Patho MSK questions

what stage of impingement syndrome do you see tendon degeneration?

3rd

what are pseudogout crystals made of?

Calcium pyrophospate

absent patellar reflex?

L4

A 55-year-old woman has been complaining of pain and swelling in several fingers of both hands for the past 2 months. She describes morning stiffness lasting 30 minutes. Her mother tells her that she had a similar condition at the same age. She denies any other joint pain or swelling. On exam, she has tenderness, slight erythema, and swelling in one PIP joint and two DIP joints in each hand. She has squaring at the base of her right thumb (the first carpometacarpal joint). There is no swelling or tenderness in her MCP joints.

Osteoarthritis

Osteoarthritis: PIP nodule? DIP nodule?

PIP = bouchard DIP = heberden

name an AI and a ricket Bourne dz associated w/ GH arthritis?

RA Lyme

• Foot and digit plantarflexion and inversion name that nerve?

Tibial nerve (L4-S2)

which injury often occurs with RCT?

bicep tendonitis

3 m/c sites to find an osteosarcoma?

distal femur proximal humerus proximal tibia

gout vs pseudo gout?

gout = sharp crystals pseudo = blunt crystals

posterolateral humeral head fx?

hill Sachs lesion

m/c cause of osteomalacia in the western world

lack of sun

what are gout crystals made of?

mono urate

Neal is a 31 yo female weight lifter w/ initial pain upon starting the workout. Dx?

osteolysis

carpal bones on the ulnar aspect of the wrist?

pisiform and hamate hook

holstein lewis Fx. nerve?

radial

what type of osteoporosis is secondary?

senile

A 24-year-old man presents to the emergency room after a fall onto his shoulder while playing football. He is an otherwise healthy man who has had no prior shoulder problems. The patient is unable to actively abduct or flex his arm secondary to pain. He is maintaining his arm in a position of slight external rotation and abduction. There is a palpable prominence inferior to his coracoid process. Sensation in his axillary nerve distribution is intact with a normal neurovascular exam.

shoulder (GH) dislocation

spondilo..... break in vertebrae?

spondilolysis

Osgood-Schlatter lesion more common in?

teenage boy

what muscles retract scapula?

traps and rhomboid

what muscle rotate scapula upward?

traps and serratus

what muscles support posture?

upper traps and levator scapula

A 20-year-old female basketball player lands awkwardly from a rebound, feels a sudden painful pop in her right knee, and falls to the ground. She is unable to return to play and feels that her knee keeps giving out when she tries to bear weight. She reports that her knee became very swollen within 1 or 2 hours after the injury.

ACL

A 30-year-old football player was injured when his left knee was rolled into accidentally by a teammate. The patient felt the knee hyperextend, bend inward, and pop. He was unable to keep playing and complained that his knee felt like it kept twisting. The knee swelled moderately over the next few hours.

ACL

A 17-year-old boy presents with an 18-month history of pain in his right ankle and both heels, with early morning stiffness and fatigue. He was forced to give up sports, and walking short distances is proving difficult due to heel pain. Examination reveals marked tenderness and swelling over bilateral Achilles tendons.

Ankylosing spondylitis

A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is a very avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms. He has to get up regularly and move around. His back symptoms also wake him in the second half of the night, after which he can find it difficult to get comfortable. He normally takes an anti-inflammatory drug during the day, and finds his stiffness is worse when he misses a dose. He has had 2 bouts of iritis in the past.

Ankylosing spondylitis

Pain in groin Weight bearing pain SLR painful Dx?

Avascular necrosis of the femoral head

• Hip flexion • Knee extension name that nerve?

Femoral nerve L2-L4

• Foot inversion/eversion and dorsiflexion • Foot drop name that nerve?

Fibular nerve

varus stress, ligament injury?

