Ortho Rosh Review exam 3
Which of the following maneuvers tests the meniscus of the knee? Anterior drawer test Lachman test McMurray test Posterior drawer test
Correct Answer ( C ) Explanation: Meniscal injuries occur frequently in patients with sudden rotary or extension-flexion motions. The menisci have no sensory nerve fibers, and the pain that results after these injuries is from irritation of the ligaments near the joint line. Several symptoms suggest the presence of a meniscal tear including: joint line pain, joint effusion, locking, and giving way of the knee. The McMurray test is performed with the patient supine and the hip and knee flexed. To check the medial meniscus, the examiner palpates the posteromedial joint line with one hand while the other hand grasps the foot. The leg is externally rotated to trap the medial meniscus, and the knee is slowly extended. Conversely, the lateral meniscus is examined with the clinician palpating the posterolateral joint line while internally rotating the leg. A painful click, popping, or thud felt in early extension is considered abnormal. It is 53% sensitive for a meniscal injury. The Anterior Drawer (A) and Lachman tests (B) are used to assess anterior cruciate ligament (ACL) instability.
A 70-year-old woman presents to clinic complaining of a dull, aching pain in her right knee that has been gradually worsening over the past two years. This pain was previously controlled with ibuprofen, but now her pain has started to limit her daily activities. What is the next best step in her treatment? Acetaminophen Glucosamine and chondroitin Intra-articular injection of cortisone with lidocaine Total knee arthroplasty
Correct Answer ( C ) Explanation: Osteoarthritis is a common malady that affects over 26.9 million Americans, and is one of the most common causes of long-term disability in the United States. There are varied risk factors for developing osteoarthritis including age, mechanical stress, and metabolic disorders such as ochronosis. Initial pharmacologic therapy consists of oral analgesics, such as acetaminophen or NSAIDs, but neither are recommended for long-term use. Steroid injections have been found to provide more long-term relief than oral therapies, and may be repeated up to every three months. More frequent injections of steroids can further exacerbate joint degeneration. The correct technique involves inserting the needle between the patella and femoral condyles with either a medial or lateral approach. The use of a local anesthetic (e.g. lidocaine) along with cortisone aids patient tolerance of the pain associated with intra-articular injection, and provides temporary pain relief while the steroid takes effect. For this patient who has failed oral therapy, an intra-articular injection of cortisone and lidocaine into the knee joint is recommended.
A runner presents with recurrent anterior knee pain. She reports a "popping" sensation followed by severe pain. These episodes are brief because the pain resolves once she moves her "kneecap back into position". In the initial evaluation of this patient, a radiologic order would most likely include which of the following views? Frogleg view Grashey view Sunrise view Swimmer's view
Correct Answer ( C ) Explanation: Patellofemoral instability is the transient displacement (usually laterally) of the patella, either partially (subluxation) or completely (dislocation), causing acute or chronic patellar pain. It is associated with a positive apprehension sign when displacing the patella laterally. Diagnosis necessitates AP, lateral, tunnel and axial views. The axial view, also commonly called the sunrise view, allows the clinician a direct visualization of how the patella sits in the femoral trochlear groove. Normally, the "train is on the tracks", in other words, the patella sits equidistantly between the femoral condyles. In patients with malalignment or instability, the "train is off the tracks", showing the patella riding, most commonly, over the lateral femoral condyle, outside of the trochlear groove. Acute cases are treated with rest, icing, splinting and compression, but may also require manual reduction. Chronic recurrent cases require aggressive physical therapy and intermittent bracing. The frogleg lateral view (A) is used in evaluating the hip, not the knee. The Grashey view (B) is used in evaluating the glenohumeral joint, not the knee. A swimmer's view (D) is used to evaluate the cervicothoracic junction, not the knee.
Which of the following is a risk factor for an Achilles tendon rupture? Age older than 60 years Diabetes Fluoroquinolone usage Steroid taper
Correct Answer ( C ) Explanation: Rupture of the Achilles tendon is relatively common. It is most common in men between the ages 30 and 50 years who participate in recreational sports—the weekend warrior. However, it can occur in serious athletes. Exogenous risk factors include chronic corticosteroid usage and fluoroquinolone usage.
An 18-year-old girl presents to the ED with left ankle pain. Earlier in the day she was playing softball and slid into second base and "twisted her ankle." On exam, you note moderate swelling, tenderness, and pain with passive range of motion of the ankle. You do note some abnormal motion when stressing the joint. Which of the following is the most likely diagnosis? First-degree sprain First-degree strain Second-degree sprain Second-degree strain
Correct Answer ( C ) Explanation: Sprains are classified as ligamentous injuries resulting from an abnormal motion of a joint. In such cases, there is injury to the ligamentous fibers of a supporting joint. Sprains are graded according to the severity of pathologic findings; however, clinically the grades are often indistinct. A second-degree sprain is a partial tear of a ligament (more than first-degree). Clinically, there will be moderate hemorrhage and swelling, tenderness, painful motion, abnormal motion, and loss of function. Although there may be some laxity with stressing of the joint, an absence of end points will be seen only with complete ligament rupture (i.e., third-degree sprains).
Which of the following best classifies this fracture? Salter-Harris Type I Salter-Harris Type II Salter-Harris Type III Salter-Harris Type IV
Correct Answer ( C ) Explanation: The Salter-Harris classification of fractures describe pediatric fractures through the growth plate. These fractures are classified according to the involvement of the physis, metaphysis, or epiphysis. The classification of the injuries is important, because it affects the treatment and prognosis for the patient. The radiograph above demonstrates a Salter-Harris Type 3 fracture. This is defined by a fracture involving the physis (growth plate) and epiphysis. The fracture passes through the hypertrophic layer of the physis and extends to split the epiphysis. Because it crosses the physis and extends into the articular surface of the bone, Salter-Harris Type III fractures put the patient at risk for chronic disability. Rarely does significant deformity occur and the overall prognosis is favorable. Definitive treatment for Type III fractures is surgical.
