ortho board questions

1. muscle responsible for first 10% of abduction: * 2. muscle responsible for internal rotation of shoulder: 3. muscles responsible for external rotation of shoulder:

muscle responsible for first 10% of abduction: * supraspinatus 4. muscle responsible for internal rotation of shoulder: subscapularis 5. muscles responsible for external rotation of shoulder: infraspinatus and teres minor

• A 21 year-old female presents to the emergency department after having a cast applied to her right arm earlier that day. Approximately one hour ago she began having extreme 10/10 pain in her right arm and is in visible distress. When considering the diagnosis of compartment syndrome, permanent damage to the muscle begins after how many hours of ischemia?

o >8 hours

• A 59-year-old woman with a known history of rheumatoid arthritis presents with relatively severe complaints of pain, notable bony deformity of the hands with extra-articular findings of cutaneous nodules, scleritis, and pleurisy. On physical examination, the patient is found to have splenomegaly. Which of the following is the most appropriate laboratory evaluation to order to further evaluate the suspected diagnosis?

o A This patient presentation of known rheumatoid arthritis with severe deformities, extra-articular findings, and splenomegaly is most likely Felty syndrome. Felty syndrome is characterized by the triad of deforming rheumatoid arthritis, splenomegaly, and neutropenia. The appropriate laboratory test to order would be a CBC to evaluate for neutropenia

• A 16 year old male, who plays on his school's football team, is brought to the urgent care with right knee pain. He states that he was playing in the game last night, and while running was tackled from the right side at the level of his knee. He experienced immediate knee pain and swelling, neither of which have significantly decreased overnight, or with conservative measures. On physical exam, you note swelling around the right knee, and pain with range of motion, as well as positive Lachman's and McMurray's tests. You suspect ACL, and medial meniscus damage. What other structure may have been injured in this injury?

o ACL, MCL, and medial meniscal injury compose what is referred to as the 'Unhappy triad' or the 'Triad of O'Donohue'. These three structures are commonly injured due to the mechanism of injury described in this patient's presentation, namely that of having the foot planted with the knee in slight flexion, and lateral impact.

• A 64-year-old female presents with acute onset of severe right knee pain. She denies any trauma and her history is only significant for diabetes mellitus. On physical examination her knee has significant edema and erythema, with warmth on palpation. After an aspiration of the synovial fluid the results are: o Color: opaque yellow fluid o WBC: 90,000/mcL o PMN: 90% o Considering your suspected diagnosis what is the best treatment for this patient?

o Acute bacterial septic arthritis is associated with white blood cell counts commonly > 50,000/mcl with 90% or more polymorphonuclear cells. Compromised immunity, such as diabetes mellitus, increases the risk of septic arthritis. The effective treatment of septic arthritis requires appropriate antibiotic therapy together with drainage of the infected joint. Hospitalization is always necessary to prevent sepsis and administer IV antibiotics

• A 26 year old male presents to your urgent care clinic complaining of left shoulder pain which started during a friendly game of football with his friends. He was tackled and fell onto the tip of his left shoulder with his arm tucked, holding the ball. Now he complains of severe pain with any range of motion, especially overhead movements, and downward traction on the arm. Which of the following is the most likely diagnosis?

o An AC joint separation is classically described by the mechanism of action of falling on the tip of the shoulder with the arm tucked. As this patient did, those with AC joint injuries will have restricted ROM secondary to pain, especially with overhead movement.

• A 19 year old female athlete presents with knee instability and pain after experiencing a hyperextension injury. Which of the following describes accurately the physical exam test that is most sensitive for ACL injury?

o Applying anteriorly directed force from behind the knee as it is held in 30 degrees of flexion.

• What nerve is most commonly injured in a mid- or distal humeral shaft fracture?

o Because of the radial nerves proximity to the humerus, mid and distal shaft fractures with significant displacement can cause a radial nerve injury. Median and ulnar injuries are more commonly associated with forearm injuries. Axillary nerve injuries are most common in anterior shoulder dislocations and peroneal nerve damage occurs as a result of lower leg insult.

• A 32 year old male with no past medical/surgical history presents complaining of back pain that began this morning during his routine calisthenics. He has been in his usual state of good health and does not abuse drugs. He reports the pain is concentrated in the lower back, at times shoots down the back of his right leg, and is aggravated by sudden movements. On physical exam you note pain on straight leg raise of the right leg. Lower extremity reflexes are equal bilaterally. His strength and sensation are otherwise equal and normal. Which of the following is the next best step in the management of this patient?

o Bedrest is no longer recommended in the management of acute low back pain with radiculopathy. Early return to activity as tolerated is recommended. o Low back pain with a radicular component is treated supportively and with early return to activity as tolerated. Emergent imaging is not indicated in the absence of red flags on history and exam (fever, constitutional symptoms, direct trauma, pain less than 3-4weeks in length, history of cancer or drug abuse or immunocompromise, history of tuberculosis, age between 18yr-50yr; saddle anesthesia or incontinence).

• A 32 year old professional pianist presents to your clinic because of numbness in her hands for the last week. Her symptoms are worse at night, and have progressively become worse. On physical exam you note decreased grip strength bilaterally and a positive Phalen's test. This patient should be screened for which of the following endocrine abnormalities?

o Carpal tunnel syndrome affects patients with comorbid hypothyroidism at a higher rate than the general population, and may be correlated with poorly controlled (high TSH levels) hypothyroidism.