LCL

A 21-year-old rugby player was tackled on the lateral side of his left lower thigh. During the course of the tackle, the player felt a tearing sensation on the medial part of his knee that was associated with excruciating pain. Immediately after the play, he was unable to get up or walk. On physical exam, there is significant tenderness of the adductor tubercle and joint line. Valgus stress testing (abduction stress test) image demonstrates some medial instability at 30° of knee flexion, but with a firm endpoint (i.e., resistance is felt). Anterior drawer test image and Lachman test image are negative.

MCL

• Hip adduction name that nerve?

Obturator nerve (L2-L4)

A 13-year-old male basketball player presents with several months of insidious onset of unilateral anterior knee pain, worse during practice and games, and alleviated by rest, ice, and anti-inflammatory medications. Physical examination demonstrates prominence of the tibial tubercle, with mild swelling and tenderness to palpation over the tubercle. image Resisted knee extension also causes pain.

Osgood-Schlatter lesion

A 60-year-old woman presents complaining of bilateral knee pain on most days of the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs. She complains of stiffness in the morning that lasts for a few minutes and a buckling sensation at times in the right knee. On exam, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favoring the right side.

Osteoarthritis

A 55-year-old man complains of persistently aching legs. He is initially diagnosed with fibromyalgia. However, his blood tests reveal an elevated serum alkaline phosphatase. Subsequent x-ray of the tibia/fibia shows defects in the cortical and cancellous bone, with some degree of tibial bowing.

Paget dz

A late middle-aged woman presents with chronic right hip and anterior thigh pain, with increased localized temperature. Lately, she has needed a cane for walking. During the last 6 months her relatives have noticed a progressive hearing loss on her left side, as well as some facial changes - mostly enlargement of her mandible.

Paget dz

A 58-year-old woman presents with a 2-week history of fatigue, anorexia, fevers, and bilateral pain and stiffness in the shoulder and hip girdles. These symptoms are worse at night. Upon awakening in the morning, she feels as if she has a bad flu. She reports difficulty getting out of bed in the morning due to stiffness. Her wrists and finger joints are also painful and swollen.

Polymyalgia rheumatica

A 21-year-old male college student presents with a 4-week history of a painful, hot, and swollen left knee, low back pain with bilateral buttock pain, and left heel pain. He denies trauma and states the symptoms began acutely. He denies any fever or any other significant arthralgias. Further review of symptoms indicates the patient was treated for a chlamydia infection after he developed dysuria approximately 8 weeks ago (he was treated with a single dose of 1-g azithromycin). He admits to unprotected sexual intercourse with a new partner 2 days before the onset of his dysuria. In addition to pain and swelling, the patient reports that he has developed morning stiffness in the left knee and low back that last more than 1 hour. He continues to have episodes of dysuria. The findings of physical examination are significant for a large effusion of the left knee with warmth. Range of motion is slightly diminished. There is tenderness to palpation of the left heel at the site of the Achilles' insertion. Laboratory findings are significant for an ESR of 35 mm/hour, and both a CBC and uric acid level are within normal limits. He is HLA-B27 positive, rheumatoid factor negative, and ANA negative. The synovial fluid analysis is negative for crystals, with a total nucleated cell count of 22,000 cells/microliter (65% neutrophils). A urethral swab was positive by PCR for Chlamydia trachomatis 9 weeks ago at initial presentation of dysuria. There was no evidence of gram-negative diplococci on Gram stain.

Reactive arthritis

A 52-year-old woman presents with a 2-month history of bilateral hand and wrist pain, and swelling in her fingers. She has also recently noted similar pain in the balls of her feet. She finds it hard to get going in the morning and feels stiff for hours after waking up. She also complains of increasing fatigue and is unable to turn on and off faucets or use a keyboard at work without a significant amount of pain in her hands. She denies any infections before or since her symptoms started.

Rheumatoid arthritis

A 57-year-old woman who is typically sedentary presents complaining of shoulder pain after a trip and fall onto her outstretched hand. She has no prior history of shoulder injuries. She has pain on the lateral aspect of her shoulder and weakness with external rotation and forward elevation.

