Ortho Q & A

Question: At which level do most lumbar disc herniations occur?

Answer: More than 95% of disk herniations occur at L4 or L5.

Question: In CSF analysis, what does xanthochromia indicate?

Answer: Red blood cells in the subarachnoid space.

Question: What is the recommend splint for a scaphoid fracture?

Answer: Thumb spica splint.

Question: What is the normal pressure of a tissue compartment?

Answer: < 10 mmHg.

Question: What is a reverse Bankart lesion?

Answer: A fracture of the posterior glenoid rim from a posterior glenohumeral dislocation.

Question: Which abnormal reflex is most indicative of intraspinal pathology?

Answer: Abdominal.

Question: What is a typical radiographic finding that supports a diagnosis of a Lisfranc dislocation-fracture?

Answer: An AP view which reveals lateral shift of the second metatarsal off the middle cuneiform. (additionally Fleck Sign)

Question: What is the most commonly sprained ankle ligament?

Answer: Anterior talofibular ligament.

Question: Which ligament is most commonly damaged in an inversion injury of the ankle?

Answer: Anterior talofibular ligament.

Question: What is the first step in treatment of chemical contamination of the eyes?

Answer: Copious irrigation with normal saline should be utilized to flush the eye for 15-30 minutes.

Question: What are the unique laboratory findings of pleural effusions associated with rheumatoid arthritis?

Answer: Low glucose, low pH and high LDH.

Question: Which nerve provides innervation to the ventral surface of the thumb, index, and long finger?

Answer: Median nerve.

Question: What finding is seen on synovial fluid analysis in pseudogout?

Answer: Positively birefringent, rhomboid-shaped crystals.

Question: In addition to anti-Jo-1 and ANA, what other autoantibody may be positive in polymyositis?

Answer: Rheumatoid factor.

Question: What critical diagnoses should be considered in patients with syncope and back pain?

Answer: Ruptured abdominal aortic aneurysm, aortic dissection, pulmonary embolism and ruptured gastric/duodenal ulcer.

Question: Which other condition mimics Osgood-Schlatter disease?

Answer: Sinding-Larsen-Johansson syndrome, a similar pathology in the inferior patellar pole of boys aged 9-11 years.

Question: Name some neuromuscular causes of childhood secondary scoliosis?

Answer: Spina bifida, cerebral palsy, tethered cord syndrome, muscular dystrophy and spinal muscular atrophy.

Which of the following is the most concerning complication of a scaphoid fracture? A) Avascular necrosis B) Infection C) Malunion D) Osteoarthritis

Correct Answer A) Avascular necrosis Explanation: The radiograph demonstrates a fracture at the waist or middle third of the scaphoid. The blood supply to the scaphoid penetrates the cortex on the dorsal surface near the tubercle waist area (distal aspect of scaphoid). Therefore, there is no direct blood supply to the proximal portion of the bone. Because of this tenuous blood supply, scaphoid fractures have a tendency to develop avascular necrosis (AVN). The more proximal the fracture, the greater the likelihood of developing AVN. Infection (B) is an uncommon complication and not the most concerning complication of an isolated scaphoid fracture. Malunion (C) is a complication due to improper healing of the fracture. It mainly occurs when a scaphoid fracture goes unrecognized or there is early discontinuation of immobilization. This can lead to arthritis (D) over time due to misalignment from the abnormal motion and collapse of the bone fragments. If caught before arthritis has developed, surgery may be performed to try to improve scaphoid healing.

A 24-year-old man presents with right shoulder pain after a fall onto his outstretched hand. A radiographic demonstrates an anterior inferior articular glenoid fracture. What is the name of this radiographic finding? A) Bankart lesion B) Hill-Sachs lesion C) Labral lesion D) Luxatio erecta

Correct Answer A) Bankart lesion Explanation: A Bankart lesion is secondary to an impact injury of the posterosuperior aspect of the humeral head into the anteroinferior glenoid rim causing a fracture. It is often associated with an anterior glenohumeral dislocation from a force (often falling) with the arm in abduction and external rotation. It is best seen on CT; however, it can be identified by plain radiographics. A Hill-Sachs lesion (B) is a fracture of the posterosuperior humeral head. A labral lesion (C) refers to an injury of the glenoid labrum. Luxatio erecta (D) is characterized by inferior and sub glenohumeral dislocation.

Question: What is a Jones fracture?

Answer: Fracture of the proximal fifth metatarsal diaphysis.

Question: Which part of the body is scanned to determine bone mineral density?

Answer: Hip and spine.

Question: Which endocrinopathies predispose adolescents to Slipped Capital Femoral Epiphysis?

Answer: Hypothyroidism and growth hormone deficiency.

Question: What is the definitive treatment for refractory osteoarthritis?

Answer: Surgical intervention.

Question: Which joint is most commonly affected in gout?

Answer: The metatarsal-phalangeal joint of the great toe.

Question: What are the typical laboratory abnormalities found in patients with myofascial pain syndrome?

Answer: There are no specific lab tests to confirm or refute a diagnosis of myofascial pain syndrome.

Question: What is the Neer test?

Answer: Exam of the shoulder where the examiner performs maximal passive forward flexion with internal rotation while stabilizing the patient's scapula with the other hand.

Question: What are two relative contraindications to performing an arthrocentesis?

Answer: Overlying cellulitis and coagulopathy.

Question: What age groups are at higher risk for a malignant cause of their back pain?

Answer: Patients under 18 years or over 50 years of age.

