304.A 43-year-old man presents to the ED after falling approximately 6 ft
from the roof of his garage. The patient states that he landed on his feet but
then fell to the ground. You assess his ABC (airway, breathing, and circula-
tion), which are all normal. Vital signs are stable. Your secondary survey
reveals a swollen and tender right heel. A radiograph reveals a fractured
calcaneus. About 6 hours after the initial fall, the patient starts complain-
ing of a constant burning in his right foot. You examine the foot and elicit
pain with passive movement. There is decreased two-point discrimination.
His dorsalis pedis pulse is 2+. Which of the following is the most appro-
priate next step in management?
a. Place ice on the foot and administer analgesia.
b. Order another radiograph to look for an occult fracture.
c. Elevate the leg and place an elastic bandage around the foot.
d. Order a duplex ultrasound for suspicion of a deep vein thrombosis (DVT).
e. Measure the intracompartmental pressure of the foot.
305.A 41-year-old man is brought into the ED after having a witnessed
tonic-clonic seizure. He is alert and oriented and states that he has not taken
his seizure medication for the last week. His BP is 140/75 mmHg, HR is
88 beats per minute, temperature is 99.7°F, and his RR is 16 breaths per
minute. On examination you notice that his arm is internally rotated and
adducted. He cannot externally rotate the arm and any movement of his
shoulder elicits pain. Which of the following is the most likely diagnosis?
a. Humerus fracture
b. Clavicular fracture
c. Scapular fracture
d. Posterior shoulder dislocation
e. Anterior shoulder dislocation
306.A 24-year-old man presents to the ED complaining of right wrist
pain that began after he slipped and fell and landed on his outstretched
hand. You examine the hand and wrist, and note no abnormalities except
for snuffbox tenderness. A radiograph does not reveal a fracture. Which of
the following is the most appropriate next step in management?
a. Place an ACE wrap around the hand and wrist until the pain resolves.
b. Immobilize the wrist in a thumb spica splint and have the patient follow-up
with an orthopedist for repeat radiographs in 10 to 14 days.
c. Continue to ice the wrist for 24 to 48 hours.
d. Order a CT scan to evaluate for an occult fracture.
e. Place the wrist and arm in a cast for 6 weeks.
324 Emergency Medicine