PANCE Orthopedics Practice Questions

A 73-year-old female who arrives at the emergency room with left arm pain after tripping and falling on the sidewalk. She developed immediate pain throughout her arm. The patient has a history of osteoporosis for which and has been on bisphosphonate therapy for 12 months. Radiographs of her left arm demonstrate a spiral midshaft humeral fracture. She is given appropriate analgesia and placed in a coaptation splint. What are the 2 times that a humerus fracture requires orthopedic surgeon referral?

1. Fracture of the anatomic neck because of an increased risk of osteonecrosis 2. Significant displacement and multipart fracture

What are the 4 reasons to refer a patellar fracture?

1. Fracture with > 2 mm of articular step off 2. > 3 mm fragment separation 3. Comminuted fracture with displacement of articular surfaces 4. Disruption of extensor mechanism

Name 3 complications of an anterior shoulder dislocation.

1. Hill Sachs Lesion 2. Bankart Lesion 3. Axillary Nerve Injury

Which of the following is the underlying pathogen for the development of Lyme disease? A Borrelia burgdorferi B Bartonella henselae C Rickettsia rickettsii D Coxiella brunetti

A Borrelia burgdorferi Lyme disease is a tick-borne illness caused by the spirochete B. burgdorferi.

A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibial plateau. Which of the following is the most likely diagnosis? A Pes anserine bursitis B Prepatellar bursitis C Infrapatellar bursitis D Trochanteric bursitis

A Pes anserine bursitis

A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis? A Shin splint B Stress fracture C Osgood-Schlatter disease D Patellofemoral pain syndrome

A Shin splint Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.

A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen's test is positive; however, there is no atrophy of the thenar eminence. Which of the following is the initial step in management of this patient? A Wrist splint for 2-6 weeks B Corticosteroid injection C Surgical referral D Darvocet

A Wrist splint for 2-6 weeks The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.

A 10-year-old boy who arrives at your ED complaining of severe right elbow and forearm pain after sustaining a blunt injury to his right arm. On examination, the affected arm is swollen and tender around his elbow. Radiographs demonstrate a displaced fracture of the proximal ulnar diaphysis and radial head dislocation. What is the diagnosis? A) Monteggia Fracture B) Galeazzi Fracture C) Night Stick Fracture D) Colles Fracture

A) Monteggia Fracture

A 45-year-old man comes to the clinic due to right shoulder pain for the past 2 months. He works as a carpenter and initially thought it was work-related. However, it has recently become more severe and often awakens him at night. The patient describes the pain as dull, deep, and 4/10 in intensity. Medical history is remarkable for diabetes mellitus type 2 manages with metformin. The patient smoked 1 pack of cigarettes per day for 20 years, but quit 5 years ago. Vital signs are within normal limits. On physical examination, he has difficulty with shoulder movement due to pain. Passive range of motion is full but produces the pain as well. X-ray of shoulder shows a mixed radiolucent and sclerotic lesion with a ring-and-arc pattern of calcifications. The cortex appears thickened, but a periosteal reaction is scant. Which of the following is the most likely diagnosis? A. Chondrosarcoma B. Paget disease of the bone C. P

A. Chondrosarcoma Chondrosarcoma is a malignant cartilage-producing tumor that usually arises in the axial skeleton, proximal shoulder, and ribs. It is seen in individuals over 40 years and more common in men. On imaging, it appears as amixed radiolucent and sclerotic lesionwith aring-and-arc pattern of calcificationor flocculent densities. Periosteal reaction is usually absent.

A 44-year-old man presents to his primary care physician with worsening left shoulder pain. He can no longer do bench presses or shoulder presses at the gym due to weakness and pain. The pain is primarily located over the lateral shoulder, is worse at night, and is preventing him from obtaining adequate rest. Past medical history is otherwise unremarkable. He has no history of recent trauma or surgeries to the left shoulder. The patient subsequently undergoes a MRI of the left shoulder, which reveals the following: Which of the following physical examination maneuvers is most likely to yield a positive test, given this patient's clinical findings? A. Empty Can Test B. Scarf Test C. Lift off test D. Neer Test E. Yergason Test

A. Empty Can Test The empty can test (also termed Jobe test) has a high specificity for supraspinatus injuries.

A 45-year-old woman presents to her primary care PA to evaluate a nodule on the wrist. The nodule appeared on the right wrist one month ago and has slightly increased in size since then. She has not experienced any pain or limitations in her daily activities but is worried it "might be cancerous." Past medical history is notable for hypothyroidism, for which she takes levothyroxine. She does not smoke, consume alcohol, or use illicit substances. Vital signs are within normal limits. The patient also has no systemic symptoms, the nodule is painless and on the dorsum of her hand. Which of the following is the most appropriate management for this patient's clinical condition? A. Reassurance and observation B. Screw and plate fixation C. Topical nifedipine D. Needle aspiration E. Surgical excision

A. Reassurance and observation This patient presents with an asymptomatic nodule on the volar aspect of the wrist. This presentation is most consistent with a ganglion cyst based on the above image. In the absence of significant pain or limitations in functional mobility, she should be treated with close observation and surveillance.