A 34-year-old man presents to the emergency department complaining of extreme left lower leg pain. Three hours earlier, his leg was crushed between his truck and trailer. On physical exam, the pain is exacerbated by passively dorsiflexing the ankle and the leg feels hard and firm. There is diminished sensation in the left foot. Which of the following is the most likely diagnosis? A) Acute arterial occlusion B) Compartment syndrome C) Deep venous thrombosis D) Superficial thrombophlebitis

Correct Answer B) Compartment syndrome Explanation: The man in this case most likely has acute compartment syndrome. Compartment syndrome occurs when tissue pressure within a closed compartment compromises perfusion and results in muscle and nerve ischemia. In the extremities, compartment syndrome may occur acutely, usually following trauma, or chronically, seen usually in athletes. Acute compartment syndrome is much more common than chronic compartment syndrome. Fractures are the most common cause of acute compartment syndrome. Other potential causes include crush injuries, thermal burns, highly constrictive bandages, penetrating injuries, bleeding disorders, animal envenomations, and extravasation of intravascular fluids. The anterior compartment of the lower leg is the most common site. One of the most common and earliest symptoms of ACS is pain out of proportion to the apparent injury. Physical manifestations may include pain with passive muscle stretching, firm "wood-like" feeling of the compartment, pallor from compromised vasculature, diminished sensation, or muscle weakness. Motor deficits are late findings. The diagnosis is based on clinical findings and serial measurements of compartment pressures. Immediate surgical consultation should be obtained if acute compartment syndrome is suspected, as this is a surgical emergency. Initial management involves removing any dressings, splints, or casts and keeping the limb level with the torso. Definitive treatment is a fasciotomy. Complications of untreated acute compartment syndrome include muscle contractures, sensory deficits, paralysis, and infection. Acute arterial occlusion (A) manifests with the 5 P's: pain, pallor, pulselessness, paresthesias, and paralysis. Atrial fibrillation is one of the most common causes of acute arterial occlusion. Based on this man's age and history of acute trauma, acute compartment syndrome is more likely. Deep venous thrombosis (C) occurs when blood coagulates within one of the deep veins. Symptoms of deep vein thrombosis include edema, pain, tenderness, warmth, and erythema. Deep vein thrombosis risk factors include immobility, hypercoagulability, and vascular injury. It is unlikely that the man in this case developed a deep vein thrombosis in the three hours after his initial injury. Superficial thrombophlebitis (D) is caused by thrombus formation in a vein located near the skin. Superficial thrombophlebitis is typically seen in patients who are hypercoagulable or immobilized, in patients with varicose veins or systemic lupus erythematosus, and in patients with venous catheters. Superficial thrombophlebitis typically causes induration, erythema, and tenderness along the affected vein.

A 73-year-old woman presents with right knee pain for the past several months that has been worse over the last three days. It is worse with walking and better with rest. She has not tried anything to alleviate the pain. Physical examination reveals bony enlargement of the knee and joint line tenderness. An X-ray is ordered and shows narrowed joint spaces, and subarticular reactive sclerosis. She denies any injury or previous surgery on the knee. Which of the following is the best initial pharmacologic treatment? A) Glucosamine plus Chondroitin B) Ibuprofen C) Prednisone D) Tramadol

Correct Answer B) Ibuprofen Explanation: Ibuprofen has the lowest side-effect profile with the most significant pain relief and is the initial analgesic of choice for osteoarthritis. In mild disease, topical NSAIDs are recommended prior to the initiation of oral NSAID use. Acetaminophen can also be used when NSAID use in contraindicated. With the use of tylenol it is important to consider the safety concerns associated with overuse and an increased awareness of its negligible and non-clinically significant effects on pain. History will generally reveal mechanical pain and physical exam may be relatively benign or may reveal crepitus, joint line tenderness, and bony enlargement. It is the most common joint diseases affecting older adults and can lead to disability. For many patients, adequate monotherapy is enough to control symptoms of pain. Other nonpharmacologic treatments include exercise, weight loss (if necessary), and avoidance of aggravating activities. Glucosamine and chondroitin (A) are not discouraged from use if the patient reports symptom improvement but research trials have failed to show significant clinical benefit. Prednisone (C) may provide pain relief but has an increased side effect profile and should not be used long-term for osteoarthritis. Tramadol (D) is used as an alternative pain relief medication; however, this interacts with many other medications and should be used with caution in older adults.

Which of the following fractures requires orthopedic referral? A) First distal phalanx fracture without intra-articular involvement B) First metatarsal fracture with 1 mm displacement C) Midshaft fifth metatarsal with 1 mm displacement D) Second metatarsal fracture with 2 mm displacement «

Correct Answer ( B ) Explanation: All first metatarsal fractures, including first metatarsal fracture with 1 mm displacement, should receive an orthopedic referral. Metatarsal fractures are the second most common type of foot fractures in adults, behind toe fractures. Direct blows and twisting injuries are the most common mechanisms of metatarsal fracture. Greater force is typically needed to fracture the first metatarsal due to its larger size. Risk factors for metatarsal fractures include osteoporosis, diabetes, and decreased physical activity. Patients with metatarsal fractures usually present with acute onset of foot pain and difficulty walking. Physical exam is often notable swelling and ecchymosis. Point tenderness is common, but swelling may make localization difficult. The tarso-metatarsal joint should be palpated to evaluate for Lisfranc injury. Three-view plain radiographs are recommended as initial diagnostic imaging. All open fractures require emergent orthopedic referral. In non-athletes, indications for orthopedic referral include multiple metatarsal fractures, intra-articular fractures, first metatarsal fracture, or second to fifth metatarsal fracture displaced greater than 3-4 mm. Initial management for minimally displaced involves a posterior splint, non-weight-bearing status, elevation, and ice. Healing typically occurs within 6 weeks in the majority of adults with metatarsal fractures. Midshaft fifth metatarsal fracture with 1 mm displacement (C), first distal phalanx fracture without intra-articular involvement (A), and second metatarsal fracture with 2 mm displacement (D) do not require orthopedic referral. These fractures can be managed with a walking cast or air boot. Patients with nondisplaced or minimally displaced second to fifth metatarsal fractures should have radiographs repeated 5-7 days after the injury to assure the fracture remains non-displaced. All first metatarsal fractures require orthopedic referral because it is a major contributor to the foot's ability to bear weight.