• Elderly man involved in car crash, hyperextend neck, develop burning sensation and paralysis in both upper extremities, but maintains good motor in lower extremity, what affected

o Central cord syndrome o Anterior cord syndrome: all functions are lost except for position and vibration; MOI: blowout of vertebral bodies o Posterior: show loss of position and vibration

• A 56-year-old male who works in construction climbing ladders has developed pain to the right foot for several days. You have seen and examined the patient a few days after the patient started complaining of pain to the foot. Your initial x-rays of the foot are negative for fracture. He continues to have pain, and decreased ability to bear weight. Based on this clinical scenario, how many days after the initial examination should another x-ray be ordered to look for a stress fracture?

o D Radiographic evidence of stress fractures is not immediately apparent after the initial onset of symptoms. Estimates of anywhere from 14 to 42 days before visible signs of a stress fracture can be detected on X-ray have been put forth with a commonly utilized range of 14 to 30 days. Any answer choice above that included numbers less than 14 days would simply be inaccurate due to the gradual appearance of the classic x-ray findings of a stress fracture. After 180 days from the time of stress fracture onset, the fracture should be nearly healed if managed properly

• Which of the following is NOT a sign of flexor tenosynovitis

o Erythema o The rest of these are signs: fusiform soft tissue swelling, pain with passive extension, hand held in flexion

what is Essex-Lopresti fracture

o Essex-Lopresti fracture-dislocations comprise of a comminuted fracture of the radial head accompanied by dislocation of the distal radioulnar joint.

• Which of the following items in the history of a patient with a knee injury caused by lateral impact would most increase your suspicion of anterior cruciate ligament damage? Are ACL injuries caused by hyperextenion or hyper flexion?

o Feeling a pop accompanied by immediate pain and swelling o This is the classic history for a patient with an ACL injury. Though they may not be able to bear weight after the injury, this could occur in injuries other than the ACL. Hyperextension movements are more common in ACL injury than are hyperflexion.

• In a 4-year-old female child who presents with "toeing in," which of the following is the likely etiology

o Femoral anteversion o A "Toeing in" in children before the age of 2 is typically due to tibial torsion; however, any "toeing in" after the age of 2 to 3, is usually due to femoral anteversion. The femur has more internal rotation that results in the presentation. Genu varum is known as bowleg and genu valgum is known as knock-kneed.

• A 16 year old high school student presents to the clinic with her mother complaining of left wrist pain. She admits the pain has been intermittent for the past week, but seems to be getting worse. She feels the pain mostly in the dorsal wrist, but somewhat into both the thumb and lateral forearm. On physical exam she is mildly tender to palpation over the affected area, there is mild swelling without redness or warmth, and her grip strength is decreased on the left. Which of the following physical exam tests would you expect to be positive in this patient?

o Finkelstein test o This patient most likely is experiencing DeQuervain's tenosynovitis, an inflammation of the extensor pollicis brevis and abductor pollicis longus due to repetitive tasks. The Finklestein's test will yield a positive result, and confirm your suspected diagnosis.

• Sensation in which of the following places would indicate that sensory function is intact for median, radial, and ulnar nerve distributions?

o First dorsal web space, the thenar eminence, and the 5th digit o These three areas cover the sensory distributions of the radial, median, and ulnar nerves respectively.

• 46 female is getting conscious sedation to remove bunion; given midazolam. Midway ins urgery, she become agitated and combative; what should be administered immediately

o Flumazenil: a benzodiazepine antagonist to hasten recovery from benzodiasepines used in anesthetic and diagnostic settings and reverse the CNS depressant o Glucagon antidote for BB overdose o Naloxone opiod receptor antagonist o Nitrite is antidote for cyanide poisoning

• A 2 year old boy is brought to the urgent care by his parents who state that the child isn't using his left arm and has been practically inconsolable for the past hour. They report that they were playing outside together and Dad picked the child up by his hands like he always does, and since that time their boy hasn't moved his left arm. On exam you find he is not willingly moving the arm, is non-tender to palpation, and cries when you attempt to supinate the forearm. Which of the following is the next best step in the management of this patient?

o Fully supinate the forearm and flex it completely till it touches the upper arm o Clear history, so no x-ray needed as next step

• A 22-year-old man is seen in the emergency department because of pain and swelling of the right wrist and forearm since accidentally falling onto his outstretched hand two hours ago. Physical examination shows intact skin, and swelling and deformity of the distal right forearm. Neurovascular examination shows no abnormalities. X-ray study of the forearm shows a dorsally displaced fracture of the distal one-third of the radius, and dislocation of the radioulnar joint. Which of the following is the most likely diagnosis?

o Galeazzi fracture-dislocations consist of fracture of the distal radius with dislocation of distal radioulnar joint and an intact ulna. A Galeazzi-equivalent fracture is a distal radial fracture with a distal ulnar physeal fracture. Although this injury is primarily seen in children (peak incidence of 9-12 years of age), in adults, it is estimated to account for ~7% forearm fractures. Galeazzi fracture-dislocations typically occur following a FOOSH injury with a flexed elbow.