A 42-year-old male presents with right upper extremity numbness, dysesthesia, weakness, and arm pain with exertion. The symptoms are aggravated by activity and reaching overhead. Which of the following is the most likely diagnosis? A. Thoracic outlet syndrome B. Median nerve compression C. Biceps tendon rupture D. Carpal tunnel syndrome E. Subclavian steal syndrome

A. Thoracic outlet syndrome Thoracic outlet syndrome (TOS) refers to a constellation of signs & symptoms that occur due to compression of the neurovascular bundle in the space of the thoracic outlet. Causes include trauma, repetitive injuries, anatomical defects, and pregnancy. The clinical presentation depends on what is being compressed (i.e., nerve, vein, and/or artery), but may include the following: pain, numbness, weakness, muscle weakness, fatigue, swelling, or coldness. Often these symptoms are aggravated by activity or raising the arm overhead. Diagnostic tests include ultrasound, x-ray, CT scan, EMG, MRI, etc. Treatment options depend on what type of TOS the patient has (e.g., physical therapy for neurogenic TOS).

A 37-year-old right-hand dominant male fell off his bicycle four days ago and injured his left non-dominant shoulder. There is an abnormal contour of the left shoulder with an elevation of the clavicle, AC joint tenderness, and pain with cross-chest testing. The axillary radiograph shows no anteroposterior translation. Classic example of:

AC Joint Separation

A 27-year-old male presents to the office with pain and swelling of his left knee. He was playing soccer with friends and as he was running, he stopped short to change directions and felt a "pop" in his left knee, followed by pain and swelling. A Lachman test is performed which demonstrates increased anterior translation of the tibia compared to the uninjured leg with no distinct endpoint. What type of injury did this patient likely sustain?

ACL

"Pop" at time of injury + Swelling caused by hemarthrosis = ??

ACL injury

What is the most frequently ruptured tendon?

Achilles

A 48-year-old nurse, with a body mass index of 31, presents for an evaluation of back pain. She relates that historically, she had a positive PPD test a year ago and did not follow-up as directed. She has recently been experiencing night sweats and coughing. An x-ray of her lumbar spine reveals osteopenia and cortical breakdown of vertebral bodies L4 and L5. Which of the following diagnosis is most suspect? A) compression fractures secondary to obesity B) degenerative joint disease C) Pott's disease D) compression fractures secondary to osteoporosis E) spondylolisthesis

Answer: C Pott's disease Pott's disease is TB of the spine. She could have any of the other diseases, but the question states that she had a positive PPD and did not take meds...that is the clue that she has active TB in the spine.

An 80-year-old woman arrives at the emergency room with severe right shoulder pain and immobility. She fell down the steps outside her house and landed on her right side two hours prior to presentation. On exam, her right arm is abducted and externally rotated. She has decreased sensation to touch over the lateral aspect of her right shoulder. What do you think she has and what are you worried about?

Anterior Shoulder Dislocation Axillary Nerve Injury

A 17-year-old boy presents to the emergency department after sustaining a shoulder injury while playing football. The patient was diving towards the end-zone when another player collided directly with his left shoulder. On physical examination, the patient is holding the left arm adducted. Swelling is present over the lateral aspect of the left shoulder. A radiograph of the left shoulder is demonstrates widening of the acromioclavicular joint on radiography. Which of the following is the most likely diagnosis? A Clavicle Fracture B AC separation C Sternoclavicular separation D Posterior shoulder dislocation E Anterior shoulder dislocation

B AC separation

Which of the following mechanisms of action is most commonly associated with meniscal tears? A Hyperextension B Axial loading and rotation C Hyperflexion D Valgus force to the lateral knee

B Axial loading and rotation

A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the proper name for this condition? A Galezzi Fracture B Monteggia Fracture C Colles Fracture D Smith Fracture

B Monteggia Fracture

Which of the following is the correct treatment for a Grade II ankle sprain resulting from an inversion injury? A Corticosteroid injection B Rest, ice, compression, elevation C Moist heat and a walking cast D Surgical intervention

B Rest, ice, compression, elevation

A 28-year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear leukocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis? A Rheumatoid arthritis B Septic arthritis C Gouty arthritis D Osteoarthritis

B Septic arthritis

A 10-year-old boy who arrives at your ED complaining of severe right elbow and forearm pain after sustaining a blunt injury to his right arm. On examination, the affected arm is swollen and tender around his elbow. Radiographs demonstrate a distal radial shaft fracture with dislocation of the ulnar-radial joint? What is the diagnosis? A) Monteggia Fracture B) Galeazzi Fracture C) Night Stick Fracture D) Colles Fracture