Which of the following is used to diagnose and monitor scoliosis? A) Cobb angle B) Hoffman reflex C) Modified Schober test D) Pelvic tilt

Correct Answer A) Cobb angle Explanation: Scoliosis is lateral curvature of the thoracic or lumbar spine > 10 degrees. It is usually idiopathic, but can be secondary to neuromuscular disease (cerebral palsy, spinal muscular atrophy, myelomeningocele), vertebral disease (tumor, infection), neurofibromatosis, or Marfan syndrome. Symptoms usually develop in early adolescence. Females are more likely to have progressive disease requiring treatment. Adult onset scoliosis is commonly caused by spinal degenerative disk disease, facet spondylosis and spondylolisthesis. On exam, use a forward bending test to assess for vertebral and rib rotation. The diagnosis is made radiographically with weight-bearing PA and lateral full-length spinal views to measure the Cobb angle. The Cobb angle is used to quantify the magnitude of spinal deformities. To measure the Cobb angle, first decide which vertebrae are the end-vertebrae of the curve deformity (vertebrae at the upper and lower limits of the curve) and then Cobb angle formed by the intersection of two lines: one parallel to the endplate of the superior end vertebra and the other parallel to the endplate of the inferior end vertebra. The angle is plotted and scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more. The Hoffman reflex (B) involves assessing for thumb or second digit flexion when the nail of the third digit is flicked. A positive response suggests upper motor neuron disease such as cervical spinal cord injury. The modified Schober test (C) is used to quantify lumbar spine flexion and extension in the sagittal plane. It is not used to monitor worsening coronal spine curve as in progressive scoliosis. Pelvic tilt (D) refers to the height difference between the iliac crests. It is primarily used to evaluate leg-length discrepancy.

You diagnose a patient with myofascial pain syndrome. In an effort to decrease her overall pain levels, which of the following medications is most appropriate to prescribe? A) Cyclobenzaprine B) Haloperidol C) Oxycontin D) Pregabalin

Correct Answer A) Cyclobenzaprine Explanation: Myofascial pain can essentially be defined as the presence of trigger points, focal distinct painful spots located in palpable taut bands of muscles. It is a common musculoskeletal cause of pain, and can be associated with local and distal sensory abnormalities as well as autonomic, sleep and mood disorders. Treatment begins with aggressive physical therapy, which includes specific treatments of myofascial release, ultrasound, spray-and-stretch techniques, posture rebalancing and specific muscle stretch-strengthen exercises. Further treatment options include cognitive-behavior therapy and trigger point injection therapy. Medications also play a role. Muscle relaxants, such as cyclobenzaprine, provide pain relief. NSAIDs, only when used in conjunction with other active treatment, are also beneficial for pain relief. Haloperidol (B) is an antipsychotic not used in the treatment of myofascial pain. Tricyclics such as amitriptyline, however, can be used in treating myofascial pain syndrome. They are used to restore normal sleep patterns, but do not directly decrease the trigger point pain. Pregabalin (D) is cleared for use in fibromyalgia, not myofascial pain syndrome. Oxycontin (C) and other opioid medications are not recommended for myofascial pain syndrome.

Which of the following patients requires radiologic imaging for her back pain? A) A 26-year-old woman with unilateral costovertebral angle tenderness, fever, and dysuria B) A 30-year-old woman with midline lumbar pain and tenderness, fever, and difficulty urinating C) A 35-year-old woman with bilateral lumbar level back pain after lifting furniture that is worse with movement and alleviated with rest D) A 40-year-old woman with lumbar-level pain and tenderness that radiates to her left anterior thigh, with a normal neurologic exam

Correct Answer B) A 30-year-old woman with midline lumbar pain and tenderness, fever, and difficulty urinating Explanation: This patient has symptoms suspicious for a spinal epidural abscess. The classic triad is severe back pain, fever, and neurological deficits. In her case, urinary retention is her deficit, which by itself is worrisome for cauda equina syndrome. The diagnostic test of choice is MRI. Epidural abscess may require evacuation by a spine surgeon. Patients are often on IV antibiotics for many weeks. However, to avoid sterilization of the abscess and facilitate isolation of the causative organism, it is recommended that antibiotic therapy be withheld in the emergency department for suspected (or even radiographically confirmed) cases. Patients at risk for spinal epidural abscess include intravenous drug users, immunocompromised patients, alcohol abusers, diabetics, patients with malignancy, and those with recent spine procedures. Pyelonephritis (A) is an infection of the renal parenchyma and upper collecting system. In an otherwise healthy, young patient, treatment can be performed on an outpatient basis with current guidelines recommending 14 days of antibiotics. Radiographic imaging is not needed unless there is suspicion of an infected kidney stone. Nonspecific back pain (C) in the absence of "red flags" (e.g., fever, neurologic deficit, IV drug use, trauma) does not require radiographic imaging and can be managed symptomatically with resumption of usual daily activities as soon as possible. Bed rest has been shown to prolong the duration of pain, as have back exercises. Most nonspecific back pain resolves in 4-6 weeks. Radiculopathy (D) or nerve impingement syndrome may be caused by a disk herniation or other irritation of the nerve root. Given the location of symptoms, compression of the L4-L5 nerve root should be suspected but without worrisome features; imaging in the emergency department is not indicated. If her symptoms do not resolve in 4-6 weeks, an MRI of the lumbosacral spine may be warranted.