What is the most appropriate first line treatment for plantar fasciitis? Corticosteroid injection Extracorpeal shock wave ultrasound NSAIDs Surgical therapy
Correct Answer ( C ) Explanation: The plantar fascia is a tough layer of the sole that is functionally significant during foot strike and the early stance phase of walking. Plantar fasciitis is an overuse injury of insidious onset that usually begins with pain on first weight bearing in the morning or after prolonged sitting. This progresses to persistent pain during gait. Pain and tenderness are localized to the medial aspect of the heel. Plain radiography is not diagnostic but shows a calcaneal spur in 50% of patients with plantar fasciitis. NSAIDs are considered first line treatment, along with rest, ice, and shoe inserts
A 45-year-old woman presents to your office with right knee pain. She was playing volleyball yesterday when she collided with another player and was unable to continue playing. The knee was swollen this morning. She is able to walk but it is painful, and she also has pain when she attempts to bend her knee. On examination you have the patient stand flat footed on her right leg while you provide your shoulder for balance. You have her then flex her right knee to 20 degrees and rotate the femur on the tibia medially and laterally. This motion causes significant pain for the patient. You also note medial joint line tenderness. Which one of the following is the most likely cause of her knee pain? Anterior cruciate ligament tear Collateral ligament tear Medial meniscus tear Tibial plateau fracture
Correct Answer ( C ) Explanation: A medial meniscus tear is the most likely diagnosis in a patient older than 40 years of age who was bearing weight when the injury occurred, was unable to continue the activity, and has a positive Thessaly test. This test is performed by having the patient stand on one leg and flex the knee to 20°, then internally and externally rotate the knee. Meniscus tears typically occur as a result of twisting or change of position of the weight-bearing knee in varying degrees of flexion or extension. The presence of swelling due to an effusion is commonly seen immediately after the injury. Pain from meniscus injuries is commonly intermittent and usually the result of synovitis or abnormal motion of the unstable meniscus fragment. The pain is usually localized to the joint line. Magnetic resonance imaging is the criterion standard imaging study for imaging meniscus pathology and all intra-articular disorders. Most meniscal tears do not heal without intervention. If conservative treatment does not allow the patient to resume desired activities, his or her occupation, or a sport, surgical treatment is considered. Surgical treatment of symptomatic meniscal tears is recommended because untreated tears may increase in size and may abrade articular cartilage. Tibial plateau fractures (D) are caused by a varus or valgus force combined with a weight bearing force on the knee. The classically described situation in which this occurs is from a car striking a pedestrian's fixed knee known as a "bumper fracture". This patient is able to bear weight, so a fracture is not likely.
Rapid Review Achilles Tendon Rupture
Achilles Tendon Rupture Patient will be a deconditioned athlete With a history of fluoroquinolone use Complaining of "pop" or "snap" and sudden pain in the calf area PE will show absent plantarflexion upon calf squeeze (Thompson test) Treatment is posterior splint in plantarflexion, orthopedic consult
Rapid Review Ankle Fractures
Ankle Fractures Single malleolar: either distal fibula or tibia Bimalleolar: distal fibula + tibia Trimalleolar: bimalleolar fracture + posterior tibial involvement Rx: possible ORIF if unstable
Rapid Review Ankle Sprain
Ankle Sprain Partial or complete tearing of ≥ 1 ligaments MC due to inversion mechanism MC sprained: anterior talofibular ligament (ATFL) Grade I: microscopic tear, grade II: incomplete tear, grade III: complete tear RICE
Rapid Review Ankle Sprain
Ankle Sprain Partial or complete tearing of ≥ 1 ligaments MC due to inversion mechanism MC sprained: anterior talofibular ligament (ATFL) Grade I: microscopic tear, grade II: incomplete tear, grade III: complete tear RICE Grade I (A) is characterized by mild stretching and microscopic tears of the ligament. Mild swelling and tenderness is noted with no joint instability. The patient is able to bear weight and ambulate with minimal pain. Due to their benign nature, these injuries are not frequently seen in the healthcare setting. Grade III (C) is characterized by a complete tear of the ligament. Severe pain, swelling, tenderness and ecchymosis is noted with significant joint instability. There is significant loss of range and function and the patient cannot bear weight or ambulate. There is no Grade IV (D) ankle sprain Grade II ankle sprain (incomplete tear) characterized by moderate pain, swelling, tenderness and ecchymosis with mild to moderate joint instability and some loss of range and function. Typically these are painful with weight bearing.
Rapid Review Ankle Sprain
Ankle Sprain Partial or complete tearing of ≥ 1 ligaments Most often due to inversion mechanism Anterior talofibular ligament (ATFL) most commonly sprained Grade I: microscopic tear, Grade II: incomplete tear, Grade III: complete tear RICE
One Step Further Question: What is Ewing sarcoma?
Answer: A marrow malignancy, common in the second decade, that causes lysis and osteomyelitis.
One Step Further Question: What is the most common cause of an acute hemarthrosis after a sports-related knee injury?
Answer: ACL tear.
One Step Further Question: What antibiotic is first-line therapy for human bite infection prophylaxis?
Answer: Amoxicillin-clavulanate.
One Step Further 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.
One Step Further Question: Which two anatomic compartments are the most affected in acute compartment syndrome?
Answer: Anterior compartment of the leg and the volar compartment of the forearm.
One Step Further Question: What is the most common injury associated with traumatic hemarthrosis of the knee joint?
Answer: Anterior cruciate ligament (ACL) rupture.
One Step Further Question: Which anatomical structures are involved in the "unhappy triad"?
Answer: Anterior cruciate ligament, medial meniscus and medial collateral ligaments.
One Step Further Question: If a patient has ankle instability, what physical exam tests should be positive?
Answer: Anterior drawer test and talar tilt test
One Step Further Question: In what age group are physeal injuries most common?
Answer: Boys aged 12-15 and girls aged 9-12.
One Step Further Question: What are the indications for non-operative management of a complete ACL tear?
Answer: Bracing and lifestyle modifications should be considered in adult patients with a complete tear if their daily activities do not involve jumping, cutting, or heavy manual labor.
One Step Further Question: Which type of foot anomaly is plantar fasciitis common in?
Answer: Cavus feet.
One Step Further Question: What is cauda equina syndrome?
Answer: Damage to the cauda equina causes loss of function of the lumbar plexus (nerve roots) of the spinal canal below the termination (conus medullaris) of the spinal cord.
One Step Further Question: What physical exam finding is a contraindication to manual reduction of a tibiofemoral dislocation?
Answer: Dimple sign.
One Step Further Question: What is the MRI finding which confirms a diagnosis of hip avascular necrosis?
Answer: Femoral head hypointensity (T1) and double-line signs (T2).
One Step Further Question: What is the treatment for a SLAP tear?
Answer: First-line treatment is usually non-operative management with nonsteroidal anti-inflammatory drugs and physical therapy, with consideration for surgery if the patient fails conservative treatment.