B) Galeazzi Fracture

A 2-month-old infant boy is evaluated for the first time since delivery. The patient was born at 40 weeks gestation via vaginal delivery and had a normal prenatal and postnatal birth history. He feeds 2-3 oz of breastmilk and formula every 2-3 hours. He is in the 75th percentile for height, 75th percentile for weight, and 50th percentile for head circumference. On physical examination, there is prominent head posturing. The head is tilted to the right side, and the chin is rotated to the left shoulder. A mass is palpable in the inferior portion of the neck on the right side. The mass is firm and does not transilluminate with a penlight. The rest of the physical examination, including the reflexes and muscular tone of the extremities, is normal. Which of the following is the most likely cause of this patient's condition? A. Clavicle fracture B. Congenital muscular torticollis C. Lymphangioma D. Vertebral anomaly E. C

B. Congenital muscular torticollis

A 10-year-old boy is brought to the clinic by his parents due to limping and pain in the right leg. The patient is a very active child who likes to run and play, but during the past few weeks, he was reluctant to go out and play. The patient's parent also noticed he was limping. He often complains of night pain, which his parents attributed to growing pain. They gave him some acetaminophen, which provided relief. Vitals are within normal limits. On physical examination, there is tenderness over the lower part of the right fibula. The range of motion is full, and the rest of the physical exam is within normal limits. An x-ray is obtained and reveals a 1.5 cm lucent nidus surrounded by a rim of osteosclerotic reaction. Which of the following is the most likely diagnosis? A. Osteoblastoma B. Osteoid osteoma C. Osteochondroma D. Osteosarcoma E. Ewing sarcoma

B. Osteoid osteoma Osteoid osteoma is a benign bone-forming tumor. It typically arises at the metaphyseal cortex of the distal femur or proximal tibia. On x-ray, it appears as a central nidus surrounded by a sclerotic rim. Clinically, it causes pain that responds to NSAIDs.

A 65-year-old man comes to the office because of deep and aching hip pain. The pain is constant throughout the day and worsens with weight-bearing activity. The patient also reports that his shoe size has increased over the past year, and he has progressively lost hearing from both ears. Medical history includes admission for a renal calculus one-month ago. Laboratory investigations demonstrate an isolated increase in serum alkaline phosphatase. A pelvic x-ray is obtained. What diagnosis are you most concerned about? A. Osteochondroma B. Paget's Disease of Bone C. Osteoporosis D. Osteosarcoma E. Osteomalacia

B. Paget's Disease of Bone

A 45-year-old woman presents to her primary care physician to evaluate bilateral wrist pain. The patient has worse pain at night and is associated with paresthesias of the first, second, third, and half of the fourth finger. She states, "I need to figure out what is going on. I can barely sleep at night." Past medical history includes hypertension, type II diabetes mellitus, rheumatoid arthritis, and obesity. She smokes a pack of cigarettes daily and drinks two to three beers nightly. She currently works as an office secretary. Vital signs are within normal limits, and physical examination does not reveal any deformity or swelling of the wrist. Which of the following will best assist in diagnosing this patient's underlying condition? A. CT of the wrist B. Phalen maneuver C. Finkelstein test D. MRI of the wrist

B. Phalen maneuver This patient presents with pain and paresthesias in the distribution of the median nerve, and she has multiple risk factors for the development of carpal tunnel syndrome. Of the tests listed, the Phalen maneuver is most likely to reveal the underlying diagnosis.

A 67-year-old man comes to the clinic due to progressive fatigue and back pain over the past few months. Initially, the patient attributed the pain to strenuous work in the garden but decided to seek care when he noticed no improvement. The patient also noted a 10 lb (4.5 kg) weight loss without changes in his diet. Medical history is significant for smoking 1 pack of cigarettes per day for 35 years and diabetes mellitus type 2. Laboratory values are obtained and Abnormalities are shown below: Low Hgb High Cr High Total Protein Low Albumin Low Sodium High Calcium Radiograph of the spine reveals multiple areas of hyperlucency at the lumbar and thoracic regions. Which of the following is the most likely underlying cause? A. Prostate B. Plasma Cell Cancer C. Langerhans Cell Histiocytosis D. Gastrointestinal Cancer E. Small Cell Lung Cancer

B. Plasma Cell Cancer Multiple myeloma is the malignant proliferation of plasma cells that produce monoclonal immunoglobulins. The condition is characterized by renal failure, bone pain, hypercalcemia, normocytic anemia, and lytic bone lesions.

