SmartyPANCE - Make me Ortho smart

Does osteoarthritis affect the metacarpophalangeal joints?

*NO!* Osteoarthritis is a joint disorder that *does not involve* the metacarpophalangeal joints

Where are Heberden's nodes found?

- Distal interphalangeal joint (DIP) -someone with OA waching "HD" TV w/ "High BP" = heberden-distal & Bouchard proximal

Patient will present as → a 24-year-old male presents with abrupt onset of swelling, pain, redness, and increased warmth in his right knee. He denies any injury or previous joint issues. The symptoms began yesterday along with generally not feeling well and possibly a low-grade fever. His past medical history is unremarkable. He takes no medications and has no known drug allergies. He denies tobacco use, consumes alcohol socially with no recent episodes of heavy drinking, and follows a vegetarian diet. He is sexually active with a recent new partner. On physical examination, T: 100°F, right knee is edematous and erythematous with increased warmth, and ROM decreased by pain. The left knee has no change in skin color or temperature with full pain-free ROM in flexion and extension. The examination of the hip and ankle joints is unremarkable. Right knee synovial fluid analysis reveals increased leukocytes and the absence of crystals.

-Septic Arthritis Buzz - swelling, pain, redness, & increased warmth in right knee, sexually active w/ newbie, right knee is edematous & erythematous & warm, ROM decreased by pain

Does pain associated with OA worsen or improve w/ activity & rest?

-Worsens with use -improves w/ rest

The major complication of slipped capital femoral epiphysis is A. Avascular necrosis of the hip B. Osteochondritis dissecans C. Leg-length discrepancy D. Transient synovitis of the hip E. Intoeing

A. Avascular necrosis of the hip

Identification of hip fracture and initiation of treatment is imperative to avoid such complications as avascular necrosis (AVN). Which of the following groups are most at risk for AVN? A. Children and adolescents B. Teenagers C. Adults in middle age D. The elderly

A. Children and adolescents AVN is more common in patients in the pediatric and adolescent age groups. This outcome is due to the precarious nature of the blood supply to the subchondral region of the femoral head, which does not stabilize until years after skeletal maturity, after which collateral flow develops.

A 68-year-old man presents to his primary care PA with a chief complaint of pain when he walks. He states that the pain is the worst in his left great toe but is also present in his hips and knees. He says that his symptoms are worse with activity and tend to improve with rest. His symptoms have progressively worsened over the past several years. He has a past medical history of obesity, type II diabetes mellitus, smoking, hypertension, and hypercholesterolemia. He drinks three beers per day. He admits to having unprotected sex with a prostitute on a recent trip to Thailand. His current medications include metformin, insulin, lisinopril, atorvastatin, and hydrochlorothiazide. Examination of the lower extremity results in pain. There is crepitus of the patient's hip when his thigh is flexed and extended. Which of the following is the most likely diagnosis? A. Osteoarthritis B. Rheumatoid arthritis C. Infectious arthritis D. Gout E. Pseudogout

A. Osteoarthritis This patient is presenting with chronic pain in his joints that is worsened with activity and relieved by rest suggesting a diagnosis of osteoarthritis. Osteoarthritis occurs secondary to degeneration of the cartilage in the joint. Common locations for it to occur include, but are not limited to, the hip, knee, and great toe. Risk factors include trauma, overuse, increasing age, and obesity. Patients will typically complain of pain in the joint that is exacerbated by activity and relieved by rest. There is often pain and crepitus in the affected joint. Treatment involves weight loss, physical activity as tolerated, and NSAIDs as needed. Ultimately these patients may need surgery to manage their symptoms.

Which of the following is the first-line imaging study for suspected fracture of the hip or pelvis? A. X-ray scanning B. MRI C. Bone scanning D. Linear tomography

A. X-ray scanning

Patient will present as → a 24-year-old male with severe pain in the right knee. He is a professional football player and a few hours prior to presentation, an opposing player hit his leg from his left side. Afterward, he felt a "popping" sound that was followed by severe knee pain and a sensation of knee instability. On physical exam, there is an anterior translation of the proximal tibia when pulled as the patient has the knee flexed at 90° and supine. Ice is applied to the knee and ibuprofen is prescribed. An MRI is ordered. Orthopedic surgery is consulted to evaluate if ligament reconstruction is needed.