Rotator Cuff tear

A right-handed 65-year-old man presents after painting a room in his house. He complains of pain in his right shoulder, which worsens with overhead lifting, and some night pain since the onset of symptoms. He has no past history of shoulder problems and no other medical conditions. He has no neurologic symptoms and does not complain of weakness.

Rotator Cuff tear

absent achilles reflex?

S1

which shoulder injury is consistent w/ a MVA?

SC joint

carpal bones on the radial aspect of the wrist?

Scaphoid and trapezium

• Hip extension • Knee flexion/rotation name that nerve?

Sciatica nerve (L4-S3)

A 45-year-old woman presents with fatigue and a history of positive antinuclear antibodies. She has had recurrent sensation of sand/gravel in eyes and dry mouth every day for more than 3 months.

Sjogren syndrome

where do pts present w/ parotid gland enlargement?

Sjogren syndrome

A 13-year-old African-American boy presents with hip, groin, thigh, and medial knee pain. He is overweight and recently experienced an adolescent growth spurt. On physical exam, the affected leg is externally rotated and there is limited range of motion in the hip joint. He is unable to bear weight on the affected leg.

Slipped capital femoral epiphysis

• Gluteus medius and minimus • Hip abduction name that nerve?

Superior gluteal nerve (L4-S1)

2 common causes of Avascular necrosis of the femoral head?

alcohol High dose steroids

A 50-year-old woman presents with numbness and tingling in her hands. The symptoms are worse in her right (dominant) hand and with activities such as holding a book or a steering wheel, or brushing her hair. The discomfort in her hands frequently wakes her at night and she has to shake or hang her hand out of her bed for relief.

carpal tunnel syndrome

thenar wasting, + tinnel, + phalen?

carpal tunnel syndrome

A 25-year-old man presents to the emergency room after an automobile accident. He was ejected from the vehicle. He complains of numbness in both lower extremities and cannot move his legs. There is no pinprick sensation below the umbilicus except for an anal wink, and there is no rectal tone. The bulbocavernosus reflex is weakly present.

cauda equina syndrome

A 40-year-old woman presents with back pain and difficulty with her gait. She has a long history of smoking and has had some hemoptysis recently. Her exam reveals diminished pinprick sensation from the nipple line caudally, power in the lower extremities of 4/5, absent joint position sense in the lower extremities, and diminished vibratory sense. Anal sphincter tone is intact.

cauda equina syndrome

pt has leg weakness, bladder distension and saddle numbness?

cauda equina syndrome

Reactive arthritis triad:

conjunctivitis urethritis arthritis

herniated disc, what happens with... extension: flexion:

extension: ease flexion: pain

A 38-year-old woman sees her physician with 4 years of widespread body pain. The pain began after a motor vehicle accident and was initially limited to her neck. Gradually, the pain has spread and she now complains of hurting all over, all the time. She does not have any joint swelling or systemic symptoms. She does not sleep well and has fatigue. She has irritable bowel syndrome but is otherwise healthy. Physical exam reveals a well-appearing woman with normal musculoskeletal exam, except for the presence of tenderness in 12 out of 18 fibromyalgia tender points. Routine laboratory testing is normal.

fibromyalgia

A 50-year-old woman with diabetes presents with a 2-month history of insidious onset right shoulder pain. She denies a history of shoulder trauma. She has no history of neck pain, arm/hand weakness, or numbness or paresthesias of the arms/hands. She complains of shoulder pain at extremes of range of motion and has difficulty sleeping on the affected side. She has noticed increasing difficulty with activities of daily living, including brushing her hair, as well as putting on or taking off her blouse and brassiere. Her exam shows a marked decrease in both active and passive range of motion of the right shoulder; with forward flexion (FF) to 75°, abduction (ABD) to 75°, external rotation (ER) to 15°, and internal rotation (IR) to the iliac crest with pain at extremes of motion. Rotator cuff strength is normal.