A 32-year-old man presents to the emergency department with acute left shoulder pain. The patient was lowering himself from a pullup at the gym when he suddenly felt a "pop" followed by acute pain in the anterior left shoulder. The patient has a history of left supraspinatus tendinopathy that was treated with physical therapy. The patient is otherwise healthy and does not take any medications. Physical examination reveals ecchymosis, swelling, and tenderness over the anterior left deltoid. The patient's arm is pronated and flexed at the elbow to 90 degrees. The examiner attempts to supinate the arm against resistance, which elicits shoulder pain. A radiograph of the shoulder show no abnormalities. Which of the following is the most likely diagnosis? A. Supraspinous tear B. Rupture of long head of biceps brachii C. AC Joint separation D. Subacrominal Bursitis

B. Rupture of long head of biceps brachii

A 31-year-old male presents with sudden onset of pain and swelling in his right ankle. On physical exam, you appreciate a warm, swollen, and erythematous ankle. The joint was aspirated, and the synovial fluid shows 55,000 WBCs, 80% polymorphonuclear leukocytes, low glucose levels, and no crystals. Cultures are pending at the time. Which of the following is the most likely diagnosis based on the information above? A. Osteoarthritis B. Septic arthritis C. Rheumatoid arthritis D. Psoriatic arthritis E. Gouty arthritis

B. Septic arthritis Septic arthritis is an infection of the joint space due to bacteria. It can occur at any age, although the incidence is higher in elderly and very young people. Etiologies include Staphylococcus aureus, Streptococcus spp., N. gonorrhoeae (in young, sexually active adults). Septic arthritis either happens due to hematogenous spread or direct inoculation by microorganisms s/t trauma or iatrogenesis (e.g., joint surgery). Clinical features include joint pain/swelling, warmth, and decreased ROM. The gold standard for diagnosis is synovial fluid analysis (Although make sure to note WBC count alone is insufficient to rule in or out septic arthritis). Patients should be given IV antibiotics (4-6-week course).

What protein found on urinalysis is commonly associated with multiple myeloma?

Bence Jones Proteins

Difference between Bennett and Rolando Fractures and How to treat them?

Bennett fracture is an intraarticular fracture through the base of the 1st metacarpal (thumb) with large distal fragment dislocated radially and dorsally because of an axial blow to a partially flexed MCP. Rolando fracture: comminuted Bennett's fracture Treatment: ORIF

Treatment for Paget's

Bisphosphonates NSAIDs Calcitonin Refer to Endocrine/Rheumatology/Orthopedic Surgeons to rule out other differential diagnosis

A 13 year old boy comes in with pain and edema over the 5th metacarpal. He states his sister threw a basketball at him and he punched it. X-ray shows a fracture of the 5th metacarpal with significant angulation. What is the name of this fracture? What type of split would you use to immobilize it?

Boxer's Fracture Ulnar Gutter

A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh that he noticed about 3 days ago. Physical exam reveals a large annular lesion with a bright red outer border and partial central clearing. Which of the following is the most likely diagnosis? A Rheumatoid arthritis B Kawasaki disease C Lyme disease D Nongonococcal arthritis

C Lyme disease After an incubation period of 3 to 32 days, erythema migrans develops at the site of the tick bite. Within days or weeks after the onset of erythema migrans the patients develop a severe headache, mild stiffness of the neck, migratory musculoskeletal pain, arthralgias and profound malaise and fatigue.

An 18 year-old male presents with pain in his wrist after he fell off of a moving motor cycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of the wrist. Which of the following is the recommended treatment for this patient? A Ace wrap of the wrist B Closed reduction of the fracture site C Thumb spica cast application D Open reduction of the fracture site

C Thumb spica cast application Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.

In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A Femur B Humerus C Vertebral Spine D Tibia

C Vertebral Spine

A 45-year-old man comes to the office due to an acute onset of back pain. Two hours ago, he felt a sharp, middle-back pain while lifting a heavy box. The patient describes the pain as "shooting" and burning, 7/10 in severity, and radiating from the back to the right foot. He does not have any bowel or bladder symptoms. Vitals are within normal limits. On physical examination, knee jerk and Achilles reflexes are 2+ bilaterally. Straight leg raise is positive on the right side. Motor strength for dorsiflexion is 5/5 on the left compared to 3/5 on the right lower extremity. Which of the following nerve roots is most likely affected by this patient's condition? A. L1 B. L4 C. L5 D. S1 E. S2

C. L5

A 33-year-old woman presents to her primary care PA due to persistent right wrist pain. The patient has been experiencing pain on the thumb-side of the wrist every time she holds or grips an object. She recently delivered a healthy, full-term baby four weeks ago. Her past medical history is unremarkable, and she does not take any medications. Vitals are within normal limits. On physical examination, swelling and tenderness to palpation are noted at the radial aspect of the right wrist. Repetitive tapping over the volar part of the wrist does not reproduce the pain. While the patient is grasping the right thumb with the right four digits, the PA places the wrist in ulnar deviation. This maneuver reproduces the pain. Which of the following best describes the pathogenesis of this patient's disease process? A. Entrapment and compression of the median nerve B. Occult fracture of the distal radius C. Myxoid degeneration o

C. Myxoid degeneration of the abductor pollicis longus and the extensor pollicis brevis This patient presents in the postpartum period with pain over the radial aspect of the wrist and a positive Finkelstein test. These findings are consistent with De Quervain tenosynovitis, characterized by myxoid degeneration of the abductor pollicis longus and extensor pollicis brevis.

How to tell the difference between patellofemoral syndrome and chondromalacia syndrome. Is it necessary to tell the difference between the 2 for treatment?

