysis of urine, Ben Jones protein is positive.
What is the diagnosis? What are the main and additional diagnostic methods? What are the orthopedic treatment tactics?
Additional questions:
Additional survey methods.
Orthopedic regime for the patient.
Further treatment tactics.
31. Situational task
A mother and a 15-year-old boy complained to an orthopedist-traumatologist about the appearance of shoulder pain after exercise, without injury. At inspection active movements in a shoulder are possible but painful and limited. On radiographs: in the metaphysis of the humerus, a homogeneous focus of osteolytic destruction (2.5x4 cm) with a clear contour, delimited by the rim of sclerosis, thinning of the cortical layer. The growth zone is not disturbed. In dynamics dynamics of the center is appreciable.
What is the diagnosis?
What are the methods of confirming the child's diagnosis?
What are the treatment tactics?
Additional questions.
Additional survey methods.
Differential X-ray diagnosis of aneurysmal cyst and malignant bone tumor.
32. Situational task
A 29-year-old woman applied to the trauma department with complaints of swelling and pain in the n / 3 forearm, which lasted for about 4 months, for no apparent reason. On examination - local soreness of the distal metaphysis of the radial bone, joint function is not impaired. On the radiograph: in the distal epimetaphysis of the radial bone, lytic destruction of 2/3 of the diameter of the bone (3 cm in diameter), without demarcation, trabecularity (s-m "soap bubbles"), destruction of the cortical layer is determined. Cytology: osteoclasts - giant multinucleated, and osteoblasts.
What is the diagnosis? What are the main and additional diagnostic methods? What are the orthopedic treatment tactics?
Additional questions:
Differential X-ray diagnosis of giant cell tumor, bone tuberculosis, cystic remodeling of the pineal gland.
Prognosis of the disease.
33. Situational task
A 42-year-old patient went to the trauma department with complaints of pain in the lower third of the right shoulder, which is exacerbated by minor movements. According to the patient, he was injured as a result of falling from a height of one meter. At clinical inspection deformation in the lower third of the right shoulder, pain on a palpation, pathological mobility is defined. In addition, the dysfunction of the hand is determined: the impossibility of active extension of the hand, withdrawal of the first finger, impaired sensitivity in the area of I-III fingers. The radiograph shows an oblique fracture of the lower third of the humerus with a slight displacement of the fragments in length and width while maintaining the axis
What are the optimal treatment tactics?
A. anesthesia, closed repositioning, immobilization
B. closed reposition, fixation by an intramedullary blocking core
C open reposition, fixation with a metal plate
D. open reposition, fixation by an intramedullary blocking core
34. Situational task
The 38-year-old patient went to the trauma department with complaints of pain in the left ankle joint, which is exacerbated by minor movements, loss of capacity. According to the patient, he was injured as a result of falling from a height. At clinical inspection pain on a palpation, deformation in the field of an ankle joint, hemarthrosis is defined. X-ray examination data
What are the optimal treatment tactics?
A - closed reposition, fixation with a plaster bandage "boots"
B - closed reposition, additional percutaneous fixation with a spitz and plaster bandage "boots"
С - open reposition, stable-functional osteosynthesis
35. Situational task
A 74-year-old patient was taken to the traumatology department of KShMD with complaints of pain in the left hip joint, which is exacerbated by minor movements, loss of ability to work. According to the patient, she was injured as a result of a fall 7 days ago. After the fall, the pain was minor. During this time I walked with a stick. On the day of hospitalization, when she got up from the chair, she felt a sharp pain, which prompted her to seek medical help. At Clinical examination reveals pain on palpation in the hip joint, moderate external rotation of the lower extremity, a positive symptom of "stuck heel" and axial load. X-ray examination data: punctured fracture of the neck of the left femur.
In order to clarify the patient's diagnosis, computed tomography was performed, the data of which are presented
On the basis of the received data formulate the diagnosis and tactics of treatment
A - external immobilization with a plaster cast bandage / orthosis
B - skeletal traction, external immobilization with plaster cast bandage / orthosis
C - open reposition, stable-functional osteosynthesis
D - unipolar endoprosthesis
E - total arthroplasty
36. Situational task
The patient fell from a height of 5 meters. Delivered 1 hour after the injury. Upon admission, the condition is serious. The skin is pale, breathing - 28 breaths. per minute, blood pressure - 80/40 mm. rt. Art. Pulse 120 beats. for a minute. On examination: pelvic ring deformity, symptoms of Verneil, Lareya, Joyce are positive. The abdomen is tense, no peritoneal symptoms.