1. antidote for BB overdose 2. antidote for opoid receptor antagonist 3. antidote for cyanide poisoning

o Glucagon antidote for BB overdose o Naloxone opiod receptor antagonist o Nitrite is antidote for cyanide poisoning

• What is the most worrisome complication associated with hip dislocation?

o Hip dislocation, often caused by 'dashboard injury' or posterior directed force causing posterior dislocation, may result in injury to the acetabular artery which may lead to avascular necrosis and femoral head collapse.

• A patient who has recently begun treatment for systemic lupus erythematosus with hydroxychloroquine returns to your clinic because she is experiencing side effects from the medication. Which of the following is most likely her complaint?

o Hydroxychloroquine may cause macular damage, and thus result in impaired night vision in patients taking this medication. Patients with SLE should be monitored at least yearly by an ophthalmologist to monitor for these retinal changes. All other side effects are not commonly associated with the use of this medication for treatment of SLE.

• What anatomic abnormality may predispose a person to develop impingement syndrome or rotator cuff tendonitis?

o In general the acromion process should be flat inferiorly to allow smooth passage of the rotator cuff tendons, in type 2 or type 3 acromion processes however, the underside of the acromion is not flat, but curved or hooked respectively and thus may predispose a patient to those conditions.

• Which of the following is the correct description of kyphosis?

o Increased convex curve of spine o Increased concave curve is lordosis (this of caving in)

• Which disc space is likely to have been damaged if on physical exam you observe anterior tibialis weakness and an asymmetric patellar reflex?

o L4, L5, not L3 and L4

• Which of the following clinical interventions is indicated in the treatment of Legg-Calve-Perthes disease?

o Legg-Calve-Perthes disease (LCPD) results from avascular necrosis of the femoral head, proximally. This condition tends to occur most often in males, ages 4-10. These patients should be referred to an orthopedist for evaluation and treatment. Abduction splinting is the treatment of choice in LCPD, with the goal of maintaining femoral head shape within the acetabulum as it heals.

• Man got into a brawl and was stabbed; see winged scapula and can't raise arm about horitzontal; what nerve is affected

o Long thoracic o Long thoracic nerve innervate serratus anterior, abduct arm from 90-180

• A family friend calls you because her mother was recently diagnosed with Polymyalgia Rheumatica. She has been doing some research, but wants to know what the usual treatment is for this condition. Which of the following would be your response?

o Low dose corticosteroids for a couple of years and close follow-up with Rheumatology

• What is the hallmark sign or symptom of herniated disc disease?

o Lumbosacral radiculopathy is the hallmark symptom of herniated disc, observed in 95% of cases.

• A 14 year old boy presents to your clinic complaining of 'bumps' on his legs. Physical exam reveals non-tender bony protuberances on the distal femur and proximal tibia. Which of the following is the most likely diagnosis?

o Osteochondroma

osteomyelitis in adults vs. children 1. MC area of occurrence in each 2. MCC based on age 3. treatment

o Osteomyelitis • In children MC in long bones (tibia, femur), MCC is staph, • If have sickle cell, MCC is salmonella • Newborn, <4month: group B strep; Nafcillin or oxacillin + 3rd gen cephalosporin • >4 months: staph aureus: • MSSA: Nafcillin or oxacillin or cefozolin (ancef) • MRSA: Vanco or linezolid • Sickle cell: salmonella; 3rd gen ceph or FQ (cpiro or levo) • Pseudomonas: cipro or levo; ceftazimide or cefipme • In adults • MC is staph, ocurrs in lumbar vertebrae

• A 22 year old volleyball player is brought to your office complaining of bilateral anterior knee pain, although she admits it is worse on the right. Her pain began the second week of the season, and has progressively gotten worse. She admits that now after practice her knees are swollen and she has to ice them until bedtime, though she won't allow this to keep her from practicing. She admits that pain is worse with jumping, and going up and down stairs. She has tried ibuprofen without significant relief. On physical exam you note anterior tenderness and edema just inferior to the patella. Which of the following is the most likely diagnosis?

o Patellar tendonitis is inflammation at the patellar tendon due to repetitive stressors or trauma that most commonly occurs in athletes ages 16-40.

• A 32 year old African American female, who is being treated successfully for Systemic lupus erythematosus, presents after having a miscarriage. Which of the following tests should be ordered to assess this patients risk for further miscarriage or blood clots?

o Patients with SLE are at increased risk for developing Anti-phospholipid syndrome (APS), which may cause blood clots or recurrent miscarriages. Serum anti-phospholipid antibodies are the best test to indicate the presence of this condition.

• A 64-year-old postmenopausal female presents for an annual examination. She is 5'0" and weighs 92 pounds; compared to her examination 3 years ago she has lost an inch in height. After performing a dual-energy x-ray absorptiometry (DXA) scan the diagnosis of osteoporosis is confirmed and she is started on appropriate treatment. How often should she be recommended to follow-up with a DXA bone density scan?

o Recommendations for patients diagnosed with osteoporosis without a fracture is every 2-3 years (C). This guideline is approved based on age, risk factors, or previous fractures. A post-menopausal woman at age 64 without a presenting fracture can be followed every 2-3 years with bone density imaging (DXA scan). Medications and other treatment options may need earlier or more frequent follow-up depending on the treatment plan.

red flags for low back pain that indicate further investigation (i.e. x-rays)

o Red flags for low back pain that indicate further investigation (often with initial xray lumbar series) generally include: trauma, constitutional symptoms, age>50, immunosuppression, history of cancer, history of IV drug use, prolonged use of corticosteroids, history of osteoporosis, focal neurologic deficits, duration greater than 6 weeks, or history of prior back surgery. This female patient is older than 50 years, and xrays should be ordered to evaluate for possible compression fracture secondary to undiagnosed osteoporosis.