One Step Further Question: What class of antibiotics is associated with tendon rupture?
Answer: Fluoroquinolones. "FluoroquinoLONES hurt attachments to your BONES."
One Step Further Question: What is a Jones fracture?
Answer: Fracture of the proximal fifth metatarsal diaphysis.
One Step Further Question: Avascular necrosis is a complication of which traumatic hip injuries?
Answer: Hip dislocation or femoral neck fracture.
One Step Further Question: What imaging modality is the gold standard for diagnosing an anterior cruciate ligament injury?
Answer: MRI.
One Step Further Question: What concomitant knee injury should be evaluated for in patients with pes anserine bursitis?
Answer: Medial collateral ligament injury (strain or tear), due to its insertion site near the bursa.
One Step Further Question: What antibiotic can cause a disulfiram effect?
Answer: Metronidazole.
One Step Further Question: What birefringence is acute gout associated with?
Answer: Negative birefringence.
One Step Further Question: What is the most common radiographic finding for a Salter-Harris Type V fracture?
Answer: Norma
One Step Further Question: What are two common complications of untreated recurrent patellar instability?
Answer: Quadricep weakness and patellar arthrosis.
One Step Further Question: Which grading system is used to assess skeletal maturity?
Answer: Risser classification system.
One Step Further 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.
One Step Further Question: What is the most common infectious agent in acute osteomyelitis?
Answer: Staphylococcus aureus.
One Step Further Question: Which patellar pole is the most common site of osseous nonunion in bipartite patella?
Answer: Superolateral.
One Step Further Question: High ankle sprains involve a partial tear of which ligament?
Answer: Syndesmosis.
One Step Further Question: Examination of which structure is important in any suspected ankle fracture or injury?
Answer: The fibular head. External rotation forces at the ankle can cause a Maisonneuve fracture, a compilation of fibular head fracture, tear of the ankle's medial collateral ligament and disruption of the tibiofibular syndesmosis.
One Step Further Question: What is the prognosis for greater trochanteric pain syndrome?
Answer: The syndrome is generally self-limiting and resolves spontaneously.
One Step Further 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.
Rapid Review Anterior Cruciate Ligament (ACL) Tear
Anterior Cruciate Ligament (ACL) Tear Patient with a history of quickly stop moving and change direction while running Complaining of pop and swelling Diagnosis is made by Lachman's Test (most sensitive) and Anterior Drawer Test
Rapid Review Avascular Necrosis
Avascular Necrosis Causes: corticosteroids (most common), alcohol Most common site: femoral head MRI
Rapid Review Compartment Syndrome
Compartment Syndrome PE will show Paresthesias, Pallor, Pulselessness, Poikilothermia, Paralysis, and Pain out of proportion to exam (6 P's) Most commonly caused by tibia fracture If Delta pressure < 30 mm Hg treatment is fasciotomy Comments: Most common sites - forearm, lower leg. Pain is the first symptom.
Which of the following wounds is a potential candidate for primary closure? Facial laceration from a dog bite Laceration on sole of the foot after stepping on an unknown object in a stream Laceration over the metacarpal-phalangeal joint sustained during a fistfight Puncture wounds on the leg as a result of a dog bite
Correct Answer ( A ) Explanation: Although dog bite wounds are high risk for infectious complications, those that are cosmetically deforming are often closed primarily, especially on the face. Dog bites are high risk for infection from organisms commonly found in the dog's mouth, which include S. aureus, P. multocida, and S. viridans. Although controversy exists over management of animal bite wounds, generally it is agreed that wounds that are cosmetically deforming (including those on the face) should be repaired primarily. All bite wounds must be thoroughly irrigated and cleansed. Wounds on the extremities and that are not as cosmetically concerning are generally left open or loosely approximated.
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? Cyclobenzaprine Haloperidol Oxycontin Pregabalin
Correct Answer ( A ) 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.
A 55-year-old man presents with new and insidious onset groin pain that began 5 months ago. His medical history includes sickle cell anemia. He currently abuses alcohol. Examination reveals painful hip rotation and decreased range of motion. There is no midline pelvic pain with resisted hip adduction. Pelvic radiographs reveal mild subchondral sclerosis about the femoral head, but no joint space narrowing or osteophytosis. Which of the following is the most likely diagnosis? Avascular osteonecrosis Legg-Calve-Perthes disease Osteitis pubis Osteoarthritis
Correct Answer ( A ) Explanation: Osteonecrosis of the femoral head is usually caused by a traumatic disruption of its blood supply or poor circulation due to other diseases. It most commonly occurs bilaterally and in those aged 40-60 years. Risk factors include a history of hip dislocation or femoral fracture, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, chronic steroid or alcohol use, myeloproliferative disorders and sickle cell disease. Insidious onset of deep groin, hip or buttock pain predominates, however, acute presentations occur with acute collapse of the necrotic femoral head. Examination typically reveals antalgic gait and decreased and painful hip flexion, rotation and abduction. Radiographs early in the disease may be normal, or may reveal the earliest radiographical sign of this disease, subchondral femoral head sclerosis. MRI is necessary when the diagnosis is strongly suspected and the initial radiographs are normal or only positive for subchondral femoral head sclerosis. Pre-collapse treatment includes risk factor modification, physical therapy and pain management. Hip arthroplasty is typically reserved for function limiting head collapse. Secondary osteoarthritis is a common disease complication.