Determine the optimal set of treatment measures in this period?
A. Simultaneous compensation of life support systems and indirect osteosynthesis of the damaged pelvis by an external fixation device
B. Compensation of life support systems and after their stabilization the choice of method of treatment of a damaged pelvis
С. Compensation of life support systems and after their stabilization the implementation of open osteosynthesis of the damaged pelvis
D. Compensation of life support systems and after their stabilization of treatment of the damaged pelvis by the method of constant traction
37. Situational task
A 42-year-old patient fell from a height of 2.5 meters on his left leg. Complains of pain in the left thigh. Objectively: pulse 88 per minute, blood pressure - 110/75 mm Hg. art., deformation, pathological mobility and crepitation in the middle third of the thigh.
Which transport immobilization is optimal in this case?
A. Dieterichs tire
B. Cramer's tire
C. Pneumatic rail
D. Immobilization by improvised means
Е. Bandage the damaged limb to a healthy one
Patient S., 65 years old, slipped on the street and fell on the palm of a straightened left hand, after which there was a sharp pain in the radial wrist. At inspection deformation of the lower third of the left radial bone in the form of a step, considerable hypostasis, a hypodermic hematoma is defined. At axial loading feels sharp pain. Active and passive movements in the left radial-carpal joint are significantly limited, painful.
What damage does the patient have?
What is the mechanism of injury and why the damage most often occurs in this area?
What treatment tactics are shown in this case?
Additional questions:
Types of fractures and terms of fusion.
Complications are possible in the early, middle and long periods after the injury.
Features of the rehabilitation period.
2. Situational task
Patient M., 40 years old, was clinically and radiologically diagnosed with a closed oblique fracture of the humerus with a displacement of fragments along the length by 1 cm and at an angle. The brush hangs down, the patient cannot fully unbend it and withdraw the first finger.
What fracture occurs in this case, and what do the symptoms described in the patient indicate?
What treatment tactics are needed in this case?
Additional questions:
Classification of humeral fractures.
Early and late complications are possible.
Indications for different types of osteosynthesis.
Fusion time and what it depends on.
3. Situational task
Patient M., 64 years old, after hip arthroplasty on the third day had the following symptoms: sudden deterioration of general condition, a sharp drop in blood pressure, shortness of breath, a feeling of pressure behind the chest, shortness of breath, nasal wings are involved in breathing. Objectively: the face is pale, the presence of pale cyanotic skin purple papules on the cheeks, lateral surfaces of the abdomen, chest. Auscultatory: wet rales. The temperature is elevated. Radiologically: heaviness and compaction along the bronchial tree.
Make and justify the diagnosis in this patient?
With what pathological processes it is necessary to carry out differential diagnosis?
Justify the tactics of treatment taking into account the diagnosis and age of the patient.
Additional questions.
Measures to prevent fat embolism in endoprosthesis and osteosynthesis of long bones?
Indications and contraindications to hip arthroplasty.
4. Situational task
A 66-year-old patient complains of pain in the right humerus, limb dysfunction. Eight months ago he was treated conservatively for a transverse fracture of the right humerus. Closed repositioning and plaster immobilization were performed. Objectively, there is painless mobility in the middle third of the right humerus. X-rays determine the gap at the level of the middle third of the right humerus, the edge of the bone ends is determined by osteosclerosis, the presence of closing plates and the closure of the bone marrow canal.
What do the described clinical and radiological symptoms indicate?
As a result, such pathological processes can occur?
What treatment tactics are used in such situations, why?
Additional questions:
Stages of bone regeneration.
Types of fractures and timing of humeral fusion.
5. Situational task
Patient K., 2 years old. Complaints of rapid fatigue when walking (the child asks for hands), instability and gait disturbance of the "diving" type. From the anamnesis it is known that the child began to walk at 1 year and 6 months, and often fell. The last time she fell the day before. Examination shows malnutrition of the muscles of the right thigh, removal of the right thigh to 70 degrees. X-ray on the right side revealed an increase in the acetabular angle to 45 degrees, the shape of the roof of the acetabulum is flattened. The head of the femur is reduced in size, its shape is changed, the neck of the femur is shortened. The gap along the line of Calve and Shenton on the right is determined.