A 46-year-old woman presents with muscle weakness that has progressively worsened over the last several months. She has particularly noticed it when trying to stand up from a seated position, and she now has to use the armrests. Physical examination reveals weakness of the deltoids and hip flexors. Testing positive for which of the following autoantibodies is most consistent with the diagnosis? A) Anti-dsDNA B) Anti-Jo-1 C) Anti-SCL-70 D) Anti-SS-A

Correct Answer B) Anti-Jo-1 Explanation: Anti-Jo-1 (and other autoantibodies recognizing the aminoacyl tRNA synthetases) are the most commonly positive myositis-specific autoantibodies. These occur in approximately 20 to 30 percent of patients with polymyositis. Individuals who test positive for these autoantibodies often have other manifestations in addition to the myopathy, including interstitial lung disease, nonerosivve arthritis, fever, Raynaud phenomenon, and Gottron papules. In addition, antinuclear antibodies are found in more than half of patients with polymyositis. Polymyositis should be considered in patients who have progressive weakness of the proximal muscles over a period of months. Other lab abnormalities include elevated creatine kinase, aldolase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). Electromyography (EMG) will show an irritable myopathy, and muscle biopsy will reveal perivascular lymphocytic infiltrates. Anti-dsDNA (A) (anti-double stranded DNA) is associated with systemic lupus erythematosus (SLE) and, to a lesser degree, rheumatoid arthritis. Anti-SCL-70 (C) is associated with scleroderma and anti-SS-A (D) is associated with Sjogren syndrome and SLE. There is a weak association with rheumatoid arthritis, as well.

A 55-year-old man with a history of peptic ulcer disease presents to your office with a complaint of right knee pain that started last night. On physical exam his knee is erythematous, warm and exquisitely tender to palpation. Synovial fluid analysis reveals the presence of positively birefringent calcium pyrophosphate dihydrate crystals. Which of the following is the most appropriate therapy? A) Allopurinol B) Colchicine C) Indomethacin D) Vancomycin

Correct Answer B) Colchicine Explanation: Calcium pyrophosphate crystal deposition disease, also referred to as pseudogout, is a common crystal-induced arthropathy that generally affects the large joints. Pseudogout has a similar clinical presentation to gout, but the etiology is different. Pseudogout may be idiopathic, especially in the elderly. It may also be caused by trauma, hyperparathyroidism, hemochromatosis, and medications that cause hypomagnesemia such as loop diuretics or proton pump inhibitors used in peptic ulcer disease. Patients present with acute onset of severe pain, inflammation and edema in the knees, ankles, elbows or wrists. Pseudogout is generally monoarticular, but may present in multiple joints as well. Diagnosis is by synovial fluid analysis, so arthrocentesis is necessary for patients with monoarticular arthritis. Initial treatment for pseudogout when two or less joints are inflammed is aspiration and intraarticular glucorticoid injection. When injection is not feasible, treatment is with nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine. Workup of the underlying metabolic problem causing the pseudogout attack will help to prevent future flare-ups. Allopurinol (A) is used in the long-term treatment of gout to prevent flares. It should not be used for an acute case of gout. Indomethacin (C) is an NSAID that is first-line in the treatment of acute attacks of both gout and pseudogout. NSAIDs are contraindicated in patients with peptic ulcer disease, heart failure, renal insufficiency, and hypersensitivity to NSAIDs. Vancomycin (D) is used in the treatment of septic arthritis, which can have a similar clinical presentation to both gout and pseudogout.

A 12-year-old baseball player presents with knee pain. It occurs mainly during running the bases. Tenderness and edema are prominent about the right tibial tuberosity, and resisted knee extension is painful. The remainder of the knee examination is normal. Radiographic examination of this patient would most likely reveal which of the following abnormalities? A) Bipartite patella B) Heterotopic ossification C) Increased density of the femoral condyles D) Pars interarticularis defect

Correct Answer B) Heterotopic ossification Explanation: Tibial tuberosity osteochondritis is called Osgood-Schlatter disease (OSD). Repetitive quadricep contraction can lead to avulsions at the secondary ossification center between the tibial tuberosity and the patellar tendon. Incidence is greatest in adolescent boys who are active in sports. Symptoms include anterior proximal tibial pain, which is worse with running, jumping and prolonged sitting. Examination typically reveals unilateral tibial tuberosity tenderness and edema with restricted and tender kneeling. Lateral radiographs typically show spicules of heterotopic ossification anterior to the tibial tuberosity. Intermittent ice, NSAIDs and rest are common treatment options. Immobilization may be required for recalcitrant cases. Surgery is commonly unnecessary, and prognosis is typically good. Bipartite patella (A) may present with superolateral patellar pain, but not commonly with tibial tuberosity pain. Increased density of the femoral condyles (C) is not present in OSD. Increased density of the femoral head is common in Legg-Calve-Perthes disease, the childhood disorder of hip avascular osteonecrosis. A defect in the pars interarticularis (D), the bony junction of the superior and inferior articular processes of the vertebral posterior columns, can lead to spondylolisthesis and back pain, not knee pain.

You perform an arthrocentesis on a patient with knee pain. Synovial fluid analysis reveals a WBC 5,000 cells/µL with 70% PMNs. Which of the following is the most likely diagnosis? A) Hemorrhagic effusion B) Inflammatory arthritis C) Noninflammatory arthritis D) Septic arthritis

Correct Answer B) Inflammatory arthritis Explanation: The analysis of synovial fluid is essential for identifying crystalline and suppurative causes of acute arthritis. The WBC count dictates the inflammatory class of the fluid. However, an analysis is often difficult because there is significant overlap between entities. A very high fluid WBC or PMN pleocytosis indicates infection, but a modest elevation does not exclude it. Therefore, cell counts should be used as a guide rather than definitive diagnosis. WBCs between 2,000 and 75,000 are often categorized as inflammatory. However, a WBC over 50,000 has a likelihood ratio of 7.7 for septic arthritis. Hemorrhagic effusions (A) are caused by trauma to the knee or coagulopathy. The fluid is grossly bloody and may contain fat droplets (lipohemarthrosis). Noninflammatory arthritis (C) such as osteoarthritis will have <3,000 WBCs on arthrocentesis. The likelihood ratio for septic arthritis (D) increases as the joint WBC count rises. A WBC count <25,000 has a likelihood ratio of 0.32, >25,000 has a likelihood ratio of 2.9, >50,000 has a likelihood ratio of 7.7.