A 44-year-old man presents with insidious and atraumatic proximal lower leg pain. It is more tender during rest than exercise. It commonly occurs at night, and doesn't seem to improve with oral analgesics. Knee testing is negative for meniscal or ligamentous injury. A screening radiograph reveals no fracture, but does show a non-speckled calcified lesion within the proximal tibia. A bone scan shows no spine or pelvic lytic lesions. Which of the following is the most likely diagnosis? Chondrosarcoma Enchondroma Multiple myeloma Osteoid osteoma
Correct Answer ( A ) Explanation: Primary malignant bone tumors are rare and benign bone tumors are common. However, metastatic bone tumors are very common, and skeletal metastasis must be strongly considered in any patient over 40 years of age with any bony lesion. The most common bone tumors in those over 40 years of age are metastases, chondrosarcoma, fibrosarcoma and multiple myeloma. Constant deep achy pain, especially in the nighttime hours and not relieved by rest, is the main symptom of bone malignancy. Large benign tumors may present in a similar fashion. Mass is a less common presenting complaint, but may suggest a benign condition especially if it is nontender. Chondrosarcoma and fibrosarcoma are common bone malignancies in adult metaphyseal bones. Osteosarcoma also has a metaphyseal predilection, however, it occurs with lytic and blastic lesions in the second decade, with chondrosarcoma having calcified lesions and fibrosarcoma having lytic lesions. Radiographic examination is necessary. CT is best used in evaluating benign bone lesions. MRI is better for evaluating malignant bone lesions. Bone scans are used to detect other sites of skeletal lesions. A chest radiograph and CT are usually ordered if a malignant bone tumor is suspected. Routine laboratory testing is of limited use, however, in those over 40 years of age, consider urinalysis, urine and serum protein electrophoresis and PSA testing. Benign tumors may be observed or excised, while malignant tumors are excised and treated with chemotherapy and radiotherapy Enchondroma (B) is a benign cartilaginous tumor. It appears as speckled calcifications within the phalanges and metacarpals of young adults. Multiple myeloma (C) most commonly occurs in those over 40 years of age. Lytic lesions of the spine and pelvis are key findings. Osteoid osteoma (D) is a childhood and teenage benign bone lesion, commonly associated with night pain that is relieved with NSAIDs.
A 16-year-old girl presents to the clinic with complaints of left knee pain, instability and swelling after sustaining a twisting injury to the knee ten days ago during a soccer game. Which of the following physical exam findings would be most consistent with an anterior cruciate ligament tear? Positive Lachman test Positive McMurray test Positive posterior drawer Posterior sag sign
Correct Answer ( A ) Explanation: The Lachman test is performed with the patient supine. The knee is flexed to 20-30 degrees and an anterior force is placed on the tibia. The examiner looks for laxity or increased tibial translation compared to the contralateral knee. The Lachman test is described as grade 1 if there is 0 - 5 mm of anterior tibial translation, grade 2 if there is 6 - 10 mm of translation, or grade 3 if there is greater than 10 mm of translation. There is also a modifier for the presence or lack of an endpoint (i.e., A = good endpoint; B = no endpoint). Other physical exam tests that can be used to detect the presence of an anterior cruciate ligament (ACL) tear include the anterior drawer test and the pivot shift test. To perform the anterior drawer test, the knee is flexed to 90 degrees and an anterior force is placed on the tibia. Laxity or increased anterior tibial translation is a positive test. The pivot shift test is performed with the patient supine. The knee is extended and internally rotated. The examiner places a valgus stress on the knee and moves the knee from extension to flexion. The examiner will feel a clunk in the knee at approximately 20 - 30 degrees of flexion in an ACL-deficient patient as the tibia reduces from its subluxated position Both the posterior drawer test (C) and posterior sag sign (D) are used to assess the posterior cruciate ligament (PCL). For the posterior drawer test, the knee is flexed to 90 degrees and a posterior force is placed on the tibia. Laxity or posterior tibial translation is a positive test. To look for a posterior sag sign, the patient is examined in the supine position. The hip is flexed to 45 degrees and the knee is flexed to 90 degrees with the patient's foot on the exam table. Increased posterior translation of the tibia on the femur compared to the contralateral side, as a result of gravity, indicates a PCL injury.
Which of the following tests is the most accurate physical examination maneuver to identity an injury to the anterior cruciate ligament? Lachman's test McMurray's test Thompson test Valgus stress
Correct Answer ( A ) Explanation: The anterior cruciate ligament (ACL) is one of the four major ligaments of the knee (anterior cruciate, posterior cruciate, medial collateral, and lateral collateral). It provides anterior stability to the knee joint and is the most commonly injured ligament of the knee. The Lachman's test is the most accurate test for the ACL. In this test, the knee is flexed to 20 or 30 degrees and the thigh is stabilized. The tibia is then pulled anteriorly to look for abnormal excursion.
Which of the following fractures requires orthopedic referral? AFirst distal phalanx fracture without intra-articular involvement BFirst metatarsal fracture with 1 mm displacement CMidshaft fifth metatarsal midshaft with 1 mm displacement DSecond 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
Which of the following is a common cause of non-traumatic avascular necrosis of the hip? Cholecystitis Chronic corticosteroid use Chronic marijuana use Iron deficiency anemia
Correct Answer ( B ) Explanation: Although a specific causative disorder is not identified in 20% of the cases, known atraumatic causes include chronic corticosteroid therapy, chronic alcoholism, hemoglobinopathy (e.g., sickle cell anemia), and chronic pancreatitis. When a patient has an increasingly painful hip, buttock, thigh, or knee and no history of recent trauma, avascular necrosis (AVN) of the femoral head should be considered. AVN is bilateral in 40 to 80% of patients. It is common in relatively young patients, the mean age at diagnosis is 38 years. AVN also is an emerging complication associated with human immunodeficiency virus (HIV) infection. It is unclear whether the virus itself or the treatments are the pathogenic agents.
A 14-year-old girl sprained her ankle. She rates her pain 5/10. On examination, she has moderate tenderness and swelling with decreased range of motion secondary to pain. Although quite painful, she is able to ambulate. What is the grade of this ankle sprain? Grade I Grade II Grade III Grade IV
Correct Answer ( B ) Explanation: Ankle sprains are caused by partial or complete tearing of one or more ligaments that support the ankle joint. Injuries are most often due to an inversion mechanism, causing injury to the lateral ligaments. The anterior talofibular ligament (ATFL) is the first ligament to be injured, followed by the calcaneofibular ligament (CFL), and finally, in the most severe lateral sprains, the posterior talofibular ligament (PTFL). A syndesmotic ankle sprain (high ankle sprain) involves the ligaments that connect the tibia and fibula. Ankle sprains are graded I, II or III based on exam findings and functional loss. The patient in the above scenario has a Grade II ankle sprain (incomplete tear) characterized by moderate pain, swelling, tenderness and ecchymosis with mild to moderate joint instability and some loss of range and function. Typically these are painful with weight bearing.