What diagnosis will you make for the patient?
On the basis of what radiological signs will you differentiate the diagnosis?
What treatment plan will you determine for this patient, taking into account the established diagnosis and age?
Additional questions.
Clinical symptoms of dysplasia and congenital hip dislocation in children under 1 year, after 1 year.
X-ray diagnosis of dysplasia, congenital hip dislocation, Putti triad, Hilgenreiner scheme.
Treatment of children with hip dysplasia depending on age.
6. Situational task
Patient L., 64 years old, complains of pain in the lumbar spine, with irradiation to the lower extremities more on the left, pain in the sacroiliac and hip joints, restriction of active and passive movements in the spine. Examination reveals the gait of the "rope walker", weakness, hypoaesthesia and paresthesia of the lower extremities, lumbar lordosis is increased, palpation reveals a step between the spinous processes - L5 vertebrae. Radiographs showed a 40% displacement of the L4 vertebra to the anterior. The results of CT examination determine the signs of spondylolysis of the L4 vertebrae.
Make and justify the diagnosis in this patient?
With what diseases it is necessary to carry out differential diagnosis?
Justify the tactics of treatment taking into account the diagnosis (with the degree and / or stage of the lesion), the presence of complications, the patient's age.
Additional questions.
Classification of spondylolisthesis.
Typical clinical and radiological manifestations.
Indications for surgical treatment and its content.
7. Situational task
The 28-year-old patient received a penetrating gunshot wound to the middle third of the left leg, a gunshot fracture of the tibia and fibula in the middle third. He was injured about 1-2 hours ago. The limb is immobilized with an improvised splint, the bandage is soaked with blood, but no bleeding is detected. The patient is semi-conscious, constantly complaining of pain in the injured limb.
What immediate actions should you take when assisting a patient?
What will be the step-by-step tactics of your actions?
What complications need to be anticipated and why?
What sutures should be applied to the wound in this patient?
Additional questions.
What types of sutures do you know, in which cases and in which locations of wounds they should be applied?
Rules for applying a tourniquet?
Zones of the wound canal with a gunshot wound?
Types of surgical treatment of gunshot wounds, their purpose and essence?
8. Situational task
A 12-year-old girl complains of morning stiffness in the joints, pain and restriction of movements in the right knee joint, fever 37.3 ° C - 37.6 ° C for 3 weeks. During the last 2 months he was treated by an ophthalmologist for keratitis that developed after ARI. Palpation of the knee joint is sensitive and painful, flexion contracture in this joint is determined. Ultrasonographically, exudative-proliferative synovitis, proliferation of the synovial membrane up to 7 mm, thickening of the joint capsule were determined in the joint. General blood test: erythrocytes 3.6 x1012 / l, Hb 116 g / l, leukocytes 9.8x109 / l, ESR 50 mm / hour. SRB ++++.
Make and justify the previous diagnosis of this patient, taking into account the history and age?
With what diseases it is necessary to carry out differential diagnosis?
Justify the tactics of treatment taking into account the diagnosis (with the degree and / or stage of the lesion), the presence of complications, the patient's age.
Additional questions.
Modern diagnostics of JRA: anti-SSR, anti-MCV, ultrasonography, MRI.
Modern approaches to the basic therapy of JRA: biological agents, minimally invasive organ-preserving surgical interventions.
9. Situational task
A 38-year-old patient fell from the 5th floor while working on a construction site. The patient at the examination is excited, disoriented, systolic blood pressure - 90 mm Hg, Algover index - 0.9. Complains of pain in the pelvis and abdomen. Examination shows tension in the muscles of the anterior abdominal wall, with the upper half of the abdomen involved in the act of breathing, and the lower half is immobile ("two-story abdomen"). 3-4 minutes after Selivanov's intra-pelvic blockade on both sides, the tension in the muscles of the anterior abdominal wall disappeared.
Given the mechanism of injury, clinical symptoms and examination results, establish and justify a preliminary diagnosis?
Justify consistent tactics of care depending on the type of injury and the patient's condition?
Additional questions.
Phases and stages of traumatic shock.
Classification of pelvic fractures.
Complications of pelvic fractures (early, late, distant).
Indications for surgical treatment of pelvic fractures.