Which structure is compressed by a far lateral unilateral disc herniation between L4 and L5 lumbar vertebrae? A) L3 nerve root B) L4 nerve root C) L5 nerve root D) No nerve roots as this is below the level of the nerve roots

Correct Answer B) L4 nerve root Explanation: Far lateral unilateral disc herniation between L4 and L5 usually compresses the L4 root as it crosses the disc before exiting at the L4 intervertebral foramen. Pain may be localized around the medial side of the leg. Numbness may be present over the anteromedial aspect of the leg. The anterior tibial muscle may be weak, as evidenced by the inability to heel walk. The quadriceps and hip adductor group, both innervated from L2, L3, and L4, also may be weak and, in extended ruptures, atrophic. Reflex testing may reveal a diminished or absent patellar tendon reflex (L2, L3, and L4) or anterior tibial tendon reflex (L4). Sensory testing may show diminished sensibility over the L4 dermatome, the isolated portion of which is the medial leg and the autonomous zone of which is at the level of the medial malleolus. Unilateral disc herniation between L3 and L4 results in compression of the L3 (A) or L4 nerve root. A posterolateral unilateral disc herniation between L4 and L5 results in compression of the L5 root (C). The nerve roots are still present at this level (D). Although the spinal cord terminates near lumbar nerves L1 and L2, the spinal nerves continue as a bundle of nerves called the cauda equina.

The scaphoid articulates with which of the following bones? A) Hamate B) Radius C) Triquetrum D) Ulna

Correct Answer B) Radius Explanation: The scaphoid bone is one of the eight carpal bones, which altogether with the distal radius and ulna, make up the bones of the wrist. The carpal bones are arranged in two rows of four bones. The proximal row consists of the scaphoid, lunate, triquetrum, and pisiform, while the distal row consists of the trapezium, trapezoid, capitate, and hamate. The wrist has many complex articulations which allow for complex movements, including the radiocarpal joint, the midcarpal joint, and the distal radioulnar joint, which allow wrist flexion, extension, radial deviation (abduction), ulnar deviation (adduction), circumduction, pronation, and supination. The scaphoid and lunate bones articulate proximally with the radius to form the radiocarpal joint. The radius also articulates with the ulna at the distal radioulnar joint. The ulna does not directly articulate with the carpal bones, but rather has an interface with the triangular fibrocartilage complex, known as the articular disk, which binds together the distal ends of the radius, ulna, lunate, and triquetrum. Scaphoid fractures can be radiographically difficult to detect. In 15% of cases, radiographs taken immediately after injury fail to show a fracture line. Therefore, if a scaphoid fracture is suspected, the wrist should be immobilized in a thumb spica splint and follow-up should be arranged for repeat clinical evaluation and radiographic imaging in seven to ten days. The scaphoid bone does not articulate with the hamate (A), triquetrum (C), or ulna (D).

Which of the following stable patients with back pain should have an emergent MRI performed? A) 23-year-old man with a positive straight leg raise and otherwise normal neurologic examination B) 30-year-old woman with back pain and dysuria C) 34-year-old man with a history of intravenous drug abuse with back pain and constipation D) 45-year-old woman with back pain after a car accident with no midline tenderness and normal neurologic examination

Correct Answer C) 34-year-old man with a history of intravenous drug abuse with back pain and constipation Explanation: The majority of patients who present with back pain do not require emergent imaging. However, those who may have a serious cause of their back pain including cauda equina syndrome, epidural abscess, vertebral osteomyelitis and other causes of cord impingement should be considered for emergent imaging of the spine. Patients that present with back pain should be screened for "red flags" in their presentations that support one of these critical diagnoses. These red flags include age (both extremes), history of cancer (especially those known to metastasize to bone), fever, weakness, saddle anesthesia, change in bowel or bladder function (incontinence or retention/constipation), trauma, history of immunocompromise (including chronic steroid use) and intravenous drug abuse. Patients with these components to their presentations have a higher risk of dangerous diagnoses and should be considered for early imaging with either CT (better for bony abnormalities) or MRI (better for spinal cord visualization). A positive straight leg raise (A) (pain radiating from the back into the leg below the knee) is suggestive of a protruding disk but can be worked up as an outpatient. Patients with symptoms of pyelonephritis (B) rarely require imaging unless there is a more complicated picture to their presentation (presence of kidney stone, sepsis, septic shock). Patients with trauma but no midline tenderness and a normal neurologic examination (D) do not require imaging.

A 16-year-old boy presents complaining of right ankle pain after injuring himself while playing basketball. He states that he "twisted his ankle" when he landed on another players foot trying to get a rebound. He has not been able to walk on his right foot since this occurred two hours ago and cannot do so in the ED. On examination, his pulses are intact. Strength and sensation are normal. The ankle is swollen laterally. He is tender over the lateral malleolus and at the base of the fifth metatarsal. No tenderness or swelling is noted over the proximal tibia and fibula. Which of the following is true regarding emergency department radiographic work-up of this patient? A) A complete ankle series is the only indicated study B) A complete foot series is the only indicated study C) Both a complete ankle and a complete foot series are indicated D) No radiographic imaging is indicated at this time

Correct Answer C) Both a complete ankle and a complete foot series are indicated Explanation: The patient should undergo X-rays of both the ankle and the foot. The Ottawa Ankle Rules (OAR) are a clinical decision making tool used to help determine the need for radiographic imaging following blunt ankle injury. They apply to acute injuries that have occurred within the previous 48 hours, however, are not useful in the subacute or chronic phase. The OAR were not designed to be general guidelines for foot injuries; the foot rules only apply to the midfoot and do not apply to the hindfoot or forefoot. The patient has bony tenderness in the foot and therefore should have a complete series of foot X-rays. By only obtaining a complete ankle series (A), a clinically significant foot injury may be missed. The patient has bony tenderness in the ankle and therefore should have a complete series of ankle X-rays. By only obtaining a complete foot series (B), a clinically significant ankle injury may be missed. According to OAR this patient should have radiographic imaging in the ED (D). The rules do not apply when the patient is acutely intoxicated, difficult to assess, has altered mental status, multiple injuries, diminished sensation, or neurologic deficits.