A factory worker sustains a crush injury to his lower left leg. He has 9/10 sharp pain, distal pallor and paresthesias. The skin is intact but swollen. Minimal passive plantar flexion reproduces significant pain. Which of the following measurements are necessary to confirm a diagnosis? Ankle-brachial index and wedge pressure Diastolic blood pressure and intracompartmental pressure Mean arterial pressure and jugular venous distension Stroke volume and heart rate
Correct Answer ( B ) Explanation: Extremity compartments are bound by fascial planes and contain muscles, nerves and arteries. Acute compartment syndrome occurs when the vascular supply is unable to properly perfuse these structures. Cases are typically acute and traumatic, especially when long bones, such as the femur and tibia, fracture, or when there is a crush injury. Pathologically, injury causes intracompartmental pressure to build, which decreases venous outflow, which backs-up arterial inflow, which ultimately leads to ischemic necrosis in as little as 4 hours. Pain out of proportion to injury, distal paresthesias, distal paresis or paralysis and distal pallor are common presenting symptoms. A key physical finding is intolerable passive stretching of muscles about an injury site. Since necrosis is imminent if left untreated, suspected compartment syndrome needs immediate diagnosis and treatment. Compartment syndrome is confirmed when the diastolic blood pressure minus the intracompartmental pressure is ≤ 30 mm Hg or absolute compartment pressure > 30-40 mm Hg. Once confirmed, surgical fasciotomy of the compartment is essential for favorable prognosis. The wound is left open. Delayed closure or skin grafting is performed after edema has resolved
A track-and-field athlete presents to orthopedic clinic with insidious onset anterior knee pain. Examination reveals tenderness over the lateral patella. Which of the following radiographic findings suggests bipartite patella over patellar fracture? Narrowed patellofemoral joint space Rounded patellar fragment Sharply demarcated patellar fragment Soft tissue swelling indicative of hemarthrosis
Correct Answer ( B ) Explanation: Failure of secondary ossification in one or two of the patellar poles is called bipartite or tripartite patellae. The missing bone is replaced by thick fibrous tissue. This is mainly an asymptomatic condition, however, it may be a cause of anterior knee pain. Symptom onset is insidious and may occur after repeated knee stretching seen in jumping sports, or symptoms can arise after frank trauma. In either case, disruption of the fibrous band is causative. During examination, tenderness over the unfused fragment is frequently encountered. Knee effusion or hemarthrosis is usually absent. Its presence, however, suggests patellar fracture. Furthermore, the radiograph can differentiate a disrupted bipartite patella from a patellar fracture, in that a bipartite fragment has rounded edges, and a patellar fracture has sharp fragment edges. Activity modification, which may include knee immobilization and crutches, is the main treatment. This gives the fibrous disruption time to heal and strengthen. A narrowed patellofemoral joint space (A) suggests a decrease in patellar cartilage, as in patellofemoral syndrome or chondromalacia patellae. It does not help differentiate bipartite patella from patellar fracture. A patellar fragment with sharp edges (C), or one associated with soft tissue swelling indicative of hemarthrosis (D), suggests the acute bony disruption of patellar fracture and not the fibrous disruption of bipartite patella.
Which of the following describes a grade 3 ankle sprain? Complete ligamentous rupture with concomitant distal fibular fracture Complete ligamentous rupture with considerable swelling, pain, and significant laxity Partial tear with mild laxity and moderate pain, tenderness, and instability Partial tear without laxity and only mild edema
Correct Answer ( B ) Explanation: Grade 3 sprain is a complete rupture resulting in considerable swelling, increased pain, significant laxity, and often an unstable joint. Ankle sprain involves stretching or tearing of the ligaments of the ankle. There are three grades of ankle sprain as determined by the extent of ligamentous injury. This injury is a common cause of morbidity in the general population, and the ankle is the most commonly injured joint complex among athletes. Patients who play sports experience approximately one ankle sprain for every 1000 person-days of competition. It is estimated that more than 23,000 ankle sprains require medical care in the United States per day. Eighty-five percent of all ankle sprains occur on the lateral aspect of the ankle, involving the anterior talofibular ligament and calcaneofibular ligament
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? Bipartite patella Heterotopic ossification Increased density of the femoral condyles Pars interarticularis defect
Correct Answer ( B ) 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.
Which of the following antibiotics is associated with spontaneous tendon rupture? Amoxicillin Doxycycline Levofloxacin Sulfamethoxazole
Correct Answer ( C ) Explanation: Fluoroquinolone drugs, including levofloxacin, have been associated with spontaneous tendon ruptures. Fluroquinolones are a commonly prescribed antibiotic class. The class includes ciprofloxacin, moxifloxacin and levofloxacin. The fluoroquinolone class of drugs has a number of side effects, the most serious of which are prolongation of the QTc and spontaneous tendon rupture. Tendon rupture appears to be more common in older patients. The overall risk is between 0.1 - 0.4%. These drugs are discouraged for use in pregnant women and children secondary to their effect on cartilage.
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? Fibulotalar Metatarsophalangeal Tarsometatarsal Tibiotalar
Correct Answer ( C ) 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.
An 8-year-old boy was playing in his father's garden-shed and stepped on a nail. At that time, his father cleansed and dressed the wound appropriately. However, seven days later, the boy presents with difficulty walking. Examination shows a lateral sole puncture wound that is associated with surrounding warmth, erythema and edema. He also has an antalgic gait. Distal neurovascular examination is normal. An AP radiograph shows a round cuboid lucency. Which of the following is the most appropriate intervention at this time? Bone scan Oral antibiotics Surgical debridement Topical antibiotic ointment
Correct Answer ( C ) Explanation: In children, acute osteomyelitis commonly occurs with hematogenous spread or direct contamination, as in stepping on a nail. Pain, edema, erythema, warmth and generalized malaise are common symptoms of acute osteomyelitis. It is also important to consider cellulitis and septic arthritis in any case of suspected osteomyelitis. Laboratory investigation includes CBC, CRP and ESR, all of which may be normal early in the disease course. Blood cultures, which reveal the causative organism in up to 50% of cases, should also be obtained. Radiographs are also recommended. Early films may only show soft tissue swelling, but are useful in ruling-out fracture or neoplasm. Follow-up radiographs around a week after the injury usually shows periosteal elevation and bone lucency, two signs of bony destruction and significant pathology. In addition to blood cultures, aspiration is recommended if one can identify involvement of a specific bone and neoplasm has been ruled-out. Intravenous antibiotics are started immediately. Surgical debridement, especially in the case of nail puncture wounds, is strongly recommended, as failure to completely eradicate infection with Pseudomonas aeruginosa, the most common organism in nail puncture wounds, can lead to chronic refractory osteomyelitis, additional joint destruction, limb-length discrepancies, limb dysfunction and pathological fracture.