Chondromalacia patella has pain similar to PFP but has pathologic changes on the underside of the patella - SOFTENING, EROSION, FRAGMENTATION and an MRI is needed for the diagnosis Both are treated with PT so kind of unnecessary

23-year-old woman arrives at the emergency room after a biking accident. She reports acute pain after falling on her shoulder. On physical exam, there is swelling, erythema, and tenderness on the anterior aspect of her right shoulder. No tenting of the skin is noted. Distal pulses are intact, and there is no motor or sensory deficits. She is sent for further imaging. This is a classic vignette of what type of fracture?

Clavicle

A 15-year old with fall to an outstretched hand now presents with acute onset of wrist swelling. On imaging, there is a distal radial fracture with the distal segment protruding upward (dorsal angulation). What type of fracture is this?

Colles Fracture

An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis? A Avascular Necrosis B Myositis Ossificans C Compartment Syndrome D Reflex Sympathetic Dystrophy

Compartment Syndrome

A 30-year-old male arrives at the emergency room after a motor vehicle accident. Upon arrival, he has difficulty breathing and reports shoulder pain. On physical exam, he has decreased breath sounds on the right side and significant tenderness of his right shoulder. There is overlying ecchymosis, swelling, and erythema over his right scapula and limited range of motion. This is a classic presentation of a scapular fracture. With scapular fractures, what should you be worried about and what actions should you take to treat the patient?

Concomitant Injuries Get a Chest CT Consult trauma and orthopedic surgery Treat pain Rule out other injuries

A 14-year-old boy presents to the office complaining of anterior knee pain. He states the pain is most sever when he plays basketball or squats down. On exam you note a pronounced, tender tibial tubercle. What is the mainstay of treatment for the likely diagnosis in this patient?

Conservative (NSAIDs, ice, rest, elevation) Patient has Osgood-Schlatter Disease.

A 24-year-old man presents to the emergency department with left-sided shoulder pain. The patient was playing flag football when he tripped and fell on an outstretched left arm. Physical examination is notable for a gap along the lateral edge of the left acromion process. The left arm is in slight abduction and external rotation. Which of the following is the most likely diagnosis? A Superior glenohumeral joint dislocation B Posterior glenohumeral joint dislocation C Sternoclavicular joint separation D Anterior glenohumeral joint dislocation E Inferior glenohumeral joint dislocation

D Anterior glenohumeral joint dislocation

A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done? A X-ray of the lower leg and ankle. B Doppler studies. C Bone scan. D Compartment pressure

D Compartment pressure Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.

A 12-year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a slight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded by osteosclerosis seen here. Which of the following is the most likely diagnosis? A Osteosarcoma B Legg-Calve-Perthes disease C Osgood-Schlatter disease D Osteoid osteoma

D Osteoid osteoma Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin.

A 32-year-old male presents with an acute onset of pain and swelling in his left ankle. On physical exam, the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis? A Gout B Pseudogout C Acute rheumatic fever D Septic arthritis

D Septic arthritis Leukocytosis and a low synovial glucose are indicative of septic arthritis.

A 66-year-old male presents to his primary care physician complaining of increasing discharge from an ulcer on the plantar aspect of his right great toe. He has a long history of poorly controlled diabetes with complications including chronic renal failure and bilateral peripheral neuropathy to the mid-calf. He denies any pain or fevers/chills. Examination confirms warmth and erythema of the area surrounding the ulcer. A probe can be passed into the ulcer; however, it is not readily apparent if bone can be contacted with the probe. Laboratory evaluation is significant for a WBC count of 17k/uL and an ESR of 116 mm/h. Which of the following would be the most accurate diagnostic test for this patient's condition? A) Three-phase bone scan of the foot B) Ultrasound of the great toe C) AP and lateral radiographs of the foot D) MRI of the foot E) CT scan of the foot

D) MRI of the foot This patient is suffering from osteomyelitis secondary to a diabetic foot infection. MRI is the most accurate diagnostic imaging test for osteomyelitis.

A 14-year-old boy is brought to his primary pediatrician for evaluation of left knee pain. He plays basketball for his high school team, and the pain started four weeks following the start of the season. The pain is worsened with running and jumping and relieved with rest. He has no significant past medical history. Vitals are within normal limits. He is at the 75th percentile for height and 40th percentile for weight. Physical examination reveals anterior knee pain at the inferior knee/proximal tibia. Which of the following best describes the etiology of this patient's condition? A. Muscular imbalance and decreased stability of the patellofemoral joint B. Degenerative alterations to the patellar tendon C. Displacement of the femoral epiphysis from the femoral neck D. Chronic avulsion of the secondary ossification center of the tibial tuberosity E. Abnormal formation of the acetabulum and the femoral head

D. Chronic avulsion of the secondary ossification center of the tibial tuberosity Osgood-Schlatter disease refers to a traction apophysitis of the tibial tubercle due to repetitive strain and chronic avulsion of the secondary ossification center at the tibial tuberosity.