10. Situational task
The patient complains of sharp pain in the left knee joint, numbness of the foot, which appeared as a result of an accident 3 hours ago. The foot is pale, cold. Pulse on a. dorsalis pedis is absent. The knee joint is thickened, deformed, the limb is shortened by 5 cm. Passive and active movements in the knee joint are sharply painful, limited, there is an elastic deformation.
Based on the results of the examination, make and substantiate the previous diagnosis, determine further tactics of the examination?
Justify further tactics of treatment of the patient taking into account the type of injury and possible complications?
Additional questions.
Clinical symptoms of damage to the anterior, posterior cruciate ligaments, lateral ligaments of the knee joint.
Symptoms of damage to the menisci of the knee joint.
Tactics of treatment for injuries of the menisci of the knee joint (conservative treatment, meniscus suture, meniscus resection).
11. Situational task
The 62-year-old patient fell on his outstretched arm from the height of his height while walking. I felt a sharp pain in my shoulder joint. I tried to get up and get to my feet - I felt a crunch in my shoulder again and pain again. After injury, all active movements in the shoulder joint became impossible, the attempt to move is accompanied by pain in the deltoid region. The shoulder joint is increased in size due to edema and hemarthrosis, deformed, its contours are smoothed. Positive symptom of axial loading. Sharp pain on palpation below the projection of the head of the humerus, pain in the projection of the large tubercle. The patient is overweight, has a history of thyroid surgery, takes thyroxine.
Formulate a diagnosis? What are the reasons for the displacement of fragments? Treatment? When is a control radiograph of the damaged segment performed?
Additional questions:
For which age category are these injuries characteristic?
Classification of fractures of the proximal humerus
Causes of post-traumatic contracture of the shoulder joint
12. Situational task
Xvora, 63, fell on an outstretched arm in the radial wrist joint. Complains of pain and inability to move in the right wrist. The distal part of the forearm is bayonet-shaped deformed - deformation of the "table fork", swelling of soft tissues. Palpation is sharply painful. The radiographs determine the fracture of the radial bone in the area of the distal metaepiphysis, the fracture line runs horizontally.
Formulate a diagnosis. Name the typical displacements of fragments and medical manipulations to restore the segment.
Additional questions:
What are the possible complications in the conservative treatment of this injury?
Classification of fractures of the distal epimetaphysis of the radial bone.
13. Situational task
A 23-year-old patient was injured in an accident. He was a taxi passenger. Complains of severe pain in the left hip joint. Lying on his back, forced body position. The severity of lordosis of the lumbar spine. The left leg is bent, brought and rotated outwards. There is a shortening of the limb. Palpation - depression under the pupar ligament on the left and protrusion above the area of the acetabulum behind. Movements in the hip joint are severely limited, extremely painful, a positive symptom of "spring resistance." Impossibility to align the lower limb.
Your diagnosis? Treatment tactics? What remote complication is possible with this injury?
Additional questions:
Definition of "central hip dislocation".
14. Situational task
The patient, 35, fell on his half-bent right arm. I felt severe pain in the forearm, elbow joint, the elbow joint stopped functioning. Clinically, the forearm is somewhat shortened, deformity, swelling of soft tissues in the elbow joint. Movements in the latter are sharply limited, when trying to move - pain and a feeling of obstruction on the anterior surface of the joint. Palpation in this area is determined by protrusion. At the border of the upper and middle third of the ulna is determined by pain, abnormal mobility and crepitation.
Preliminary diagnosis? Treatment? When is the control radiography of the damaged segment performed, the conditions of performance?
Additional questions:
Possible complications of this injury?
Differential diagnosis.
15. Situational task
A 42-year-old patient of athletic build with complaints of pain in the left knee joint, moderate restriction of movement - lack of extension 100, possible flexion from 100 to 1000, gait disturbance - limping, pain increases during long gait, after exercise and disappears completely. at rest. From the anamnesis it was found out that 8 years ago he received an injury of the left knee joint during sports, did not seek help, treated himself. Over time, he began to feel insecurity (instability) in the knee joint. On examination, the knee joint is of normal shape and configuration. At a palpation temperature in the field of a joint within norm. The pain is localized along the medial ligament, the projection of the medial joint space, moderate synovitis of the knee joint, a positive symptom of the "anterior drawer", "Lachman" - the test. On the radiograph of the left knee joint in the anterior-posterior projection of the narrowing of the joint space, mainly in the medial part of the joint, the marginal bone growths more on the medial surface, subchondral sclerosis.