ACL Tear BUZZ -hit from left side, felt popping sound, sensation of knee instability, anterior translation of proximal tibia when pulled

Patient will present with → Pop and swelling after a quick plant and twist injury - common in skiers, football, and basketball players. Quickly stop moving and change direction while running, landing from a jump, or turning can result in injury to the ACL

ACL injury

Patient presents as → a 48-year-old male with calf and heel pain with weakness and difficulty walking. The patient sustained an injury yesterday while he was playing tennis. He was attempting to change direction when he felt a "pop" in Achilles tendon region and he felt like he was kicked in the back part of his leg. Since the injury, he has been unable to put any weight on the involved extremity. He provides an additional history that for the past 6 months his primary care provider has been treating him for Achilles tendonitis with corticosteroid injections. On physical exam, you note a palpable gap along with increased resting ankle dorsiflexion in the prone position with knees bent. The Thompson test reveals lack of plantar flexion when the calf is squeezed.

Achilles Tendon Rupture Buzz -calf & heel pain w/ weakness & difficulty walking Pop in achilles tendon region, kick in back of leg, unable to bear weight on leg, palpable gap, increased resting dorsiflexion, thompson test

What is most likely indicated in the initial management of Osgood-Schlatter disease?

Activity restriction: Refraining from the activity that initially caused the condition is essential. Decreasing intensity of physical activity is indicated both short-term following injury, and long-term for one to two years. However, the patient should still remain physically active to strengthen surrounding muscles.

Name the top three risk factors for osteoarthritis

Age, obesity, and joint trauma

Osgood-Schlatter Disease is characterized as what type of syndrome?

An overuse syndrome

Patient presents as → a 34-year-old male who brought into the ER by EMS after a high impact MVA. He is experiencing severe ankle pain, edema, deformity, and inability to bear weight. On exam, there is exposed bone and skin. An x-ray of the affected extremity is seen here.

Ankle Dislocation Buzz -pain, edema, deformity, & inability to bear weight

Patient presents as → a 20-year-old male with complaints of left lateral ankle pain following an injury that occurred when he was landing from a jump while playing basketball. On examination, there is tenderness over the anterior talofibular ligament. He has an antalgic gait and requires rest after walking 15 steps. The calcaneofibular and posterior talofibular ligaments are nontender to palpation. Anterior drawer testing is positive for pain and loss of endpoint. Inversion subtalar tilt test does not cause any pain and there is a firm endpoint.

Ankle Sprain Buzz -lateral ankle pain, landing from jump while playing BBall, tenderness over ATF ligament, anterior drawer +, inversion subtalar tilt test = no pain

Patient will present as → a 49-year-old female with progressive left hip pain and limp which has become progressively worse over 13 months. Her past medical history is significant for heterozygous sickle cell anemia and she is has been under hydroxyurea treatment for about 20+ years. She is on no other medication and denies alcohol or tobacco use. The pain is localized to the groin, lateral hip, and buttocks and she reports a sudden increase in pain about two months ago after her last sickle cell crisis. Physical exam reveals a left hip with painful restriction of ROM and a limp. Right hip has mild symptoms. An MRI is performed with results seen here.

Avascular necrosis (HIP) Buzz -progressive left hip pain & limp -sickle cell anemia -groin, lateral hip, butt -after sickle crisis

A 68-year-old woman presents to the emergency department with a three-day history of severe progressive pain of the right knee that had begun after an audible painful click upon standing from a sitting position. At presentation, the patient was not able to stand on her right leg. Body temperature was 98.6 The day before it was 100.7 °F. The right knee is swollen and warm, but no redness is seen. Palpation is painful at the lateral joint space. Flexion/extension of the knee is 60-50 degrees. Blood examination shows a C-reactive protein (CRP) level of 169mg/l and leucocytes of 7.3x109/l. X-ray studies of the right knee reveal osteoarthritis of the medial compartment with some loose bodies. What is the next best step in the management of this patient? A. MRI of the Knee B. Joint aspiration C. Blood cultures D. Check serum CRP levels

B. Joint aspiration The definitive diagnostic test is identification of bacteria in the synovial fluid. In the setting of suspected joint infection, synovial fluid aspiration should be performed (prior to administration of antibiotics); fluid should be sent for Gram stain and culture, leukocyte count with differential, and assessment for crystals. If synovial fluid cannot be obtained with closed needle aspiration, the joint should be aspirated under computed tomography (CT) or fluoroscopic or ultrasound guidance. Certain joints, such as the hip or sacroiliac joint, may require surgical arthrotomy for diagnostic aspiration.