A 70-year-old woman presents to the emergency department to evaluate left wrist pain. The patient was cleaning the bathroom when she slipped, fell, and landed on an outstretched left arm. She was subsequently unable to move her left wrist due to pain. Past medical history is notable for hypertension, and she takes amlodipine daily. She does not smoke or consume alcohol. Vital signs are within normal limits. Physical examination demonstrates swelling and deformity of the left wrist. Plain films of the left wrist show dorsal angulation of the distal radius fracture fragment. Which of the following is the most likely diagnosis? A. Galeazzi fracture B. Smith fracture C. Bennett fracture D. Colles fracture E. Monteggia fracture

D. Colles fracture The wrist's two common fracture patterns are the Colles fracture and Smith fracture. A Colles fracture will demonstrate dorsal angulation of the distal radius fracture fragment, while a Smith fracture will demonstrate volar angulation.

A 36-year-old man presents to his primary care PA with worsening left shoulder pain. The patient is an avid weightlifter. However, over the past several months, he has experienced worsening left shoulder pain that is exacerbated by overhead movements. He has no history of major trauma or surgery. On physical examination, the patient has weakness in the left shoulder after downward pressure is applied while both arms are at 90° elevation in the scapular plane with full internal rotation. Which of the following anatomic structures is most likely to be disrupted given this patient's presentation? A. Biceps Brachii B. Infraspinatus C. Subscapularis D. Supraspinatus E. Teres Minor

D. Supraspinatus This patient presents with left shoulder pain that is exacerbated by overhead activities. There is reproducible weakness with the empty can test. These findings are consistent with rotator cuff injury. The most commonly injured rotator cuff muscle is the supraspinatus.

A 32-year-old female presents to the office complaining of pain at the radial side of her wrist that is most prominent upon movement of the thumb. She is 4 weeks post-partum; Past medical history is otherwise unremarkable. On exam tenderness is noted over the radial styloid and pain is experiences with passive ulnar deviation of the wrist with the thumb flexed in the palm. What is the likely diagnosis in this patient?

DeQuervain Tendinosynovitis

___________ is a common neurological issue of Paget's Bone Disease

Deafness

What is the earliest presenting symptom of Multiple Myeloma?

Deep Achy Bone Pain

A 55-year-old woman presents to her primary care PA with left shoulder pain. The pain started insidiously two weeks ago and tends to be worse at night. She has also experienced decreased range of motion in the left shoulder. The patient did not sustain any recent injuries. Past medical history is notable for hypertension, type II diabetes mellitus, and hyperlipidemia. On physical examination, the patient demonstrates limited active and passive range of motion, with associated pain. The shoulder radiograph is unremarkable and show no abnormalities. Which of the following is the most likely diagnosis? A. Humeral head fracture B. Subacromial bursitis C. Anterior glenohumeral joint dislocation D. Glenohumeral osteroarthritis E. Adhesive Capsulitis

E. Adhesive Capsulitis

A 23-year-old man comes to his primary care PA to evaluate the sudden onset of numbness and tingling in the right upper extremity following a workout. The patient was performing sit-ups when he experienced a sharp pain in his neck, followed by numbness and tingling in his right hand. He does not have any symptoms while at rest. He reports several similar episodes in the past. He is a bodybuilder. Vital signs are within normal limits. The right lateral neck appears larger when compared to the left lateral neck. The patient has no spinal tenderness to palpation. Which of the following is the most likely underlying cause of this patient's symptoms? A. Exogenous testosterone use B. Cervical rib obstruction C. Pancoast tumor D. Herniated cervical disk E. Anterior scalene hypertrophy

E. Anterior scalene hypertrophy This patient is experiencing thoracic outlet syndrome. The most common cause of thoracic outlet syndrome is a scared scalene (scalene hypertrophy)

Which of the following is the most commonly involved ligament in low ankle sprains? A. Deltoid ligament B. Anterior tibiotalar ligament C. Calcaneofibular ligament D. Posterior talofibular ligament E. Anterior talofibular ligament

E. Anterior talofibular ligament

A 71-year-old man comes to his primary care physician seeking evaluation for worsening pelvic pain. The pain is dull and constant, is present throughout the day, and is sometimes worse with weight-bearing. In addition, the patient complains of progressive hearing loss in both ears. Vitals are within normal limits. Physical examination is notable for warmth over the lateral pelvic walls and reduced sensorineural hearing loss in both ears. The remainder of the physical examination is noncontributory. A plain film radiograph of the pelvis is ordered and reveals significant sclerosis, with evidence of osteolytic lesions and cortical thickening. Which of the following set of serum laboratory findings will be most likely present in this patient? A. Elevated Calcium, Normal Phosphate, Normal Alk Phos B. Elevated Calcium, Decreased Phosphate, Elevated Alk Phos C. Decreased Calcium, Decreased Phosphate, Elevated Alk Phos D. N