Primary diagnosis?
What is the cause of these changes in the knee joint?
3 What diseases of the knee joint need to be differentially diagnosed?
Your treatment plan?
Additional questions:
Define the concept: joint deformity, joint contracture, osteoarthritis, osteonecrosis.
16. Situational task
A 33-year-old patient went to the polyclinic (KDC KDC) with complaints of pain in the left hip joint, which worsens after prolonged walking and restricted movement. Joint pain began to progress after childbirth. From the anamnesis: in childhood the patient was treated for hip dysplasia, and in the last three years - for lumbosacral radiculitis. At inspection malnutrition of muscles of the left hip, considerable restriction of rotational movements of a joint, moderate restriction of bending, removal of the left lower extremity, pain at a palpation in a projection of a joint crack is defined. On the radiograph of the left hip joint in the anterior-posterior projection of the narrowing of the joint space, increased obliqueness of the acetabulum of the pelvis, cervical-diaphyseal angle of the femur 1400, subchondral sclerosis, moderate marginal bone growths - osteophytes of the joint.
Primary diagnosis?
What additional diagnostic examination should be used?
Justify the treatment plan taking into account the etiological factor.
Recommendations for outpatient treatment.
Prognosis for disease progression and further treatment.
Additional questions:
What are the main causes of osteoarthritis of the joints?
17. Situational task
Patient 35y. carried out repair of the car sitting squatting. At sharp rise with turn there was a sharp pain from the inside of the right knee joint, active and passive movements in it suddenly became impossible. The joint became slightly swollen. He can stand on his feet only with the help of a stick, limping. I went home, put a warming compress on my knee. In the morning he went to the clinic. Swollen joint contours it smoothed. Palpation determines the presence of free fluid in the joint, the patella is running, local pain on the medial side in the projection of the joint space. Movements - lack of extension to 200, impossible due to sharp pain and a feeling of mechanical obstruction in the joint. Bending is possible up to 900. Deviation of the lower leg to the middle increases the pain. No pathology was detected on radiographs of the knee joint.
Primary diagnosis?
Differential diagnosis of a knee injury?
What additional diagnostic examination should be used?
Justify the treatment plan.
Additional questions:
What is the function of the menisci of the knee joint.
18. Situational task
The 32-year-old patient had a sports injury of the left knee joint about 3 years ago, due to which he was treated on an outpatient basis for 2 months. Currently, periodically disturbed feeling of instability and moderate pain in the right knee joint. Periodically something jams and movements and joints become impossible. The patient eliminates these violations independently by rocking and rotational movements of a shin. According to the patient at this point, "something crunches and the joint begins to normal work ". The pain is exacerbated during the descent down the stairs. On examination, there is a moderate atrophy of the thigh muscles. Movements in the knee joint in full. in the knee joint and at the same time press on the area of the joint space on the inside there is pain.
Primary diagnosis?
Differential diagnosis of a knee injury?
What additional diagnostic examination should be used?
Justify the treatment plan
Additional questions:
What are the ligaments of the knee joint, you know what their function is for the knee joint.
19. Situational task
Patient B., 27 years old, applied to the trauma department with complaints of pain in the left upper arm and shoulder joint. He was injured 3 hours ago when he fell from a bicycle on his left shoulder. Swelling, tenderness on palpation, step-like deformation in the area of the acromioclavicular joint are determined in the area of the upper arm; when pressing on the acromial end of the clavicle - a positive symptom of the "key". The upper arm is shortened. Movements in the shoulder joint are limited due to pain.
Preliminary diagnosis, treatment tactics.
Additional questions.
What other damage can you suspect and make a differential diagnosis?
What method of treatment would you offer to a patient with an acromioclavicular joint of the Tossi type 3?
20. Situational task
Patient B., 27 years old, applied to the trauma department with complaints of pain in the left upper arm. He was injured 3 hours ago when falling from a Segway on his left shoulder. In the upper arm is determined by edema, severe pain on palpation in the middle third of the clavicle; when pressing on the acromial end of the clavicle - a negative symptom of the "key", smoothing of the supraclavicular and subclavian fossae. The upper arm is shortened. Movements in the shoulder joint are limited due to pain.
Preliminary diagnosis, treatment tactics.
Additional questions.
What is a typical clavicle fracture site?
What are the indications for surgical treatment of a clavicle fracture?