A 26-year-old man is training for a marathon and presents to the Emergency Department with right knee pain. The pain began during a run yesterday and has become progressively worse. He is unable to ascend stairs without significant pain. Palpation below the medial joint line of the knee elicits pain. You suspect anserine bursitis. The tendon of which of the following muscles is affected with this diagnosis? Biceps femoris Gastrocnemius Gracilis Vastus medialis
Correct Answer ( C ) Explanation: The tendons of the gracilis, sartorius and semitendinosus muscles insert onto the medial tibia below the knee joint and overlie the pes anserinus (Latin for "goose's foot") bursa. Pes anserine bursitis occurs commonly in runners, obese women with osteoarthritis and in other overuse syndromes. It is thought to be due to tight hamstrings, leading to increased friction and irritation of the bursa. Patients complain of anterior medial knee pain below the joint line and tenderness to palpation over the bursa. Symptoms may worsen with overuse or with certain activities such as squatting, running, or ascending or descending stairs. It usually is not symptomatic when walking on flat surfaces. Diagnosis is clinical. Management consists of rest, ice, proper stretching and nonsteroidal anti-inflammatory medications. The condition is self-limiting, and most athletes are able to return to play after a period of conservative therapy.
A 59-year-old woman presents to clinic with complaints of right lateral hip pain which has been ongoing for four months. She is unable to sleep on her right side secondary to the pain. The patient has pain and tenderness with palpation of her greater trochanter. There is no erythema and no soft tissue swelling. The patient has tried nonsteroidal anti-inflammatory drugs and physical therapy for the last six weeks but her pain persists. What is the most appropriate next step in management? Amitriptyline Clindamycin Corticosteroid injection Trochanteric bursectomy
Correct Answer ( C ) Explanation: This patient has greater trochanteric pain syndrome (previously known as trochanteric bursitis) which typically presents as lateral hip pain which is worse with lying on the affected side, and tenderness with palpation of the greater trochanter. Greater trochanteric pain syndrome is the most common cause of lateral hip pain in adults. First-line treatment is conservative therapy, including nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy. If pain does not adequately respond to these interventions, a corticosteroid injection to the trochanteric bursa is recommended. This can be done with or without ultrasound guidance. The injection can provide both diagnostic and therapeutic benefit.
A 6-year-old boy presents with ankle pain after getting kicked while playing soccer. He has tenderness anteriorly along the ankle joint. An X-ray is shown above. The patient has significant pain when walking. Which of the following is the most appropriate management? Analgesics and follow up in 2 weeks CT scan of the ankle Immobilization of the ankle and non-weight bearing Immobilization of the ankle and weight bearing as tolerated
Correct Answer ( C ) Explanation: This patient presents with signs and symptoms concerning for a Salter-Harris Type I fracture and should be immobilized and made non-weight bearing. Children's bones, unlike those of adults, contain cartilaginous centers near the end of the bone that give rise to new bone growth (epiphysis). Because these areas are radiolucent, they are not visualized on radiographs. Injuries to the epiphysis may result in abnormal bone growth if they do not heal. Therefore, when injury to this area is suspected, conservative management with splinting and non-weight bearing (if lower extremity) status is recommended to promote healing and discourage worsening injury. Injuries to these areas are referred to as Salter-Harris Type I injuries (displacement of the epiphysis). The Salter-Harris classification system was designed to aid in the description and management of pediatric fractures.
A 42-year-old man presents with foot complaints. Last night, he was awakened with severe pain in his right great toe. He denies a history of recent injury. Examination reveals significant edema and erythema of the first metatarsophalangeal joint. The overlying skin is intact but warm. Range of motion, both passive and active, are limited. Which of the following is the most likely diagnosis? Pediculosis Pellagra Pes planus Podagra
Correct Answer ( D ) Explanation: Arthritis has several causes other than degeneration (OA) and autoimmune dysfunction (RA). Deposition of crystals into the synovium is one of those causes. Gout involves deposition of monosodium urate crystals. Acute, nighttime onset of intense monoarticular edema and pain is typical of gouty arthritis. 50% of cases occur in the great toe's metatarsophalangeal joint, which is termed podagra, while other cases commonly occur in the knee and tarsal joints. Joint aspiration and fluid analysis is recommended. Radiographs may be normal, or may only show soft tissue edema. Serum uric acid levels may be normal during an acute attack of gout, however, interval asymptomatic hyperuricemia commonly exists between, and prior to, the onset of acute attacks. Acute cases are treated with colchicine, indomethacin, intraarticular corticosteroids and decompressive-aspiration. Pellagra (B) is vitamin B3 (niacin) deficiency, characterized by diarrhea, dermatitis and dementia. Desquamation, keratosis and erythema of sun-exposed skin are the common cutaneous findings. Pes planus (C), or flat-feet or fallen-arches, is a foot arch deficiency that results in a majority of the sole of the foot coming in contact with the ground. Ankle eversion predominates. It can result from biomechanical defects, trauma, normal aging, obesity and pregnancy. It is usually involved with ankle pain and/or instability, but not digital joint edema and erythema.
A young woman presents with ankle pain and edema. While wearing high-heel shoes, she twisted her ankle upon stepping off a curb. She is tender about the lateral malleolus. Skin and neurovascular examination are normal. She has no medial tenderness. Ligament testing is negative. Radiographic examination reveals a non-displaced lateral malleolar fracture below the ankle joint. The tibia is unaffected. Which of the following is the most appropriate definitive treatment for this patient? AClosed reduction BDebridement CNon-weight-bearing orthosis DWeight-bearing cast
Correct Answer ( D ) Explanation: Fracture of the ankle may include injury to the medial malleolus (tibia), the lateral malleolus (fibula), the posterior malleolus (tibia), the talus and the collateral ligaments. Stability of the fracture depends on how many sides are injured. Stable fractures involve only one side of the joint, whereas unstable fractures include both sides of the joint. Stable fractures are treated with 4-6 weeks of a weight-bearing cast or brace
A 51-year-old man presents to emergency room with severe pain in his right great toe. He has a history of chronic gout and has had multiple, similar flares. He recently began taking a new medication to control his cholesterol. Which of the following medications did this patient most likely begin taking? Atorvastatin Ezetimibe Gemfibrozil Niacin
Correct Answer ( D ) Explanation: Niacin is used to treat hyperlipidemia and can exacerbate gout. Niacin or nicotinic acid naturally occurs as Vitamin B3. When niacin is used in doses 100-300 times the recommended daily allowance, a reduction in triglycerides and low-density lipoproteins (LDL) can be observed. Niacin is thought to decrease very low-density lipoprotein synthesis, thereby lowering LDL. Additionally, niacin partially inhibits release of free fatty acids from adipose tissue and increases the rate of lipoprotein lipase activity, which lowers blood levels of triglycerides. The therapeutic use of niacin is limited due to its extensive side effects. Most notably, niacin causes prostaglandin-mediated flushing and pruritus that is intolerable for many patients. Slowly increasing the niacin dose, using slow-release preparations, taking niacin with food, and taking aspirin 30 minutes before the niacin dose may attenuate adverse effects. Niacin is contraindicated in patients with hepatic disease, severe hypotension, or active peptic ulcer disease. Niacin can exacerbate hyperuricemia and hyperglycemia and should be avoided in patients with chronic gout or diabetes. Baseline liver transaminases, uric acid, and glucose should be obtained before initiation, after increasing dose, and every six months at maintenance dose. Other medications that can cause a gout flare include tacrolimus, cyclosporine, loop and thiazide diuretics, and low-dose aspirin. Atorvastatin (A), an HMG-CoA reductase inhibitor, is not known to exacerbate gout. The most common side effects of atorvastatin are headache, gastrointestinal complaints, and myalgia. Ezetimibe (B) is a cholesterol absorption inhibitor that has minimal side effects. Side effects of ezetimibe include headache and diarrhea. Gemfibrozil (C), a fibric acid derivative, has minimal side effects of nausea, vomiting, flatulence, and constipation and is generally well tolerated. Gemfibrozil is contraindicated in patients with a history of gallstones.