A 29-year-old woman presents with a chief complaint of dry eyes. Which of the following would indicate the need for testing for a systemic illness? A) Anticholinergic use B) Clear discharge C) Dry mouth D) Long term contact lens use

Correct Answer C) Dry mouth Explanation: Sjogren's syndrome is a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva leading to dry mouth and eyes (keratoconjunctivitis sicca). Work up for Sjogren's includes lab work to identify the auto-antibodies (ANA, RF, anti SS-A, anti SS-B (formally anti-Ro and anti-La)), a Schirmer test (for tear production) and a biopsy of the salivary glands. Patients may also present with dryness of other mucous membranes including the vagina and the nasal passageways. Complications of Sjogren's include dyspareunia, corneal abrasions, dental caries, malabsorption syndromes to due to pancreatic failure, lymphoma, polyneuropathy, lung and kidney disease and other rheumatologial complaints. Treatment options include artificial tears and saliva, topical ophthalmic steroids, systemic steroids or cytoxic agents or a combination of both. Anticholinergic use (A) can lead to dry eyes, but symptoms will resolve when the agent is withdrawn. Long term contact lens use (D) can increase tear evaporation, decrease tear flow and increase infections, but is not due to a systemic illness. Clear discharge (B) is associated with viral conjunctivitis and is typically self-limited

A 63-year-old man with hypertension and dyslipidemia presents with pain and swelling of his left great toe. He denies trauma or fever. Examination reveals an exquisitely tender and swollen first metatarsophalangeal (MTP) joint on his left foot. Arthrocentesis yields fluid as shown above. What is the first line therapy for this patient? A) Acetaminophen B) Allopurinol C) Ibuprofen D) Probenecid

Correct Answer C) Ibuprofen Explanation: This patient presents with monoarticular arthritis and a synovial fluid sample consistent with gout. Gout is a systemic disorder that manifests with joint inflammation. It is caused by precipitation of uric acid crystals from extracellular fluid. Hyperuricemia results either from underexcretion of end products of purine metabolism from the kidney or overproduction (more rare). During an episode of gout, polymorphonuclear cells ingest the crystals and release cytokines leading to an inflammatory reaction within the synovium. The most commonly affected joint is the first metatarsophalangeal (MTP) joint followed by the knee. It is important to consider that patients with gout are at a higher risk of developing septic arthritis because the joints are chronically damaged. In patients with a history of gout that present with symptoms concerning for septic arthritis (pain, fever, decreased range of motion) arthrocentesis should be performed to rule out the presence of infection. Management of gout should be split into acute gouty attack treatment and long-term prophylaxis. The mainstay of acute therapy is NSAIDs and colchicine. Indomethacin, naproxen and ibuprofen all may be used in acute treatment. Colchicine inhibits microtubule formation reducing the inflammatory response to uric acid crystals. Unfortunately, the drug has a number of side effects that are almost universally experienced at therapeutic doses (nausea, vomiting, diarrhea). Acetaminophen (A) does not have anti-inflammatory properties and offers little benefit in acute gouty attacks. Allopurinol (B) is a xanthine oxidase inhibitor that prevents production of uric acid. It is useful in patients with increased synthesis and decreased clearance of uric acid. Allopurinol should not be started at the time of an acute attack of gout because it can lead to a transient increase in uric acid levels. However, patients already prescribed allopurinol should continue to take it at the same dose during acute episodes. Probenecid (D) is useful in prophylaxis but not for acute episodes.

A 67-year-old woman has a bone mineral density T-score of -2.8 standard deviations. Which of the following is the most likely diagnosis? A) Normal bone density B) Osteopenia C) Osteoporosis D) Severe osteoporosis

Correct Answer C) Osteoporosis Explanation: Osteoporosis is a very common disease that leads to increased risk of bone fracture in those affected. Risk factors for osteoporosis include advanced age, female gender, Caucasian and Asian race, body weight less than 58 kg, cigarette smoking, increased alcohol intake, previous fracture and family history of hip fracture. Bone mineral density (BMD) is used to assess risk and is determined by using dual-energy x-ray absorptiometry (DXA) scan. DXA scan results are reported as T-scores which provide information about the progression of disease and risk of fracture, categorizing patients on the spectrum from normal bone density to severe osteoporosis. Osteoporosis is defined by a BMD of 2.5 or more standard deviations below the young adult female reference mean which is equivalent to a T-score of less than or equal to -2.5 standard deviations. Normal bone density (A) is defined as a T-score greater than or equal to -1 standard deviations. Osteopenia (B), also known as low bone mass, is diagnosed with a T-score of between -1 and -2.5 standard deviations. Severe osteoporosis (D) occurs with the presence of one or more fractures and a T-score of less than or equal to -3.5 standard deviations.

Which of the following clinical findings differentiates rheumatoid arthritis from osteoarthritis? A) Involvement of the PIP joints B) Polyarticular involvement C) Presence of constitutional symptoms D) Symmetric joint involvement

Correct Answer C) Presence of constitutional symptoms Explanation: Osteoarthritis (OA) and rheumatoid arthritis (RA) share a number of features but constitutional symptoms are only seen in RA. RA is a chronic inflammatory disease. Patients often present with fever, weakness and musculoskeletal pain lasting for weeks to months. Arthritis involves symmetric joints of the hands, wrists and elbows. Morning stiffness is common and usually last for about an hour. Inflammation may affect other organs leading to hepatitis, scleritis, myocarditis, pericarditis and pleuritis. Atlantoaxial subluxation may also occur and cervical spine precautions should be maintained during intubation. Both RA and OA often involve the PIP joints (A) and can be monoarticular or polyarticular (B). Symmetric joint involvement (D) is common in both RA as well as OA.