21. Situational task
Patient P., 72 years old, was taken to the trauma department with complaints of pain in the right hip joint, impaired limb impotence. She was injured in her own apartment when she fell on her right side due to dizziness. At inspection: the patient in consciousness, position of the patient on a back, relative shortening of the right extremity on 2 cm is defined; external rotation of the limb, a positive symptom of a stuck heel, the tip of the great acetabulum is located above the Roser-Nelaton line, movements in the hip joint cause pain, axial load of the right limb, causes pain in the right hip joint.
Preliminary diagnosis. Doctor's tactics.
Additional questions:
What are the fractures of the proximal femur?
What are the tactics of conservative treatment in the presence of contraindications to surgical treatment?
22. Situational task
A 24-year-old patient came to see an orthopedist-traumatologist with complaints about the impossibility of complete extension of the right knee joint. In the anamnesis 2 days ago he played football, suffered an injury to the right knee joint (the mechanism of injury is rotational). On examination: relative shortening of the right lower limb, passive and active movements in the knee joint cause severe pain, right knee joint in a semi-bent position, movements in the right knee joint 0/30/60. Palpation pain along the joint slit on the inside of the knee joint.
Preliminary diagnosis. Doctor's tactics.
Additional questions.
What additional damage to the structure of the knee joint can be suspected?
Is conservative treatment possible in this case, if so, which one?
What is the function of the menisci in the knee joint?
23. Situational task
A 39-year-old patient came to see an orthopedist-traumatologist with complaints of pain in the right hip joint. Anamnestically ill for about 7 years, the pain in the right hip joint worsened after childbirth, which was 6 years ago, from the anamnesis it is also known that the patient in childhood was treated for hip dysplasia. In orthopedic examination: gentle lameness on the right lower limb, relative shortening of the right lower limb 2 cm, multiplanar contracture of the right hip joint, when trying to rotate, there is severe pain in the right hip joint.
Preliminary diagnosis. Doctor's tactics.
Additional questions.
Is dysplastic osteoarthritis of the hip joint primary or secondary osteoarthritis?
What are the radiological signs of osteoarthritis?
24. Situational task
A mother and a 6-month-old girl came to see the orthopedist of the traumatologist. The mother complains of limited abduction in the hip joints, especially the left, asymmetry of the buttocks. From the anamnesis: the first childbirth, natural childbirth, full-term child, sciatica, child development corresponds to age. In orthopedic status: abduction in the hip joints on the right to 60 degrees, on the left to 50 degrees, relative shortening of the left lower extremity, external rotation, positive c-m piston, the apex of the great acetabulum of the left femur is above the Nelaton-Roser line, Brian triangle left .
Preliminary diagnosis. Doctor's tactics.
Additional questions.
What are the radiological signs of habitual hip dislocation, what are the symptoms of the Putti triad?
What disease will develop in a patient in adulthood with untimely treatment of hip dysplasia?
25. Situational task
Patient N., 38 years old, was taken to the admission department with complaints of intense sharp pain in the area of the left forearm of a dissecting nature, which is not removed by analgesics. The anamnesis revealed that the patient had an extensor fracture of the left humerus 4 hours ago. Emergency care at the trauma center - a closed reposition was performed and a circular plaster bandage was applied from the wrist bones to the left shoulder. On examination - the fingers of the hand are pale, swollen, bent, when you try to stretch the back of the hand, the pain increases, there is a growing hypoesthesia in the area of innervation of the median and ulnar nerves.
Preliminary diagnosis. Treatment tactics.
Additional questions.
What is compartment syndrome?
What are the optimal timing of fasciotomy?
26. Situational task
A 38-year-old patient was taken to the admission department with complaints of pain in the right shoulder joint and inability of the latter to function. On examination, the right arm is bent at the elbow, removed from the torso and supported by the forearm with a healthy hand. The contours of the shoulder joint are smoothed, the resistance of the acromial process of the scapula is revealed, the deformation of the shoulder joint resembles an epaulette, under the acromial process of depression. There are no active movements, in the study of passive movements - elastic mobility
Preliminary diagnosis. Doctor's tactics.
Additional questions.
What are the treatment tactics for habitual shoulder dislocation?
What methods of shoulder dislocation do you know?
With what injuries carry out differential diagnosis of anterior dislocation of the shoulder?