A 30-year-old woman complains of anterior knee pain that gets worse with prolonged sitting, going up and down stairs and with deep squats. She has no known history of knee injury. She exercises three times a week on her exercise bicycle. She is average weight and played basketball as a high school student. Which of the following is the most likely diagnosis? Chronic anterior cruciate ligament tear Osgood-Schlatter disease Osteochondritis dissecans Patellofemoral syndrome
Correct Answer ( D ) Explanation: Patella-related pain is the single most common cause of knee pain. Patellofemoral pain syndrome is a multifactorial syndrome characterized by aching anterior knee pain that worsens with activities that stress the patellofemoral joint (climbing stairs, kneeling). Patients complain of diffuse, aching anterior knee pain that is exacerbated by loaded flexion activities such as stair climbing, jumping, or prolonged sitting (theater sign). On exam there may be patellar crepitation. The diagnosis is clinical and knee radiographs provide limited information (articular cartilage loss). Treatment includes activity modification and an exercise program consisting of quadriceps strengthening (medial quadriceps) and hamstring flexibility. NSAIDs are recommended for symptomatic care. Osteochondritis dissecans (C) is due to repetitive small stress to the subchondral bone that leads to osteonecrosis (most commonly the medial femoral condyle). Most cases begin in childhood although individuals may not become symptomatic until late adolescence or early adulthood. Early diagnosis is critical, as the injury has a better potential to heal while the bones are still growing. Osgood-Schlatter disease (B) is caused by rupture of the growth plate at the tibial tuberosity, which causes stress on the patellar tendon. It most commonly occurs in rapidly growing adolescents (10-15-years-old) and is five times more common among those active in sports and up to three times more common in boys.
A 16-year-old girl presents to clinic with 3 weeks of worsening right knee pain. She attends dance class since age 5 and now dances 20 hours a week. She denies any inciting injury and continues to dance on the injured leg. On exam, she has pain at the inferior and medial pole of the right patella with no swelling or erythema of the knee. Which of the following is the most likely diagnosis? Anterior cruciate ligament rupture Medial meniscus tear Patella dislocation Patellofemoral pain syndrome
Correct Answer ( D ) Explanation: Patellofemoral pain syndrome occurs in about a quarter of those involved in athletics and more commonly in women and those between the ages of 10 and 35 years. Symptoms include pain with going up and down stairs and prolonged sitting or squatting. Individuals may have a sensation of the knee buckling or giving way. Swelling, popping or grinding sensations may be present. Treatments include non-steroidal anti-inflammatory medications, ice, quadriceps strengthening, stretching, patella bracing and orthotics.
A 10-year-old boy presents to clinic with complaints of right posterior heel pain. There was no preceding injury. The pain has been ongoing for four months. He is a soccer player and notices the pain primarily when wearing his cleats during soccer. On physical exam, the patient has pain with medial-lateral compression of the calcaneus. Which of the following is the most likely diagnosis? Achilles tendon rupture Iselin's disease Plantar fasciitis Sever disease
Correct Answer ( D ) Explanation: Sever disease, also known as calcaneal apophysitis is believed to be a traction apophysitis of the Achilles tendon at the calcaneal apophysis related to overuse. It is most commonly seen in children ages 8-12 years and the pain is often associated with sports that use cleats. Positive physical exam findings include pain with medial-lateral compression of the calcaneus (positive compression test) or pain with direct palpation over the apophysis. Radiographs are not required to make the diagnosis but may show increased sclerosis or fragmentation of the calcaneal apophysis. X-rays can be used to rule out other causes of heel pain if the diagnosis is unclear. Symptomatic management is the mainstay of treatment including the use of heel cups, heel cord stretching exercises, and rest and nonsteroidal anti-inflammatory drugs as needed. Iselin's disease (B) is a traction apophysitis of the tuberosity of the fifth metatarsal at the attachment of the peroneus brevis tendon. Plantar fasciitis (D) is uncommon in children and adolescents and generally presents as pain over the medial calcaneus which can radiate into the arch. The pain is most prominent with the first steps of the day.
Which nerve root is affected in a patient with loss of the ankle jerk reflex? C5 L4 L5 S1
Correct Answer ( D ) Explanation: The S1 nerve root is responsible for the ankle jerk reflex (Achilles reflex). Patients with S1 nerve root lesions will experience a diminished ankle jerk reflex, weakness with foot eversion, numbness along the lateral edge of the foot, and radicular pain along the posterior buttocks extending into the posterior thigh and calf. S1 is one of the most common locations for disc herniation. Disc herniation occurs when the collagenous annulus fibrosis tears, allowing the gelatinous nucleus pulposus to protrude. The C5 (A) nerve root is responsible for the biceps reflex and deltoid strength. L4 (B) is responsible for the knee jerk (patellar) reflex, foot inversion strength, sensation in the anterior thigh, and will cause pain in the posterior buttock that wraps around the front of the thigh and into the medial calf and foot. L5 (C) root lesions will present with intact reflexes, great toe dorsiflexion weakness, numbness in the web between the great and second toe, and pain along posterior buttock radiating into the lateral thigh and leg.