A 41-year-old male with a history of intravenous drug abuse presents to your office with acute, nontraumatic right knee pain, chills, and sweats starting 2 days ago. On physical examination, his temperature is 102.9 degrees F. The right knee is erythematous, edematous and tender to palpation and range of motion. Plain knee x-ray reveals soft tissue swelling. Which of the following is most likely the diagnosis? A. gouty arthritis B. septic arthritis c. rheumatoid arthritis d. psoriatic arthritis

B. septic arthritis This patient's signs and symptoms are most consistent with septic arthritis. IV drug abuse places this patient at even greater risk.

Patient will present as → 45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted.

Back strain/sprain Buzz -does not radiate, no sensory deficit or weakness, paraspinal muscle tenderness, spasm

What is the classic radiographic finding in a patient with ankylosing spondylitis?

Bamboo spine & squaring of vertebral bodies

Osteophytes found at the *proximal interphalangeal joints* in osteoarthritis.

Bouchard nodes (Think BP gas - Bouchard = proximal)

Patient presents as → a 49-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated by the dress shoes she wears for work. Physical examination reveals bursal inflammation and calluses at the medial eminence of the first metatarsal with a 1st metatarsophalangeal (MTP) joint deformity that passively corrects. A radiograph is performed with results shown here. The hallux valgus angle (HVA) is measured at 25 degrees and the intermetatarsal angle(IMA) is measured at 12 degrees.

Bunion - Hallux Valgus buzz -bilateral painful forefeet, exacerbated by dress shoes, bursal inflammation & calluses at medial eminence of first metatarsal, 1st metatarsophalangeal joint deformity

A 13-year-old boy presents to the clinic for a complaint of right knee pain that he first noticed about a year ago. It started out as mild discomfort in the area just below the kneecap, but has been getting progressively worse. Now, it hurts anytime he uses his leg, even when walking. He does not remember any injury to his knee. On examination of his knee there is swelling and exquisite tenderness over the tibial tubercle. Radiographs are normal. What is the most likely diagnosis? A. Chondromalacia patellae B. Legg-Calvé-Perthes disease C. Osgood-Schlatter disease D. Patellar dislocation

C. Osgood-Schlatter disease

Which of the following complications has a high likelihood of developing in ED management of venomous snakebites to the extremities? A. delayed serum sickness B. dislodged teeth contaminating the wound C. compartment syndrome D. delayed absorption of antivenom E. immediate death after venomous snakebite

C. compartment syndrome

Patient will present as → a 28-year-old man involved in high-speed MVC with lower back spine fracture, bladder/ bowel incontinence, decreased lower extremity sensation, and decreased lower extremity strength.

Cauda equina syndrome buzz -bladder/bowel incontinence, decreased lower E sensation, decreased lower E strength

What are the classic signs/symptoms of compartment syndrome?

Classic signs include... -pain after passive flexion/extension of foot -Paralysis -Paresthesias -Pallor -Pulses are present in most cases due to systolic pressure >30 mmHG

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

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

Which of the following statements concerning the condition described is false? A. this condition is the most common form of joint disease in the United States B. 70% to 90% of people older than 75 years have at least one affected joint C. this condition has both primary and secondary forms D. narrowing of the joint space is unusual E. pathologically, the articular cartilage is first roughened and then finally worn away

D. narrowing of the joint space is unusual

Which of the following statements regarding the condition described is false? A. pain is the chief symptom B. stiffness of the involved joint is common but of relatively brief duration C. the pain is characteristically dull and aching D. a major physical finding is bone crepitus E. the presence of osteophytes is sufficient to make the diagnosis

E. the presence of osteophytes is sufficient to make the diagnosis

Patient will present as → a 35-year-old woman presents with severe left hip pain. She was sitting in the passenger seat of a car when the car was hit head-on by another vehicle. On physical exam, she has significant pain and deformity in her left hip. She is unable to move her hip or bear weight. She is neurovascularly intact distally. Her left hip is adducted, flexed, and internally rotated.