• A 67-year old female with no past medical history presents with acute onset low back pain for 1 day while trying to lift up a table. The patient denies any recent illness, fever, numbness or weakness. She does not smoke, drink alcohol, or use drugs. The pain is located in the low lumbar midline area and is not radiating. Physical exam is unremarkable except mild tenderness to L4/L5 midline. Which of the following is the next best step in management of this patient?

o Red flags for low back pain that indicate further investigation (often with initial xray lumbar series) generally include: trauma, constitutional symptoms, age>50, immunosuppression, history of cancer, history of IV drug use, prolonged use of corticosteroids, history of osteoporosis, focal neurologic deficits, duration greater than 6 weeks, or history of prior back surgery. This female patient is older than 50 years, and xrays should be ordered to evaluate for possible compression fracture secondary to undiagnosed osteoporosis.

• Which of the following is the most specific test used for detecting Sjogren's syndrome?

o Sensitivity versus Specificity is an important concept. The specificity of a test refers to the ability of the test to help diagnose a condition, whereas the sensitivity of the test refers to the ability of the test to help rule out a condition. Anti-La is the most specific test used for diagnosing Sj gren's syndrome.

cause and treatment of septic arthritis

o Septic arthritis • MCC is staph • N. gonorrhea in young adults • MC in knee • Dx: synovial fluid is yellow, turbulent, WBC>50K, PMN >75% • Management o Abx prompted by gram stain o Gram positive cocci: nafcillin (vanco if MRSA) o Gram negative cocci or gonococcol: ceftriaxone, or cipro o Gram negative rod: ceftriaxone +gentamicin o No organism: nafcillin or vanco + ceftriaxone •

Synovial fluid labs * non inflammatory * inflammatory * septic

o Septic joint will have >50K WBC, >75% PMN, yellow in appearance, glucose is low o Non inflammatory will be <10K o Inflammatory but not spectic will have 1K to 100K WBC, with 50% PMN, will look yellow, glucose will be above 25mg/dL, but lower then blood

• Which of the following regimens is acceptable in the treatment of osteomyelitis caused by Staphylococcus aureus ?

o Six weeks of IV antibiotics followed by 1-2 weeks of outpatient oral antibiotics

• A 12-year-old boy is brought to the office by his mother for evaluation of a limp he has had for the past week. He does not recall any trauma, but does have some pain in his left knee. Body mass index is 30. Physical examination of the left lower extremity shows decreased internal rotation at the left hip compared with the right. The left knee is non-tender, and has full range of motion. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

o Slipped capital femoral epiphysis (SCFE) represents a unique type of instability of the proximal femoral growth plate. It is one of the most important pediatric and adolescent hip disorders encountered in medical practice. Clinically, patients may report hip pain, medial thigh pain, and/or knee pain; an acute or insidious onset of a limp; and decreased range of motion of the hip. Accurate diagnosis combined with immediate treatment is critical. It occurs two to three times more often in males than females. A large number of patients are overweight for their height.

what is the purpose of a speeds test

o Speeds test: Generally used in evaluation of bursitis or biceps tendinopathy.

• Which of the following is the most common side effect of methotrexate?

o Stomatitis or gastritis are the most common side effects of methotrexate.

• A 44-year-old woman is seen in the office for evaluation of right foot pain that she has had for the past five days. She denies any trauma, but states that she practices martial arts for exercise. The pain is located at the bottom of the foot, and is most intense when she gets out of bed in the morning and begins to walk. Physical examination of the foot shows moderate tenderness on the plantar surface overlying the calcaneus. The remainder of the examination shows no abnormalities. In addition to recommending oral nonsteroidal antiinflammatory medication, which of the following is the most appropriate additional next step in management?

o Stretching is the best treatment for plantar fasciitis. Home exercises to stretch the Achilles tendon and plantar fascia are the mainstay of treatment, and reduce the chance of recurrence.

• Several months after sustaining a crushing injury to arm, pt complain of burning arm pain, that not respond to meds; even hurts when rubbed by clothes; arm is cold, cyanotic, and moist. Pulse and neurological function of 3 major nerves is in tact. What is dx and therapy

o Sympathetic block and surgical sympathectomy o This is complex regional pain syndrome o Need to use sympatheic nerve block, if done early can alleviate the sx

• Radiculopathy due to nerve root compression occurs most commonly at which nerve root within the brachial plexus?

o The C7 nerve root is affected the most often (approximately 45-60%). This radiculopathy can result from foraminal encroachment of the spinal nerve, cervical disk herniation, tumor, and multiple sclerosis. C7 radiculopathy can present with weakness in the triceps, which cause elbow extension, and finger flexion and extension.

• What is the first type of motion that is lost as a person develops progressively worsening osteoarthritis of the hip joint?

o The earliest sign of the development of osteoarthritis of the hip is often the loss of internal rotation. As the condition worsens, muscular contractures may develop which hold the affected limb in a flexed and externally rotated position, which has great consequence on the individual's gait and functioning level.