27. Situational task
Patient, 68 years old. Hospitalized in the trauma department for a fracture of the femoral shaft, which occurred suddenly while walking. From the anamnesis: 5 years ago for breast cancer the patient underwent chemotherapy and mastectomy on the left. On the radiograph, a transverse fracture of the femoral shaft, the edges of the fracture are indistinct and have signs of small focal destruction of the cortical layer up to 3.5 cm in diameter.
What is the diagnosis?
What methods of examination are shown to the patient?
What are the orthopedic treatment tactics?
Additional questions.
Additional survey methods.
Prevention of complications in the early and long periods after injury.
Features of rehabilitation.
28. Situational task
Patient P. is 19 years old. Turned to an orthopedist with complaints of intense progressive pain and increased swelling in n / 3 thighs. Ill for 6 months, denies the injury. Regarding osteoarthritis of the knee joint, NSAIDs, physiotherapy, ointments without effect were prescribed. On examination, palpation: the lower third of the right thigh was club-shaped thickened, on the medial surface in the area of 8x6 cm elastic consistency, sharply painful, immobile in relation to the bone, the circumference tightened in n / 3: S / D = 38 / 46cm. Function of the knee joint: flexion 100g, extension 165g. On radiographs: in the distal metaphysis with the transition to the lower third of the femoral shaft there is an increase in soft tissue (7.8x6 cm), which has signs of intense osteosclerosis, which resembles "clouds" and continues centrally, peeling of the cortical layer in the form of a visor; bone epiphyses are not changed.
What is the diagnosis?
What are the main diagnostic methods?
Additional questions.
Additional survey methods.
Differential X-ray diagnosis of osteogenic sarcoma and benign tumors.
Further treatment tactics.
29. Situational task
Patient P. is 49 years old. She went to an orthopedist with complaints of moderate pain and increased swelling in the n / 3 thighs, which appeared about 1 year ago. Received NSAIDs, physiotherapy, ointments with a negative effect. On examination: the lower third of the right thigh was club-shaped thickened, in the area of 8.5x6 cm, elastic consistency, moderately painful, and mobile in relation to the bone, the circumference of the thigh in n / 3: S / D = 39 / 47cm. Movements in the knee joint are painful: flexion 120g, extension 180g. On radiographs: in the distal third of the thigh you can see an increase in soft tissue, in the form of a more intense oval shadow, size 8x5.5 cm, without clear contours, thinning of the cortical layer; bone epiphyses are not changed. Cytology: tumor maligna.
What is the diagnosis?
What are the main diagnostic methods?
Additional questions.
Additional survey methods.
Orthopedic regime for the patient.
Further treatment tactics.
30. Situational task
Patient P. is 65 years old. She went to an orthopedist with complaints of moderate and increasing pain in the thighs, on the outer surface, which appeared for about 4 months. therefore, the injury is denied. On examination: lame, the upper third of the thigh is not changed, local soreness in the area of the great acetabulum, inguinal fold. Movements in the hip joint are painful: bending 120g, withdrawal 35g, rotation 35g. Limbs of equal length. On radiographs: narrowing of the joint space of the hip joint; in b / 3 of the femoral shaft significant osteolytic destruction up to ½ diameter with a smooth, indistinct contour, 4x5.5 cm. In the analysis of urine, Ben Jones protein is positive.
What is the diagnosis? What are the main and additional diagnostic methods? What are the orthopedic treatment tactics?
Additional questions:
Additional survey methods.
Orthopedic regime for the patient.
Further treatment tactics.
31. Situational task
A mother and a 15-year-old boy complained to an orthopedist-traumatologist about the appearance of shoulder pain after exercise, without injury. At inspection active movements in a shoulder are possible but painful and limited. On radiographs: in the metaphysis of the humerus, a homogeneous focus of osteolytic destruction (2.5x4 cm) with a clear contour, delimited by the rim of sclerosis, thinning of the cortical layer. The growth zone is not disturbed. In dynamics dynamics of the center is appreciable.
What is the diagnosis?
What are the methods of confirming the child's diagnosis?
What are the treatment tactics?
Additional questions.
Additional survey methods.
Differential X-ray diagnosis of aneurysmal cyst and malignant bone tumor.