Hip dislocations Buzz - pain & deformity in left hip -adducted -flexed -internally rotated

Patient will present as → a 67-year-old male who arrives at your emergency department for pain in his right leg. The patient was reaching for a box of cereal when he fell from a small footstool. He experienced immense pain in his right leg and presented to the emergency department shortly thereafter. The patient has a past medical history of osteoporosis and diabetes mellitus managed with insulin and metformin. On physical exam, you note a shortened, externally-rotated right lower extremity. Radiography is ordered with results seen here.

Hip fracture Buzz - immense pain in right leg -osteoporosis -shortened -externally rotated right lower leg

What medication can be given to children with Osgood-Schlatter disease experiencing pain?

Ibuprofen (NSAIDs) can be given to children with Osgood-Schlatter disease experiencing pain.

In children, Osgood-Schlatter disease may result in what complication at the tibial tuberosity?

In children, Osgood-Schlatter disease may result in avascular necrosis at the tibial tuberosity or in a(n) avulsion fracture, with the tibial tuberosity separating from the tibia

Joints affected by septic arthritis have white blood cell count greater than what?

Joints affected by septic arthritis have purulent synovial fluid, white blood cell count greater than 50,000/mm3, and an elevated erythrocyte sedimentation rate and C-reactive protein

Patient presents as → a 23-year-old elite dancer falls and sustains an injury to her left foot. She has pain and inability to bear weight on her injured foot. She has no plantar ecchymosis but does have tenderness over her lateral foot. A radiograph of her foot is seen here.

Jones Fracture

Patient will present as → a 23-year-old male who is the front seat passenger in a motor vehicle accident. There is a noticeable deformity in his knee. Radiographs are seen here. Examination reveals an inability to extend the knee and weak foot pulses. After unsuccessful attempts at closed reduction, it is noted that the pulses are no longer palpable and the foot is cool.

Knee dislocation Buzz - deformity in knee

Patient will present as → a 25-year-old soccer player injures his knee after colliding with an opposing player during a game. On physical exam, his Lachman is weakly positive. He has laxity to varus stress with the knee flexed to 30 degrees. Dial test of the tibia shows increased external rotation at 30 degrees, but not at 90 degrees in comparison to the contralateral leg.

LCL Tear BUzz - laxity to varus stress, distal test of tibia

Patient will present as → a 26-year-old college football player is brought to the emergency department after being hit on the lateral side of the left knee. He reports hearing a pop and then his knee buckled. He is now in severe pain and if having difficulty walking. On examination, there is swelling over the medial aspect of the left knee. There is laxity when a valgus stress test is performed on the knee. The results of the Lachman and McMurray tests are negative. You order an MRI of the knee with results seen here.

MCL Tear Buzz -hit on lateral side of left knee, hearing pop, swelling over medial aspect of L knee, laxity w/ valgus stress

Patient will present → after sustaining a valgus stress injury (from the outside), such as a hit in football. Patient will have pain with valgus stress applied to the knee.

MCL injuriy

Patient will present → after a "twist" injury with locking, a feeling of the knee giving away, walking up and down stairs or squatting is difficult and painful

Meniscal Tear

Patient will present as → a 35-year-old man with complaints of swelling and pain in left knee. The patient states that he sustained a twisting injury in a football game 3 days ago. The injury did not take him out of the game; he was able to continue participating with minimal difficulty. Over the last 2 days, the pain has progressed. He notes a catching sensation and pain that is more medially located. On physical examination, the patient is found to have tenderness over the medial joint line and limited range of motion. Forced flexion and circumduction of the joint cause a painful click.

Meniscal Tear Buzz -swelling pain in left knee, twisting injury, catching sensation, tenderness over medial joint line, forced flexion & circumduction of joint cause painful click

Patient presents as → a 37-year-old flight attendant complaining of worsening foot pain for 3 weeks. The pain is located on the plantar surface of her forefoot and is described as severe, "burning" pain. The pain also radiates into her third and fourth toes. The patient states that, at first, she thought she had a pebble in her shoe, but when she removed her shoe, she could not find any obvious offending agent in her shoe. On physical examination, you are able to reproduce the pain by grasping the medial and lateral aspect of the foot in your hand and squeezing the metatarsal heads together. There is no tenderness with palpation of the metatarsal shafts. An MRI is performed with results seen here.