frozen shoulder

A 65-year-old man presents for follow-up 6 months after a mild acromioclavicular sprain that occurred after falling directly onto the left shoulder. He was treated with sling immobilization for 2 weeks. His acromioclavicular joint pain has completely resolved, but he now complains of shoulder stiffness. He is a construction worker and has noticed difficulty reaching overhead to perform his job over the past several months. Exam shows that he has no tenderness to palpation of the acromioclavicular joint, and has a negative cross arm adduction test. He is severely limited in his range of motion, with FF to 100°, ABD to 80°, ER to 10°, and IR to the iliac crest.

frozen shoulder

A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had ("even covering my foot with the bed sheet hurts"). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot.

gout

An 85-year-old man presents with several days of swelling and severe pain in both hands limiting his ability to use his walker. He has a history of gout but has not experienced these symptoms before. On examination, he has a temperature of 100.1°F (37.8°C). There is diffuse warmth, mild erythema, and pitting edema over the dorsum of both hands. There is tenderness and limited hand grip bilaterally. There are multiple nodules around several of the proximal interphalangeal and distal interphalangeal joints, and effusion and tenderness in his left olecranon bursa with palpable nodules.

gout

• Gluteus maximus • Hip extension name that nerve?

inferior gluteal nerve (L5-S2)

A 20-year-old soccer player twists his right knee while playing the game. He immediately feels the knee swell. He continues to play the soccer game that day despite experiencing intermittent pain. He reports that the knee catches and locks intermittently. On examination the right knee joint is swollen with tenderness along the affected joint line.

meniscal tear

A 60-year-old woman recently felt a catch in her left knee when getting out of the car. She reports that, since then, her left knee has been aching when she walks several blocks or is sitting in a movie theater. She says that the knee catches, and she has intermittent swelling behind the knee. On inspection of the knee, a popliteal (Baker) cyst is noted at the posterior aspect of the knee joint. Further examination reveals positive McMurray and Apley tests.

meniscal tear

A 72-year-old man is evaluated for increasing fatigue and bone pain. His medical history is significant for chronic alcoholism, lactose intolerance, and a vertebral compression fracture 1 year ago. He is housebound without any sunlight exposure. He denies any personal or family history of kidney stones, fractures, or osteoporosis. His physical exam is remarkable for generalized tenderness of the long bones and proximal muscle weakness, with difficulty climbing stairs and a waddling gait.

osteomalacia

A 70-year-old man, 6 months after renal transplantation and on corticosteroid treatment, presents with severe back pain. X-ray evaluation of the thoracic and lumbar spine discloses evidence of multiple vertebral compression fractures.

osteoporosis

A 70-year-old woman presents to the emergency department after falling while getting out of bed. She sustained an intertrochanteric fracture of the right hip. Preoperative CXR evaluation before repair of the hip reveals that she had existing asymptomatic vertebral fractures before her fall.

osteoporosis

A 42-year-old woman presents with progressive muscular weakness and recurrent facial edema. The edema started 3 months ago and worsened to the point that she was unable to open her mouth or eyes. Concomitant to her facial rash, she experiences intermittent difficulty swallowing. Her weakness results in an inability to rise from a chair or ascend stairs. Skin examination demonstrates blue-purple discoloration on the upper eyelids with edema. Her muscle strength is 3/5 on bilateral hip flexion and 3/5 on bilateral shoulder abduction. The rest of the neurologic exam is normal.

polymyositis

A 57-year-old man presents with a 5-year history of slowly progressive leg weakness. Recently he has had multiple falls and experiences difficulties with fine tasks using his hands. Neurologic exam shows atrophy of iliopsoas, quadriceps, and finger flexors bilaterally. Manual muscle strength test finds predominant weakness in finger/wrist flexors compared with finger/wrist extensors. Additionally, it demonstrates neck flexion 3/5, neck extension 4/5, arm abduction 4/5, forearm flexion 4/5, hip extension 3/5, hip flexion 2/5, knee extension 2/5, knee flexion 2/5, ankle dorsiflexion 4/5, and ankle plantar flexion 5/5. The rest of the neurologic exam is unremarkable except for reduced patellar reflexes.