• You are evaluating a 32-year-old male who has possibly injured his Achilles tendon while planting his foot into the soft ground while playing touch football. When evaluating a patient with this suspected injury, you have the patient plantar flex his ankle as part of the exam. Based on your knowledge of anatomy, what two plantar flexing muscles attach into the Achilles tendon?

o The gastrocnemius and soleus muscles form a common tendon at their distal insertions known as the Achilles tendon. This the strongest and thickest tendon in the body and it attaches at its distal end onto the calcaneus bone of the foot. Contraction of the gastrocnemius and soleus muscles are responsible for plantar flexion of the foot and ankle.

• A 5-year-old male is being evaluated for an acute injury to the right ankle. On the x-ray of the ankle there is a distal tibia fracture that involves the separation of the epiphysis, as well as a small non-displaced chip fracture of the metaphysis of the tibia. Based on these findings, what type of Salter-Harris fracture does this child have?

o The growth plate is the most fragile part of the bone prior to bone maturation and thus is usually the first structure disrupted when force is applied. Statistically, Type II fractures are most common - those that involve both the growth plate and a chip fracture of the metaphysis.

• Upon testing a patient for function of the hip flexors, which muscle is considered the primary muscle responsible for most flexion?

o The iliopsoas muscle is the primary hip flexor muscle. It originates at T12 and L1-5 vertebrae and intervertebral disks as well as the iliac fossa of the pelvis and connects to the femur at the lesser trochanter. The gracilis muscle is considered a secondary hip adductor. Rectus femoris does help with hip flexion, but in a secondary role to the iliopsoas. Rectus femoris is also involved in knee extension. Sartorius is also involved in hip flexion, but in a secondary role. The vastus intermedius muscle is one of the four quadriceps muscles and is involved with knee extension and is not involved in hip flexion.

• Upon testing a patient for function of the hip abductors, which muscle is considered the primary muscle responsible for most abduction? 1. primary muscle for knee flexion 2. primary muscle for hip extension 3. primary muscle for hip flexion

o The primary mover in the motion of hip abduction is the gluteus medius muscle. Gluteus minimus does play a supporting role in that motion. 1. primary muscle for knee flexion: bicep femoris 2. primary muscle for hip extension: glut max 3. primary muscle for hip flexion: iliopsoas

• Which of the following is the most commonly affected site by osteomyelitis?

o The spine and hip are the most commonly affected locations in osteomyelitis.

• Which of the following physical exam tests, if positive, is most suggestive of inferior instability of the glenohumeral joint?

o The sulcus sign is performed by applying inferior traction to the arm and observing the shoulder for the formation of a sulcus at the lateral edge of the acromion process. This test is indicative of inferior instability. o Apprehension test is more indicative of anterior dislocation

• A 5 year old boy is brought to your office because his mother has noticed him walking with a limp that didn't resolve after a few days. He has now been limping for the past week, but does not complain of pain. Physical exam is unremarkable, other than mildly restricted internal rotation of the hips bilaterally. Which of the following diagnostic studies is the next best step in the evaluation of this patient?

o This clinical presentation most likely represents a patient with Legg-Calve-Perthes disease. An idiopathic avascular necrosis of the femoral head commonly affecting males ages 4-8. Bilateral hip radiography including AP, Lateral, and Frog leg views is indicated as the initial diagnostic evaluation in these patients.

• A homeless man is brought to ER b/c he has severe pain in his forearm b/c he was drinking and slept on his right hand. There is no sign of trauma, put there is pain with passive motion of fingers. Pulses are normal. What is most appropriate step in management

o This is compartment syndrome; there are reliable physical exam findings o Dx cannot be ruled out by normal pulses o Only fasciotomy will solve this problem

• A 28 year old female presents complaining that her knee gave out on her. She states that she was walking down the stairs when her knee failed to support her, and she stumbled down the last few steps without injury. She denies pain, fever, or history of trauma. This is the first time that anything like this has happened to her. On physical exam she is neurovascularly intact distally, knee stability is intact, and there is no excess fluid noted in the joint via the ballottement test. The apprehension test is positive. Which of the following is the next best step in the treatment of this patient?

o This patient had their first episode of patellar dislocation. After a first episode, when physical exam findings are minimal, reduction maintained with a brace for 2 to 3 weeks is the best course of treatment.

• A 45 year old male presents to the clinic complaining of left knee pain after playing a game of basketball with friends last week. Since that time he has had several episodes of catching and locking of the knee. On physical exam range of motion and stability are intact, and McMurray's test is positive. Which of the following mechanisms of injury is most common in this patient's condition?

o This patient is presenting with a meniscal injury. The most common mechanism causing this type of injury is axial loading with rotation. o Lateral impact with the knee in slight flexion and the foot planted→ this is MCL MOI

MOI of meniscus vs. MCL tear vs. ACL tear

o This patient is presenting with a meniscal injury. The most common mechanism causing this type of injury is axial loading with rotation. o Lateral impact with the knee in slight flexion and the foot planted→ this is MCL MOI This is the classic history for a patient with an ACL injury. Though they may not be able to bear weight after the injury, this could occur in injuries other than the ACL. Hyperextension movements are more common in ACL injury than are hyperflexion.