E. Normal Calcium, Normal Phosphate, Elevated Alk Phos An elevated Alk Phos is typically the only laboratory derangement

A 35-year-old man comes to the clinic due to back pain. Upon entering the clinic, the patient is observed to be limping and appears in pain. He discloses back pain for the past few months that has been progressively worsening. Two days ago, he felt severe pain while lifting a box at home. The patient now describes the pain as dull, 7/10 in severity, which worsens with movement and radiates to the left thigh. He has noticed numbness in the perianal region while using the toilet. Vitals are within normal limits. On physical examination, focal tenderness is noticed over the lumbar and paraspinal area. There is a loss of sensation around the perianal area but a normal anal sphincter tone. Knee jerk reflex is normal but the ankle reflex is absent on the left. Strength is 5/5 on the right and 4/5 in the left gluteus maximus and hamstring muscles. Which of the following features will prompt the need for emergent imaging? A

E. The patient's loss of sensation Could be cauda equina syndrome

What is the gold standard for rotator cuff tendinopathy/tear? What do the results indicate?

Empty Can Test Pain without weakness --> Tendinopathy Pain with weakness --> Tear

True or False: A tendon tear is most common in the quadriceps tendon over the patellar tendon.

FALSE More common in PATELLAR tendon

Difference between a hip fracture and dislocation on physical exam

Fracture: Shortened and EXTERNALLY rotated Dislocation: Shortened and INTERNALLY rotated

50-year-old female with a past medical history of diabetes mellitus complaining of prolonged shoulder pain and stiffness for 6 months. For the past few months, she reports persistent left shoulder pain that also occurs at night. She denies history of traumatic injury. On physical exam, she has decreased active and passive range of motion. She is also unable to reach 90° with passive abduction. Resisted shoulder range of motion testing is pain-free and demonstrates no strength loss. She is sent home with range of motion exercises and counseled that this will likely resolve with time. Classic example of:

Frozen Shoulder/Adhesive Capsulitis

A 16 year old comes in complaining of pain over the dorsal aspect of her lateral hand. She states that she fell on an outstretched hand yesterday. On physical exam, there is tenderness over the anatomical snuffbox. Imaging is negative for any fractures. What do you do?

Immobilize the wrist with a thumb spica cast and repeat an x-ray in 2 weeks. She probably has a scaphoid fracture --> DONT GET SUED

___________ Shoulder Dislocation has the highest incidence of axillary nerve and artery damage among all types of shoulder dislocations.

Inferior

If there is a delay in the diagnosis and repair of a knee (tibiofemoral) dislocation, it can lead to ________ and ________.

Irreparable Injuries Above Knee Amputation

What is the least commonly isolated knee ligament injury?

LCL

What knee ligament injury is associated with varus stress?

LCL

Difference between Medial and Lateral Epicondylitis on Physical Exam

Lateral: tenderness over LATERAL epicondyle, pain with resisted EXTENSION and supination Medial: tenderness over MEDIAL epicondyle, pain with resisted FLEXION and pronation

A 7-year-old boy is brought to the pediatrician's office for evaluation of left hip pain. The patient's parent noticed a left-sided limp several weeks ago and initially attributed it to a fall at the playground. The pain has persisted and is minimally relieved with rest or ibuprofen. The patient has no significant past medical history. He takes no daily medications, and immunizations are up to date. Temperature is 37°C (98.6°F), pulse is 82/min, and blood pressure is 116/72 mm Hg. The child is in the 50th percentile for height and 40th percentile for weight. Examination shows a well-appearing and cooperative child. With internal rotation and abduction of the left hip, range of motion is limited secondary to pain. The remainder of the examination is noncontributory. An X-ray of the patient's hip shows flattening of the femoral head. What is the most likely diagnosis?

Legg Calve-Perthes

What is a common concurrent injury with a calcaneus fracture because of the mechanism of injury?

Lumbar compression fracture

What is the most serious carpal fracture?

Lunate Fracture

A 31-year-old male was playing football with his friends when one of his friends landed on the lateral aspect of his right knee in an attempt to tackle him. He immediately felt a tearing sensation which was followed by severe pain. A valgus stress test is performed which displays pain and laxity at approximately 30 degrees of flexion. What structure of the knee did the patient likely injure?

MCL

What knee ligament injury is associated with valgus stress?

MCL

What is the gold standard for Multiple Myeloma? What is a suggestive result vs a definitive diagnosis?

Marrow Biopsy 10-20% > 20-30%

A 67-year-old male presents to the office today complaining of persistent elbow pain. He does not recall any trauma to the Elbow, but the pain he is experiencing in his elbow is affecting his golf game as he is an avid golfer. On exam, pain is elicited by performing wrist flexion against resistance. Tenderness would likely be felt on which part of the elbow in this patient?

Medial Epicondyle

A 43-year-old female presents to the office complaining of numbness and tingling in her hands, mostly affecting the thumb, index, middle finger, and part of the ring finger. She states it is worse at night sometimes waking her from sleep. Both a Tinel and Phalen test are positive on physical exam. The patient likely is experiencing compression of which nerve?