Morton's Neuroma Buzz -plantar surface of forefoot, severe burning pain, radiates to 3rd & 4th toes, reproduce pain by grasping sides of foot and squeezing heads together

What is the most common cause of infectious septic arthritis in young sexually active adults?

Neisseria gonorrhoeae

Name three common radiographic findings in OA

OA causes subchondral cysts, narrowing of the joint space, and joint sclerosis on radiography

Patient will present as → a 14-year-old boy with left knee pain. He denies any trauma to the knee. The patient runs cross country for his high school team and attends practice regularly. On physical exam, the tibial tubercle is pronounced and there is tenderness to palpation over the affected area. The patient reports pain upon resisted knee extension

Osgood-Schlatter Disease Buzz -cross country for HS team -tibial tubercle pronounced -tenderness to palpation over affected area

Presents as → tenderness over the tibial tubercle in a 9-14-year-old male who has undergone a rapid growth spurt and is doing sports that involve running

Osgood-Schlatter disease Buzz - tenderness -tibial tubercle -sports involving running

What physical exam finding characterizes Osgood-Schlatter disease?

Osgood-Schlatter disease is characterized by a painful lump just below the knee.

What is Osgood-Schlatter disease?

Osgood-Schlatter disease is inflammation of the patellar ligament at the tibial tuberosity.

Osgood-Schlatter disease usually affects what age group and gender?

Osgood-Schlatter disease usually affects adolescent males

Characterized by *asymmetric* joint stiffness, that *worsens as the day progresses*

Osteoarthritis

Patient will present as → a 65-year-old woman with left knee pain. The pain has been present in both knees for approximately 5 years and has been steadily getting worse. She describes stiffness, sticking and grinding of the right knee. Over the last 2 weeks, she has been taking ibuprofen almost every day, requiring an increasing frequency of doses for adequate pain control. On physical exam, there is swelling of the right knee and tenderness to palpation. There is a palpable crepitus. A weight-bearing radiograph of the left knee is shown in here.

Osteoarthritis Buzz -sticking & grinding -taking ibuprofen almost daily -knee swelling -palpable crepitus

How does OA affect the joint spaces?

Osteoarthritis typically causes *narrowed joint spaces*

Patient will present as → a 54-year-old male with fever, chills, and pain in the left foot. His symptoms progressively worsened over the course of a week. Medical history is significant for poorly controlled type II diabetes mellitus. On physical exam, there is tenderness to palpation of the left foot. Laboratory testing is significant for an elevated erythrocyte sedimentation rate and C-reactive protein; as well as, a leukocytosis. Plain radiograph demonstrates periosteal thickening and soft tissue swelling.

Osteomyelitis Buzzzzzz -fever, chills, pain in left foot, Type2DM, elevated ESR&CRP, leukocytosis

Patient will present as → a 22-year-old recreational soccer player who sustained a right knee injury 6 months ago. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee "giving way." Physical exam reveals 10° varus alignment when standing and a varus thrust with walking. Strength is full compared to the other side. Ligamentous exam reveals a stable ACL and MCL but opens to a varus stress and a 3+ posterior drawer and positive dial test at both 30° and 90° degrees of flexion.

PCL Tear Buzz -knee giving way, varus stress 3+ posterior drawer+ dial test

Patient will present with → pain and erythema of nail folds (+ abscess = paronychia)

Paronychia (ingrown toenail)

Patient will present as → a 39-year-old female who sustained a knee injury after falling from a step ladder onto her flexed knee. On physical exam, there is a palpable patellar defect, significant hemarthrosis and she is unable to extend the knee. A radiograph is shown here.

Patella Fracture Buzz -flexed knee -palpable patellar defect -hemarthrosis -unable to extend

Patient will present with → an inability to extend the knee

Patella fracture

Patient will present as → a 14-year-old boy who felt his knee "pop" while running. He noticed his patella had "slipped to the side." His PE teacher was easily able to reposition it back into place.