• A 43 year old male with a two month history of headaches, and fatigue, with intermittent arthralgias, generalized weakness, and fevers. Within the last week he developed a rash on both legs. On physical exam you notice areas of palpable purpura, as well as a mottled reticular vascular pattern on the upper thighs. On lab testing ESR is elevated, he has a mild leukocytosis, and ANCA testing is negative. Which of the following is the most likely diagnosis?

o This patient is presenting with constitutional symptoms, arthralgias, and skin findings. Palpable purpura and livedo reticularis are common findings in Polyarteritis Nodosa (a vasculitis affecting medium sized blood vessels). Symptoms can encompass a wider range of organ systems, and ANCA testing can be positive in these patients. High dose corticosteroids is the generally accepted treatment for this condition.

• A 45 year old male presents to the emergency department with severe back and posterior leg pain after lifting something heavy at work. While eliciting the history you discover that he is experiencing paresthesias on the medial aspect of both legs, and he did have an episode of fecal incontinence. What is the next step in the management of this patient?

o This patient is presenting with symptoms consistent with Cauda Equina syndrome, a neurologic emergency secondary to massive midline disc herniation that compresses several nerve roots. This patient may receive an MRI to confirm the diagnosis, but should immediately be referred to neurosurgery.

• A 32 year old female presents to the urgent care after sustaining a fall in which she caught herself with her left hand while skiing yesterday. She now complains of left wrist pain and swelling that hasn't been relieved by ice or anti-inflammatory medications. On physical exam range of motion is full, though painful, and she is tender to palpation distal to the radial styloid. Xrays of the hand and wrist are read normal. Which of the following is the treatment of choice in this patient?

o This patient most likely has a scaphoid fracture, indicated by the mechanism of injury and the tenderness over the anatomical snuffbox. Long arm thumb spica cast for four weeks, followed by a short arm thumb spica is the treatment of choice.

• What degree of rotational deformity is acceptable (meaning not requiring surgical correction) in a fracture of the fifth metacarpal?

o This statement is true. No degree of rotational deformity is acceptable in a Boxer's fracture. Angulation may be acceptable however. Up to 40 of angulation in the fifth metacarpal and 30 in the fourth metacarpal.

• A 17 year old high school quarterback presents to your clinic after having sustained some hard hits during the game last night. He now complains of right shoulder pain that he describes as a steady ache deep in the shoulder. On exam he has limited range of motion secondary to pain, with no tenderness to palpation. Which of the following physical exam tests, if found to be positive, would most increase your suspicion of a superior labrum anterior to posterior (SLAP) tear?

o Though various sources have determined that no one technique can accurately diagnose a SLAP injury, O'Brien's test one of the more reliable tests used in the assessment of these shoulder injuries. A positive O'Brien's test produces pain when the arm is adducted across the chest with the thumb pointed inferiorly, but no pain with the thumb pointed superiorly. (If pain with both movements suspect an AC joint injury).

transient synovitis labs and synovial fluid

o Transient synovitis (TS) is the most common cause of acute hip pain in children aged 3-10 years. TS causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip. Biopsy reveals only nonspecific inflammation and hypertrophy of the synovial membrane. Ultrasonography demonstrates an effusion that causes bulging of the anterior joint capsule. Synovial fluid has increased proteoglycans.

• Which of the following hip joint abnormalities follows an viral upper respiratory infection? treatment?

o Transient synovitis is the most common cause of a limp with associated hip pain in children ages 3-10 years of age and is more common in males. It frequently follows a viral upper respiratory tract infection. There is commonly nothing significant found on CBC, and an ultrasound reveals no effusion (as it would in a septic joint). Transient synovitis is treated with rest and NSAIDs.

• Which of the following joint abnormalities follows an viral upper respiratory infection?

o Transient synovitis is the most common cause of a limp with associated hip pain in children ages 3-10 years of age and is more common in males. It frequently follows a viral upper respiratory tract infection. There is commonly nothing significant found on CBC, and an ultrasound reveals no effusion (as it would in a septic joint). Transient synovitis is treated with rest and NSAIDs.

• Which of the following joint aspiration fluid analyses is most consistent with rheumatoid arthritis?

o Turbid yellow fluid with low viscosity WBC 2500 52% Neutrophils Crystals - absent Glucose low Culture - negative o Clear yellow fluid with high viscosity WBC 125 < 25% Neutrophils Crystals - absent Glucose normal (THIS IS NORMAL SYNOVIAL FLUID)

• A 64-year-old female who has a history of injectable drug use presents with blood work that reveals leukocytosis with a left shift, and there is suspicion of osteomyelitis based on the patient's prior history. Based on this history, what bone would be most affected by hematogenous osteomyelitis in adults?

o Unlike children, the long bones are rarely affected in adults with the vertebrae being the most likely location for the bone infection to occur. Lumbar vertebrae are most often affected, followed by thoracic and cervical vertebrae.

• What is the diagnostic test of choice used to confirm the diagnosis of Polyarteritis nodosa?

o Vessel biopsy is the diagnostic test used to confirm the diagnosis of Polyarteritis nodosa.