Which of the following is necessary to confirm the diagnosis of scoliosis? A) Adam's forward bend test B) Magnetic resonance imaging C) Radiography D) Scoliometer

Correct Answer C) Radiography Explanation: Scoliosis is a lateral curvature of the spine. Idiopathic scoliosis is the most common type of scoliosis and within this category, the most common type is adolescent idiopathic scoliosis (AIS). AIS is defined as a Cobb angle greater than or equal to 10 degrees, age of onset 10 years or greater and no identifiable etiology. The Cobb angle is determined on radiography and is the measurement used to monitor the progression of scoliosis. Risk factors for the development of AIS include age less than 12 years, onset prior to menarche, female sex, and double or thoracic curves. The curvature of scoliosis can progress during periods of rapid growth, such as adolescence. This can cause significant deformity and other clinical manifestations such as cardiopulmonary compromise, therefore it is important to identify and monitor patients with this condition. A number of screening measures are used to determine the likelihood of scoliosis, but radiography is needed for the diagnosis of scoliosis as determined by the Cobb angle. Physical examination for scoliosis includes the Adams forward bend test (A). The patient is observed from the back while bending forward at the waist until the spine is parallel to the ground. Lumbar or thoracic prominence on one side indicates possible scoliosis and further workup should be initiated. Magnetic resonance imaging (B) is indicated when plain radiography is suggestive of an intraspinal pathology, such as a tumor or infection. Scoliosis can be diagnosed on X-ray and MRI is unnecessary. A scoliometer (D) is a tool used for scoliosis screening and can quantify the amount of trunk rotation. Accurate use of the scoliometer is based on operator experience.

A 21-year-old track-and-field athlete trips during her last race, costing her the win, and resulting in severe foot pain. She presents with erythema and edema. During examination, stabilization of the calcaneus and rotation of the forefoot results in a clicking sensation and severe dorsal foot discomfort. Toe flexion and extension is maintained in a normal, nonpainful range. You most likely suspect a dislocation of which of the following joints? A) Fibulotalar B) Metatarsophalangeal C) Tarsometatarsal D) Tibiotalar

Correct Answer C) Tarsometatarsal Explanation: Fracture-dislocation of the tarsometatarsal joints is commonly called a Lisfranc injury. These joints exist between the three cuneiforms and the cuboid proximally and the five metatarsals distally, with the key joint being the "locking" interaction between the middle cuneiform and the second metatarsal base. Common mechanisms of injury include trauma and tripping. Pain is located on the dorsum of the midfoot, as compared to perimalleolar ligamentous pain. As such, Lisfranc injuries are easily misdiagnosed as ankle sprains. A key exam finding is pain with forefoot rotation against a stabilized hindfoot (calcaneus). This maneuver is not painful in ankle sprains or ankle mortise injury, but severely painful with Lisfranc injuries. Diagnosis can be upheld when an AP radiograph reveals lateral shift of the second metatarsal off the middle cuneiform. Nondisplaced injuries are treated with non-weight bearing casting, however, any displacement necessitates surgical intervention. Metatarsophalangeal (B) injury would typically result in painful and limited toe flexion-extension. Fibulotalar (A) and tibiotalar (D) instability/malalignment injuries occur with ankle sprain, dislocation or fracture. With these injuries, forefoot rotation around the hindfoot does not commonly result in pain.

A 16-year-old girl presents with pain to the right index finger after slamming it in a car door. Physical examination reveals a 50% subungal hematoma and intact nail folds. An X-ray shows a non-displaced distal tuft fracture. What management is indicated? A) Oral antibiotics, splinting and follow up B) Splinting and follow up C) Trephination, splinting and follow up D) Trephination, splinting, oral antibiotics and follow up

Correct Answer C) Trephination, splinting and follow up Explanation: This patient should have trephination performed to relieve pain from the subungal hematoma, be splinted in extension and follow up with a hand surgeon. Subungal hematomas are common after crush injuries to the digits. They are often associated with distal phalanx fractures. Pain associated with these hematomas can be severe as pressure increases under the nail. Management focuses on diagnosing associated injuries and providing pain relief. The easiest way to relieve pain in the digit is by relieving the pressure building under the nail. This can be accomplished with trephination of the nail. Typically, an 18-gauge needle or electrocautery device is placed over the center of the hematoma. Gentle pressure is applied until the nail is penetrated. This typically results in a drop or two of blood exiting through the hole that has been created. The patient typically experiences immediate pain relief. Nail removal is typically unnecessary. Administration of antibiotics (A) has not been shown to be helpful to prevent infection. Splinting and follow up (B) are appropriate after trephination. Even though trephination in the presence of a distal phalanx fracture technically converts a closed fracture into an open one, it is not contraindicated to perform drainage of the blood. Prophylactic antibiotics (D) are not necessary. As usual, tetanus prophylaxis should be administered as needed.

Which of the following diagnostic studies has the highest sensitivity to evaluate for acute radiculopathy? A) Cerebrospinal fluid analysis B) Electromyography C) Magnetic resonance imagingCorrect Answer D) X-ray

Correct Answer CMagnetic resonance imagingCorrect Answer Explanation: Magnetic resonance imaging (MRI) should be performed when evaluating for acute radiculopathy because it is the most sensitive diagnostic tool for a herniated nucleus pulposus or other intraspinal pathology. Radiculopathy is a disease of a nerve root caused by compression, irritation, or swelling. It most commonly is a result of a herniated disc but can also be due to malignancy, infection, or vascular disorders. An MRI is the diagnostic test of choice because it is the least invasive and least radiation-inducing procedure to visualize the cause of radiculopathy. If a patient can't undergo an MRI because of intolerance or a contraindication, a CT scan or CT myelogram with contrast can be performed instead. Cerebrospinal fluid analysis (A) is not routinely performed in the workup of radiculopathy and is only indicated if no other causes are identified or if there is a high suspicion for neoplasm or infection. Leptomeningeal carcinomatosis, Lyme disease, and cytomegalovirus are examples of causes of radiculopathy that may only be found through testing of the cerebrospinal fluid. A lumbar puncture, however, should not be obtained when there is high suspicion for an epidural abscess because there is a high risk of introducing infection into the central nervous system if the needle passes through an infected area. Electromyography (B), also known as EMG, is used to evaluate the electrical activity produced by muscles and the nerve roots that control them. This study examines the integrity and utilization of nerve roots and can help to localize injured nerves as well as provide information as to how long the nerve has been injured. An EMG is not routinely performed and should be reserved for those whose neuroimaging findings do not correlate with the patient's symptoms or when it is important to determine how long the nerve has been damaged. X-ray (D) is not routinely performed when evaluating radiculopathy as it can only visualize bony processes and not the discs and therefore would not provide enough information to make a diagnosis. If fracture, spinal stenosis, infection, or malignancy are suspected, an X-ray should be performed to evaluate the alignment of the spine, but it should not routinely be performed.