Patellar subluxation & dislocation

Patient will present with → experience of knee "popping." Patella "slipped to the side."

Patellar subluxation & dislocation

Patient will present as → a 27-year-old female presents with knee pain. Her pain worsens when she is running downhill or climbing up the stairs. She describes the pain as "achy" and being behind the knee. When sitting for long periods of time, she reports her knees feeling stiff. She denies any recent history of trauma and has never had surgery. She has tried multiple over-the-counter analgesics but were not effective. She is a registered dietician and an avid runner who is preparing for a marathon. A full knee examination is performed.

Patellofemoral Pain Syndrome Buzz -female, running, downhill, climbing, avid runner, preparing for marathon

Patient presents as → a 39-year-old woman presents with complaints of pain in her left foot of 4 weeks' duration. The patient works as a cashier in a department store, which requires her to be on her feet for long periods. She notes that the pain is most severe on the bottom of her foot and is worse upon arising in the morning and then it subsides with ambulation. On examination, there is no pain with medial and lateral compression of the calcaneus. Active and passive foot and ankle range of motion is pain-free and equal bilaterally. Resisted foot and ankle range of motion is 5/5 and pain-free. The patient has a benign medical history and no other complaints.

Plantar Fasciitis Buzz -reqires her to be on her feet, bottom of foot, worse upon arising in AM, subsides w/ ambulation

Patient will present as → a 40-year-old carpet installer who spends his working day on his knees, fitting carpets. In the past few months, he had been aware of a dull ache over his right knee, which had seemed to be aggravated by pressure and on flexion of the knee. He had been wearing kneepads, using a soft mat and trying to avoid kneeling on that knee. However, he was alarmed to wake one morning with a large, tender, fluctuant swelling over the kneecap.

Prepatellar Bursitis (Housemaid's Knee) Buzz - dull ache over right knee -aggravated by pressure & flexion -large, tender, flucutant swelling over kneecap

Septic arthritis in IV drug abuser?

Pseudomonas - treat with ciprofloxacin or levaquin

Patient will present as → a 13-year-old girl who is being seen in your office for a routine well-child exam. She denies back pain and states she began her menses 3 months ago. On Adams forward bending asymmetry in scapular height is noted. She has 5 of 5 motor strength in all muscle groups in her lower extremities and symmetric patellar and Achilles reflexes. You obtain standing PA and lateral radiographs.

Scoliosis Buzz -adams forward bending asymmetry in scapular height, standing PA and lateral imaging

What is compartment syndrome?

Tissue swelling from reperfusion --> increased intracompartmental P --> decreased capillary flow, ischemia, & myonecrosis

Patient will present as → a 22-year-old college basketball player with chronic anterior pain of her right knee. The patient has had over 6 months of physical therapy without improvement. It initially only bothered her during training, but she is now no longer able to compete and has pain with daily activities. Physical exam reveals swelling of the anterior knee and tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at distal pole of the patella in full flexion. Her MRI is shown here.

patellar tendinitis Buzz -chronic anterior pain of right knee -welling of anterior knee -TTP at distal pole of patella in full extension -no TTP at distal pole of patella in flexion

Which thoracic curvature is an indication for treatment with bracing in an adolescent with scoliosis? A. Less than 20 degrees B. 20 to 40 degrees C. 40 to 60 degrees D. 40 degrees with lumbar curvature of 30 degrees E. Greater than 70 degrees

B. 20 to 40 degrees

Which of the following durations is generally considered to define chronic low back pain? A. > 4 weeks B. > 6 weeks C. > 2 months D. > 3 months

D. > 3 month 3 months because most normal connective tissues heal within 6-12 weeks, unless pathoanatomic instability persists.

A 33-year-old male presents to your office with a complaint of right knee injury associated with pain and swelling. He states he was running after his loose dog and suddenly stopped, hyperextended his knee, heard a pop and noticed immediate swelling. On physical examination, the Lachman test and anterior drawer test demonstrates joint laxity. Which of the following ligaments is most likely injured? A. Medial collateral B. Lateral collateral C. Posterior cruciate D. Anterior cruciate

D. Anterior cruciate Anterior cruciate ligament injuries occur with sudden deceleration injuries. Patients often hear a pop and the diagnosis is aided by assessing the anterior drawer test and Lachman test. The immediate swelling as well as laxity with anterior drawer test and Lachman test should raise suspicion of anterior cruciate ligament injury.