32. Situational task
A 29-year-old woman applied to the trauma department with complaints of swelling and pain in the n / 3 forearm, which lasted for about 4 months, for no apparent reason. On examination - local soreness of the distal metaphysis of the radial bone, joint function is not impaired. On the radiograph: in the distal epimetaphysis of the radial bone, lytic destruction of 2/3 of the diameter of the bone (3 cm in diameter), without demarcation, trabecularity (s-m "soap bubbles"), destruction of the cortical layer is determined. Cytology: osteoclasts - giant multinucleated, and osteoblasts.
What is the diagnosis? What are the main and additional diagnostic methods? What are the orthopedic treatment tactics?
Additional questions:
Differential X-ray diagnosis of giant cell tumor, bone tuberculosis, cystic remodeling of the pineal gland.
Prognosis of the disease.
33. Situational task
A 42-year-old patient went to the trauma department with complaints of pain in the lower third of the right shoulder, which is exacerbated by minor movements. According to the patient, he was injured as a result of falling from a height of one meter. At clinical inspection deformation in the lower third of the right shoulder, pain on a palpation, pathological mobility is defined. In addition, the dysfunction of the hand is determined: the impossibility of active extension of the hand, withdrawal of the first finger, impaired sensitivity in the area of I-III fingers. The radiograph shows an oblique fracture of the lower third of the humerus with a slight displacement of the fragments in length and width while maintaining the axis
What are the optimal treatment tactics?
A. anesthesia, closed repositioning, immobilization
B. closed reposition, fixation by an intramedullary blocking core
C open reposition, fixation with a metal plate
D. open reposition, fixation by an intramedullary blocking core
34. Situational task
The 38-year-old patient went to the trauma department with complaints of pain in the left ankle joint, which is exacerbated by minor movements, loss of capacity. According to the patient, he was injured as a result of falling from a height. At clinical inspection pain on a palpation, deformation in the field of an ankle joint, hemarthrosis is defined. X-ray examination data
What are the optimal treatment tactics?
A - closed reposition, fixation with a plaster bandage "boots"
B - closed reposition, additional percutaneous fixation with a spitz and plaster bandage "boots"
С - open reposition, stable-functional osteosynthesis
35. Situational task
A 74-year-old patient was taken to the traumatology department of KShMD with complaints of pain in the left hip joint, which is exacerbated by minor movements, loss of ability to work. According to the patient, she was injured as a result of a fall 7 days ago. After the fall, the pain was minor. During this time I walked with a stick. On the day of hospitalization, when she got up from the chair, she felt a sharp pain, which prompted her to seek medical help. At Clinical examination reveals pain on palpation in the hip joint, moderate external rotation of the lower extremity, a positive symptom of "stuck heel" and axial load. X-ray examination data: punctured fracture of the neck of the left femur.
In order to clarify the patient's diagnosis, computed tomography was performed, the data of which are presented
On the basis of the received data formulate the diagnosis and tactics of treatment
A - external immobilization with a plaster cast bandage / orthosis
B - skeletal traction, external immobilization with plaster cast bandage / orthosis
C - open reposition, stable-functional osteosynthesis
D - unipolar endoprosthesis
E - total arthroplasty
36. Situational task
The patient fell from a height of 5 meters. Delivered 1 hour after the injury. Upon admission, the condition is serious. The skin is pale, breathing - 28 breaths. per minute, blood pressure - 80/40 mm. rt. Art. Pulse 120 beats. for a minute. On examination: pelvic ring deformity, symptoms of Verneil, Lareya, Joyce are positive. The abdomen is tense, no peritoneal symptoms.
Determine the optimal set of treatment measures in this period?
A. Simultaneous compensation of life support systems and indirect osteosynthesis of the damaged pelvis by an external fixation device
B. Compensation of life support systems and after their stabilization the choice of method of treatment of a damaged pelvis
С. Compensation of life support systems and after their stabilization the implementation of open osteosynthesis of the damaged pelvis
D. Compensation of life support systems and after their stabilization of treatment of the damaged pelvis by the method of constant traction
37. Situational task
A 42-year-old patient fell from a height of 2.5 meters on his left leg. Complains of pain in the left thigh. Objectively: pulse 88 per minute, blood pressure - 110/75 mm Hg. art., deformation, pathological mobility and crepitation in the middle third of the thigh.
Which transport immobilization is optimal in this case?
A. Dieterichs tire
B. Cramer's tire
C. Pneumatic rail
D. Immobilization by improvised means
Е. Bandage the damaged limb to a healthy one
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