A 40-year-old man who plays weekend baseball as a pitcher presents to the office stating that for the last few months his right shoulder feels like it is "going dead." He states that the pain is progressively worsening and now he is experiencing weakness with overhead activity. He also believes that he is throwing the baseball slower than previously. Which of the following is the most likely diagnosis? A) Acromioclavicular joint injury B) Adhesive capsulitis C) Glenohumeral joint dislocation D) Rotator cuff tear

Correct Answer D) Rotator cuff tear Explanation: The rotator cuff is made up of the Supraspinatus (abduction), Infraspinatus (external rotation), Teres minor (external rotation), and Subscapularis (internal rotation) muscles. Often remembered by the mnemonic SITS. Rotator cuff impingement and tearing usually begin in the supraspinatus tendon as it passes under the acromion. Patients are usually >50 years of age and will often have significant pain with abduction above the head and internal rotation. Often times, patients will complain of difficulty brushing their hair or have pain at night when rolling onto their shoulder. The condition can also occur in young patients, particularly baseball pitchers who will often hear a "pop" caused by a tear in the rotator cuff. On exam, the drop arm test and empty can test are positive. If there is weakness on exam and lack of full improvement with rehabilitative exercises and subacromial corticosteroid injection, you should suspect a tear rather than isolated impingement. Tears are diagnosed by MRI and often require surgical repair. Acromioclavicular injury (A) may be traumatic (fall onto the lateral aspect of the shoulder) or atraumatic (arthritis). A fall on the lateral shoulder can result in a stress or tearing of the acromioclavicular (AC) ligaments resulting in a shoulder separation (not the same as dislocation, which involves the glenohumeral joint). Degenerative arthritis of the AC joint is often seen in patients >50 years of age. Adhesive capsulitis (B), also known as a frozen shoulder, is usually the result from prolonged immobility due to another shoulder injury. It leads to loss of both active and passive motion of the shoulder that usually resolves over a period of 6 months to 2 years. Glenohumeral joint dislocation (C) usually occurs as a result of trauma or from extreme abduction and external rotation (serving a volleyball). On exam, there is often a defect seen at the glenohumeral joint.

A 12-year-old obese boy presents with groin and proximal anterior thigh pain. He has no pain below the knee. Physical examination shows a significant decrease in internal rotation of the affected hip. Radiographs show a widened growth plate. Which of the following is the most likely diagnosis? A) Acute transient synovitis B) Legg-Calve-Perthes disease C) Osgood-Schlatter disease D) Slipped capital femoral epiphysis

Correct Answer D) Slipped capital femoral epiphysis Explanation: Atraumatic pediatric hip pain or limp is usually caused by acute transient synovitis, Legg-Calve-Perthes disease or slipped capital femoral epiphysis (SCFE). SCFE is a fracture in the physis (growth plate) of the femoral head which leads to slippage of the overlying epiphysis. It usually occurs during adolescent growth spurts. Predisposing factors include male sex, obesity and increased sports activities. The typical age range is 10-14 years for girls and 11-16 years for boys. Patients present with pain in the anterior proximal knee or thigh that is exacerbated by activity. On exam, there is loss of hip internal rotation, particularly with the hip flexed. Patients typically walk with the involved extremity externally rotated. AP and frog-leg radiographs show "ice cream falling off the cone." All cases warrant urgent orthopedic evaluation for stabilization surgery. Patients should be nonweight bearing and restricted to bed rest until then. Complications of untreated disease include chondrolysis and osteonecrosis. Acute transient synovitis (A) is considered the most common cause of childhood hip pain or limp. It is most common in boys aged 3-6 years. Radiographs are normal. Treatment includes NSAIDs and relative rest. Legg-Calve-Perthes (B) disease is avascular osteonecrosis of the femoral head. It occurs more commonly in boys aged 4-10 years. Radiographs show a small, sclerosed femoral head and widened joint space. Osgood-Schlatter (C) disease is a common adolescent condition in those active in sports. Repeated microtrauma occurs at the apophyseal cartilage between the anterior tibial tubercle and the secondary ossification center of the patellar tendon. These patients present with anteroinferior knee or superior shin pain and tender tibial tuberosities.

A 62-year-old woman presents complaining of ankle pain following a fall from slipping on ice last night. She is able to walk across the emergency department and back but states that the pain becomes unbearable toward the end. Her posterior lateral malleolus and her anterior medial malleolus are tender to palpation. Which of the following is the correct indication for ankle radiography in this patient? A) Age B) Inability to bear weight after six steps C) Tenderness over the anterior medial malleolus D) Tenderness over the posterior lateral malleolus

Correct Answer D) Tenderness over the posterior lateral malleolus Explanation: The Ottawa Ankle Rule is a clinical decision-making rule that was developed to allow clinicians to effectively select patients who are candidates for ankle radiography after acute ankle trauma. It consists of five criteria: tenderness over the posterior lateral malleolus, tenderness over the posterior medial malleolus, tenderness over the navicular bone, tenderness over the base of the fifth metatarsal, and inability to bear weight for four steps. If any one of the criteria is present, the patient is a candidate for plain films of the ankle. Age (A) is not a criterion for ankle radiography according to the Ottawa Ankle Rule, although an age of 55 years or greater is a criterion for knee radiography according to the Ottawa Knee Rule. Inability to bear weight after six steps (B) and tenderness over the anterior medial malleolus (C) are not criteria included in the Ottawa Ankle Rule.