• A 40 year old construction worker presents complaining of right wrist pain that has worsened over the last two weeks. He admits that the pain is worse with certain tasks, or at night when he is sleeping. He also admits that at times part of his hand and his first three digits feel numb. On physical exam you find that his grip strength is decreased on the right. What is the initial treatment of choice for this patient's condition?

o Volar wrist splints, along with activity modification, and NSAIDs are the first line treatment in carpal tunnel syndrome.

• Indication of rotator cuff tear

o Weakness that is not attributable to pain or atrophy is the hallmark of rotator cuff tear. A diagnostic lidocaine injection may help determine if this is the case.

abuse vs. non abuse indications in toddler • You suspect that the patient you are seeing in the emergency room is being abused by her step-father. Which of the following injuries, if found on physical exam, would be most concerning for abusive injury?

o While there are cases of retinal hemorrhages that are accidental, a high suspicion should be maintained in an infant for shaken baby syndrome. o Non-displaced spiral fracture in the tibia of 3 year old: Also known as Toddler's fracture, this is often due to a rotational shear mechanism from low-energy trauma. In the appropriate clinical context, this is an accidental injury.

• Which of the following sets of physical exam tests, if normal, will help determine if a patient with an arm injury is neurologically intact?

o Wrist extension, thumb-index finger pinch, abduction of index and little fingers; first dorsal webspace, volar distal index finger pad and volar distal little finger pad sensation

•34 male with swollen left knee x 2 days, no hx of trauma, is homosexual with one partner, knee is swollen, tender to touch, what does synovial fluid indicate

o a fluid joint aspirate of WBC count of 93K o 48K is too low, may be inflammatory, but not septic

• football player shows inferior dislocation of humerus; weakness in lateral rotation and abduction of arm, which nerve damaged 1. nerve damaged with inability to raise scapula 2. ability to abduct arm 3. rotate arm laterally

o axillary nerve: innervate deltoid; the deltoid abducts, adducts, flexes, extends, and rotate arm medially • dorsal scapular nerve: innervate both the major and minor rhomboid muscles; raise scapula • suprascapular nerve: innervates the supraspinatus and infraspinatus; supraspinatus abduct arm and infraspinatus rotate arm laterally

• football player suffers anterior dislocation of shoulder; cutaneous sensation over the lower half of the deltoid muscle is impaired; these findings suggest damage to what

o axillary nerve; it can be damaged in anterior shoulder dislocation

• 38 female c/o of cold and pain on fingertips, has thick epidermis, finger appear clawlike what antibodies are present

o this is Scleroderma, anti-DNA tropoisomerase (anti-Sci-70); associated with CREST syndrome

o 17 y/o girl has fever, pain in knee, aspirate of knee shows WBC >65K

septic arthritis

MOA of allopurinol

• Allopurinol: decreases uric acid in urine and serum, by blocking the conversion of hypoxanthine to xanthine to uric acid

jones vs. boxers vs. bennet vs. chauffer vs.lis-franc fracture

• An avulsion fracture at the base of the fifth metatarsal, usually secondary to plantar flexion and inversion is called a Jones fracture. Also called a ballet or dancer's fracture, it is the most common metatarsal fracture. The fracture occurs at the proximal diaphysis. A Bennett fracture is an oblique fracture of the first metacarpal near the carpometacarpal joint. A boxer's fracture is a fracture of the fifth metacarpal. This is the most common fracture of the hand. A chauffer's fracture is an oblique fracture through the base of the radial styloid in the forearm. A Lisfranc fracture is actually a fracture and dislocation involving the tarsometatarsal joints.

1. Deep peroneal nerve, what action responsible, what happen if damaged 2. femoral nerve 3. saphenous nerve 5. superficial peroneal 6. sural nerve 7. tibial nerve

• Deep peroneal (L4-S2) responsible for dorsiflexion; damage results in foot drop • Femoral nerve: fibes from L2 to L4, flexor muscles of thigh, extensor of the knee • Saphenous nerve: knee, skin on medial aspect • Superficial peroneal: responsible for foot eversion; lateral compartment of foot; also sensory of the dorsal aspect of foot • Sural: lateral calf • Tibial: hamstrings, calf, sole of the foot: if injured, responsible for clawing of toes

what at risk of developing if have femoral fracture in car accident?

• Femoral fracture in car accident, person is at high risk for developing a fat embolism

what is • Femoroacetabular impingement

• Femoroacetabular impingement (FAI) is a condition where the bones of the hip are abnormally shaped. Bone spurs develop around the femoral head or along the acetabulum. Because they do not fit together properly, the hip bones rub against each other and cause damage to the joint surface or tearing of the labrum. There are 3 types of FAI: pincer, CAM and combined.

o 7 y/o boy brought in by ER for acute distress, ill the last several days, develop maculopapular rash on thighs and feet which spread to buttocks, rash does not blanch, has temp, stomach pain, blood in stool,

• Henoch-Schonlein purpura

motor function * musculocutaneous * radial nerve * median and ulnar nerve

• If the musculocutaneous nerve were to become damaged, what function would be lost? o Forarm flexion o The major muscles innervated by the musculocutaneous nerve are the brachialis and biceps brachii. Therefore, forearm flexion would be lost. Forearm extension is controlled by the triceps brachii which is innervated by the radial nerve. The wrist flexors are innervated mostly by the median and ulnar nerves. Wrist extensors are innervated by the radial nerve. The pronators (pronator quadratus and pronator teres) are innervated by the anterior interosseous and median nerves.