Median Nerve

What is the most common bone tumor overall?

Metastatic Carcinoma

A 17 year old male presents to the ER after sustaining an injury to his right arm. After x-rays are complete, the attending physician assistant informs him the X-ray revealed a proximal ulnar fracture accompanied by a radial head dislocation. This type of injury is also known as:

Monteggia Fracture

__________________ is desirable during the inflammatory and early reparative phases of bone healing because it allows for the growth of new vessels.

Nearly Complete Immobilization

What is the 2nd most common bone disease after osteoporosis?

Paget's Disease of Bone

Plantar heel pain that is worse with the first few steps in the morning and improves with ambulation = ??

Plantar Fasciitis

_____________________ is the most dangerous potential complication of a knee (tibiofemoral) dislocation.

Popliteal Artery Injury

An 35-year-old man is brought into the emergency room by his wife. She found him having a seizure on the floor and brought him in as he was complaining about left shoulder pain and an inability to move his arm. On exam, his left arm is adducted and internally rotated. On imaging, the humerus shows a "Light Bulb Sign." What is the diagnosis?

Posterior shoulder dislocation

69-year-old male with right shoulder pain for the past several months. He reports that he cannot reach above his head without severe pain. As a retired carpenter, he reports that this has significantly impacted his quality of life. Additionally, he is unable to lie on his left side at night due to shoulder pain. On physical exam, there is focal tenderness over the left anterolateral shoulder. Radiography reveals reduced space between the acromion and humeral head. Classic example of:

Rotator Cuff Tendinopathy/Tear

A 27 year old male presents to the ER after a bicycle accident he had earlier on in the day. He States his bike hit a pothole which sent him flying off his bike landing on his outstretched hands. He is now complaining of pain along the radial side of the wrist and is tender just proximal to the base of the thumb, at the anatomical snuffbox. A fracture of which bone should be suspected in this patient until proven otherwise?

Scaphoid

Name 2 things you should be ruling out with prepatellar and superficial infrapatellar bursitis

Septic Bursitis Gout

Pain along border of tibia with mild swelling in a person who had a previously sedentary lifestyle and decided to take up running = what diagnosis?

Shin Splints

A 12-year-old boy is brought to his pediatrician for evaluation of an abnormal gait. The patient first noticed a dull pain in his left medial thigh and knee three weeks ago and reports it has been difficult to bear weight on the left leg over the past week. He has no history of trauma to the leg or hip. He had an upper respiratory tract infection one month ago. Temperature is 37°C (98.6°F), pulse is 82/min, and blood pressure is 116/72 mm Hg. The patient is at the 50th percentile for height and 95th percentile for weight. Physical examination demonstrates an antalgic gait. The physician reproduces the pain with flexion, external rotation, and abduction of the left hip. A left hip radiograph shows "ice cream cone slipping off the cone" appearance. What is the most likely diagnosis?

Slipped Capital Femoral Epiphysis

A 15-year old with fall to an outstretched hand now presents with acute onset of wrist swelling. On imaging, there is a distal radial fracture with the distal segment protruding downward (volar angulation). What type of fracture is this?

Smith's Fracture

A 7-year-old girl who fell from a jungle gym and lands on her outstretched left hand. She develops immediate-onset left elbow pain and swelling. On exam, her arm is held in 30 degrees of extension and she is unable to move her elbow due to pain. A radiographic imaging shows an anterior fat pad sign and a disrupted anterior humeral line. What is the diagnosis?

Supracondylar Fracture

What marks the end of the reparative phase of bone healing?

The clinical union of the fracture where the fractured bone does not shift on physical exam, the fracture site is nontender, and the patient can use injured limb without significant pain

Which test is performed as part of the physical exam in a suspected Achilles Tendon Rupture that involves squeezing the gastrocnemius muscle, and watching for plantarflexion of the foot.

Thompson Test

____________ is the most common injury associated with acute compartment syndrome of an extremity.

Tibial Fracture

A fracture of the distal radius due to a fall on your hand, common in children that can occur on one side and not completely break through is known as?

Torus/Buckle Fracture

Describe the 5 types of the Salter-Harris Classification System

Type I: S = Straight across --> disrupts physis Type II: A = Above --> physis and goes up through metaphysis Type III: L = Lower --> physis and goes down through epiphysis Type IV: T = Through --> Crosses through epiphysis, physis and metaphysis Type V: ER = Erasure of Growth Plate --> Compression to physis

An otherwise healthy 30-year-old woman states that she sustained a left forearm injury as a result of a fall. Initial examination in the emergency room reveals a clean 2-centimeter laceration over the volar forearm, pain and swelling of the affected arm along with decreased active and passive range of motion. Radial and ulnar pulses are intact. X-rays show an isolated transverse fracture of the mid-diaphysis of the ulna. What should you be worried about in this patient?

Violence because its a nightstick fracture