Which of the following is the most reliable indication of an achilles tendon rupture? Inability to ambulate Inability to plantar flex the foot Pain along the posterior ankle Positive calf squeeze test
Correct Answer ( D ) Explanation: The achilles tendon is formed by the convergence of the gastrocnemius and soleus muscles and attaches on the posterior calcaneus. Achilles tendon ruptures tend to occur when sudden force is placed on the achilles tendon during physical activity that involves pivoting on the foot or sudden acceleration. The majority of ruptures occur in tendons that are already weakened from previous injury or degeneration. Both partial and complete ruptures can occur. Men, typically in their 30s and 40s, are significantly more likely to have an achilles tendon rupture. Patients often present with a history of sudden pain and a "popping" sensation in the posterior ankle during physical activity. On examination, there may be edema and ecchymosis over the achilles tendon and a palpable defect may be appreciated. The calf squeeze test, or Thompson test, is the most reliable indicator of an achilles tendon rupture with a sensitivity of 96%. With the patient prone or kneeling on a chair, the posterior calf is squeezed at its widest point. The absence of plantar flexion indicates a rupture of the tendon. Management includes immobilization with a short leg cast with the ankle in slight plantar flexion, known as the equinus position, and orthopedic consultation
A 35-year-old man presents to the ED after injuring himself while playing basketball. He states he felt a pop in his right lower extremity while jumping for a rebound. He can ambulate, but with a limp. On exam, squeezing his right calf elicits no plantar flexion of his foot. What is the appropriate disposition for this injury? AAdmission to hospital for serial compartment pressure measurements BElastic wrap, crutches, weight-bearing as tolerated, and orthopedic follow-up within seven days CSplint in dorsi-flexion, keep nonweight-bearing, orthopedic follow-up DSplint in plantar-flexion, keep nonweight-bearing, orthopedic follow-up
Correct Answer ( D ) Explanation: The patient has an Achilles tendon rupture suggested by the inability of his foot to plantar flex with squeezing of the calf (Thompson test). This injury is most common in middle-aged recreational athletes. Patients often note a "popping" sensation followed by acute weakness and the inability to continue activity. A defect may be palpable on examination of the distal Achilles tendon. Management in the ED includes immobilization of the extremity in a short-leg splint, keeping the foot in plantar-flexion. The patient should be nonweight-bearing until seen by an orthopedic surgeon. Definitive repair is surgical.
A 21-year-old woman is brought in by ambulance from a soccer game where she was kicked by a teammate as her left leg was planted. Per the ambulance report, the patient was found with the knee bent completely under her, crying in severe pain. She was unable to bear weight on the extremity at the scene. On examination, there is no gross bony deformity of the left leg, knee, or thigh. Peri-patellar ecchymosis and a significant effusion are noted. The knee hyperextends when the leg is lifted by the heel and the knee joint is extremely unstable on valgus and varus stress. Femoral, patellar, posterior tibial, and dorsalis pedis pulses are present. Which of the following is the most likely diagnosis in this patient? Anterior cruciate ligament tear Medial meniscus tear Patellar dislocation Tibiofemoral dislocation
Correct Answer ( D ) Explanation: Tibiofemoral dislocation is a true limb-threatening emergency. It is caused by multiple ligamentous tears due to hyperextension, posterior force to the anterior tibia, or force to the femur or fibula. Tibiofemoral dislocation is most commonly caused by a motor vehicle collision, but can be caused by sports injuries, falls or even spontaneously in very obese patients. Because of the severe ligamentous damage, many tibiofemoral dislocations will spontaneously reduce prior to presentation. Knee instability in multiple directions should raise suspicion for tibiofemoral dislocation, even if no gross abnormalities are present. Hemarthrosis or significant ecchymosis may also be present on examination. Examination should include a thorough neurovascular check, include an ankle-brachial index and a motor and sensory exam. Tibiofemoral dislocations, once recognized, should be immediately manually reduced. Serial neurovascular checks should follow, as damage to neurovascular structures are common.
Rapid Review Salter-Harris Fractures
I/II rx: nonoperative IV/V rx: surgery required Negative radiographs do not r/o a Salter I fracture
Rapid Review Lisfranc Injury
Lisfranc Injury Definition: any fracture or dislocation of the tarsal-metatarsal joint Plantar ecchymosis Fleck sign (pathognomonic): avulsion fracture of the medial aspect of the base of the second metatarsal Weight-bearing films may be necessary Treatment: Nondisplaced: non-weight bearing casting Displaced: surgery
Rapid Review Meniscus Injuries
Meniscus Injuries Knee rotary stress Rapidly changing directions, squatting Medial > lateral Clicking, locking McMurray test Medial joint line pain: medial meniscus injury Lateral joint line pain: lateral meniscus injury Ege test: pain/click on knee rotation with patient in squatting position External rotation pain: medial meniscus injury Internal rotation pain: lateral meniscus injury Dx: MRI
Rapid Review Myofascial Pain
Myofascial Pain Trigger points Rx: physical therapy, cognitive-behavior therapy, muscle relaxants
Rapid Review Osgood-Schlatter Disease
Osgood-Schlatter Disease Patient will be a boy athlete 10 - 15 years old Complaining of knee pain while running PE will show tenderness over the tibial tubercle Treatment is ice, NSAIDs, quadriceps stretching
Rapid Review Osteomyelitis
Osteomyelitis Adults: contiguous spread Children: hematogenous spread Most common: S. aureus Sickle cell: Salmonella Cat/dog bites: Pasteurella multocida Plain films: periosteal elevation or bony erosions Bone scan, MRI Long term ABX
Rapid Review Patella Fracture
Patella Fracture MC: transverse Bipartite patella: normal variant, smooth cortical margins Assess extension ability Surgery indications: > 3 mm dislocation, extensor mechanism loss
Rapid Review Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome Patient will be a women Complaining of aching anterior knee pain, that is worse with loaded flexion (stair climbing, jumping, prolonged sitting) PE will show patellar crepitation Treatment is strengthen medial quadriceps, NSAIDs
Rapid Review Patellofemoral Syndrome
Patellofemoral Syndrome Female athletes Knee pain worse after prolonged sitting, bending motions Patella compression test: patella compression into femoral groove → pain, crepitus Apprehension test: patella pushed laterally → quadriceps contracts involuntarily ↑ Q angle Rx: NSAIDs, quadriceps-strengthening exercises