first line for septic arthritis

• Naficillin is first line for staph septic arthritis

chlamydia trachomatis vs. nisseria ghonorrhea * morphology * gram stain * treatment

• Nisseria ghonorrhea infection o Gram negative diplococcic (pink) o Cause septic arthritis o Scattered necrtoc pustules on palms and soles o Tx is ceftriaxone • Chlamydia trachomatis is obligate intracellular human pathogen, its gram negative (pink), oval shaped o Treat with azithro, erythro, or ofloxocin

pathophys of osteoarthritis (2)

• Osteoarthrits: damage begins with multiple fractures in cartilage and wearing down cartilage • etiology for osteoarthritis o chondrocyte injury and abnormal collagen activity

what is whipple dz

• Whipple dz associated with infeaction of the GI tract; diarrhea, abdominal cramp after meals, weight loss, tropheryma whipple identified as causative bacterial agent; Ceftriaxone is treatment

upper extremity nerve innervation 1. axillary 2. median nerve 3. musculocutaneous 4. radial nerve 5. ulnar nerve

• football player suffers anterior dislocation of shoulder; cutaneous sensation over the lower half of the deltoid muscle is impaired; these findings suggest damage to what o axillary nerve; it can be damaged in anterior shoulder dislocation • median nerve: anterior arm, palm, and distal aspect of lateral 3.5 fingers • musculocutaneous: sensation to lateral surface of arm and forearm • radial nerve: back of the hand, arm and forearm • ulnar nerve: supplies sensation to medial side of arm, forearm, and hand

MCC of reactive arthritis vs. septic arthrits

• reactive arthritis o due to chlamydia (gram negative intracellular ovoid) and shigella, salmonella o ghonorrhea is gram negative diplococcic, cause septic arthritis

pathophys of RA vs. osteoarthritis

• see Bone erosion in rheumatoid arthritis • see subchontral sclerosis, cyst, and osteophyte in osteoarthritis

1. most appropriate screening for SLE 2. what associated with anti centromere 3. antihistone antibodies 4. anti-jo 5. anti-ro antibodies

• the most appropriate screening for SLE is ANA, then you do anti-dsDNA • anti centromere antibodies (ACA) specific for CREST • antihistone antibodies is formed by drug induced lupus • anti-Jo for dermatocytoisis • anti-Ro: neonatal lupus, Sjogren syndrome

Motor function of the following 1. anterior tibialis 2. flexor hallicus longus 3. flexor digitorum 4. peroneus brevis/longus

1. The anterior tibialis muscle is one of the important dorsiflexors of the foot and ankle. 2. The flexor hallucis longus is primarily responsible for plantar flexion of the great toe and flexor digitorum produces plantar flexion of the remaining toes. 4. The peroneus longus and peroneus brevis muscles do contribute to plantar flexion, but are not connected to the Achilles tendon. They are also the primary evertor muscles of the foot and ankle.

Anterior spinal cord injury a. MOI b. S/sx prognosis

Anterior spinal cord injury a. MOI: compression of anterior spinal arteries, flexion injuries b. S/sx: full or partial loss of bilateral pain and temp sensation c. prognosis: poor

Brown sequard syndrome a. MOI b. s/sx

Brown sequard syndrome a. MOI: hemisection injury, disk protrusion, hematoma, tumor b. s/sx: ispilateral motor loss; contralateral pain/temp sensation

• Spinal injury where rib cage and abdominal muscles become completely paralyzed, but person is still able to breath and use diaphragm

C7

Central cord syndrome a. MOI b. s/sx

Central cord syndrome a. MOI: preexisting narrowing of the spinal cord; hyperextension injury; buckling of the ligamentum flavum b. s/sx: weakness greater in upper extremities then lower; distal worse then proximal

Corticospinal tract a. where located b. what responsible for c. how tested

Corticospinal tract a. where located: posteriolateral aspect of spinal cord b. what responsible for: ipsilateral motor function c. how tested: voluntary muscle contraction

Dorsal/posterior column a. where located b. what responsible for c. how tested

Dorsal/posterior column a. where located: posterior aspect of spinal cord b. what responsible for: ipsilatearl position and vibration and light touch c. how tested: position of fingers and toes

Spinothalamic tract a. where located b. what responsible for c. how tested

Spinothalamic tract a. where located: anterolateral aspect of spine b. what responsible for: contralateral pain and temp sensation c. how tested: contralateral pain and temp

• A 23 year old male, who is an avid skier, presents after sustaining an injury while skiing earlier this week. He reports that he fell while bracing himself with his ski poles, and thinks that he may have hyperextended his thumb joint. You elicit tenderness to the ulnar aspect of the right metacarpophalangeal (MCP) joint with MCP joint laxity under valgus stress. Xray of the hand is negative. Which of the following is the treatment of choice for this patient?

Thumb spica splint and urgent hand specialist referral o This patient has a Gamekeeper's (aka Skier's) Thumb. In this condition there is an injury to the ulnar collateral ligament that stabilizes the thumb. Immobilization with a thumb spica splint and referral to a hand specialist is the general treatment.

• The most commonly fractured long bone in both adults and children is which of the following?

Tibia