polymyositis

A 65-year-old man presents with acute pain and swelling in the left leg for the past 3 days. The pain is localized in the posteromedial calf and worsens during standing and walking. There are no known risk factors for DVT, a history of previous DVT, or trauma. Past medical history is significant for hypertension and osteoarthritis of both knees. Medications include metoprolol and NSAIDs. Physical exam reveals a normal vascular exam, absent leg edema, calf tenderness, and a prominent nonpulsatile mass behind the knee. Duplex ultrasound identifies a cyst in the popliteal crease measuring 4 cm x 5 cm.

popliteal cyst

what cord does the axillary nerve branch from?

posterior cord

A 72-year-old woman presents with polyarticular joint pain. She has longstanding mild joint pain, but over the last 10 years notes increasing discomfort in her wrists, shoulders, knees, and ankles. She has had several recent episodes of severe pain in 1 or 2 joints, associated with swelling and warmth of the affected areas. These episodes often last 3 to 4 weeks. Her exam shows severe bony changes consistent with osteoarthritis in many joints, and slight swelling, warmth, and tenderness without erythema in the second and third MCP joints, left shoulder, and right wrist.

pseudogout

An 80-year-old man presents with a swollen red wrist, fever, and chills. He recalls falling out of his wheelchair several days ago but seemed well until 24 hours before admission, when he developed pain in his right wrist. His daughter noted fever and some confusion and brought him to the hospital. On exam, he appears ill and has fever to 102ºF (39ºC). There is swelling, tenderness, and redness around the right wrist with edema over the dorsum of the hand.

pseudogout

A 65-year-old retired construction worker has had lower back pain for 3 years. For the past 12 months he has been experiencing bilateral leg pain and a sense of heaviness in the legs when he is walking. The pain is relieved by bending over or sitting down. Over the past few months the distance he is able to walk has become progressively shorter and he has assumed a stooped posture. Physical exam is essentially unremarkable. Distal pulses are palpable and there is no appreciable weakness or muscle atrophy in the legs, or findings of hip or knee pathology.

spinal stenosis

A 23-year-old man presents with swelling and pain in his left arm after strenuous exercising with upper extremity lever weights. Symptoms started 75 minutes after the exercises. The arm turned reddish, and he described it as "feeling different than it ever had before". He has Raynaud phenomenon with marked cold sensitivity and writing increases his symptoms. No supraclavicular tenderness is present. He has a venous collateral over his left shoulder. He has a 4+ bilateral Adson sign and a 4+ Roos test on the left with mild anterior deltoid pain in 5 seconds. His grip is 4 out of 5 bilaterally and his interossi are 4 out of 5 bilaterally. Doppler ultrasonography of the left upper extremity demonstrated a clot in his left subclavian vein. The diagnosis of venous TOS (Paget-Schroetter syndrome) was confirmed.

thoracic outlet syndrome

A 30-year-old right-handed woman presents complaining of pain in the right side of her neck, shoulder, arm, hand, chest, and somewhat down her back. She describes her pain as dull and aching. She works as a computer operator and first noticed symptoms about 2 years ago. Along with the pain, she has developed severe numbness in her right arm and hand, which frequently wakes her at night. She notices she drops things and has marked difficulty working over her head. Common household tasks have become very difficult for her (e.g., vacuuming, sweeping, mopping). Cold exacerbates her symptoms. She has previously had 2 courses of physical therapy without improvement of her symptoms. Physical exam reveals 3+ supraclavicular tenderness on the right. She has a positive Adson sign on the right and a positive Roos test on the right in 5 seconds. Atrophy of the thenar eminence is noted in her right hand. Her grip is 2 out of 5 on the right, with a 1 out of 5 interossi on the right. Her ulnar conduction velocity on the right side is 40 m/second and on the left side is 55 m/second. Her median conduction velocity on the right side is 43 m/second and 58 m/second on the left side.

thoracic outlet syndrome