When should someone with kyphosis be treated with a Milwaukee brace?

- Curves of 45 - 60 degrees should be observed every 3-4 months and exercise prescribed for lumbar lordosis. - Curves > 60 degrees or with significant pain should be treated with bracing (Milwaukee brace).

What's the best way to differentiate spinal stenosis from lumbar radiculopathy?

- Spinal stenosis gets worse with walking and exercise - Straight leg raise (nerve root tension sign) is usually negative - Relieved with flexion at the hips and by leaning forward (sitting or leaning over shopping cart)

How do you tell RA from OA?

-OA from RA by -morning stiffness lasting <30mins -evening joint stiffness -worsens w/ use -improves w/ rest

Patient will present as → an obese 16-year-old boy with pain in his left groin, hip, and thigh. His mother notices a limp when he walks. The patient denies any recent significant trauma to his left lower extremity. On physical exam, his gait is antalgic. With the patient in the supine position, there is external rotation and abduction of the thigh with passive flexion of the hip. A radiograph of the affected hip is performed, which demonstrates an inferior displacement of the left epiphysis.

-Slipped capital femoral epiphysis Buzz -pain in left groin, hip, thigh -limp walk -external rotation & ABD of thigh

TOC for compartment syndrome?

-opening compartment via fasciotomies

What are the three causes of Thoracic outlet syndrome?

1. Congenital anomalies, including cervical rib (an "extra first rib"), abnormal fascial bands to the first rib, or abnormal scalene muscles 2. Trauma—first rib or clavicle fracture, humeral head dislocation, or crush injury 3. Repetitive use/overuse (i.e., baseball pitch

Which of the following is recommended in treating chronic low back pain, according to evidence-based clinical practice guidelines from the American Pain Society (APS)? A. Cognitive-behavioral approaches in patients who do not respond to usual interventions B. Provocative discography C. Facet joint corticosteroid injection D. Prolotherapy

A. Cognitive-behavioral approaches in patients who do not respond to usual interventions

Which of the following statements about lumbar disc disease is true? A. It usually involves the L5-S1 interspace B. It typically involves anterior herniation of the nucleus pulposus C. It usually requires surgical intervention D. Treatment involves strict bed rest for 1 to 2 weeks E. Forward flexion of the trunk often helps relieve symptoms

A. It usually involves the L5-S1 interspace

Which of the following is the initial diagnostic study of choice in patients with lumbar spinal stenosis A. MRI B. CT scanning C. Needle electromyography D. Nerve conduction studies

A. MRI

Septic arthritis in adults younger than 30 years is usually caused by A. Neisseria gonorrhea B. Staphylococcus aureus C. Pseudomonas aeruginosa D. Salmonella species

A. Neisseria gonorrhea

Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament? A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis

A. Supraspinatus -A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa.

Patient will present after → fall directly to the shoulder or outstretched hand

AC joint seperation

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

AC joint seperation Buzz -abnormal contour of left shoulder, AC joint tenderness, cross chest testing

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

Adhesive Capsulitis

Patient will present as → a 24-year-old male with severe morning back pain and stiffness over the past three months. His pain improves as the day progresses and with exercise. He also complains of photophobia and eye pain with redness. Physical exam shows a stooped posture and diminished anterior flexion of the lumbar spine. Radiography of the lumbar spine shows bilateral sclerotic changes in the sacroiliac area and squaring of the vertebral bodies. Laboratory testing demonstrates an elevated ESR and shows that the patient is HLA-B27 positive.

Ankylosing spondylitis bUzz -severe morning back pain, stiffness, improves throughout day w/ exercise, photophobia, eye pain with redness, sclerotic changes in sacroiliac area, squaring of vertebral bodies, increased ESR, HLA-B27 +

A 73-year-old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have? A. Anterior cord syndrome B. Central cord syndrome C. Brown-Séquard syndrome D. Complete cord transection E. Cauda equina syndrome

B. Central cord syndrome The central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown-Séquard syndrome consists of weakness and loss of posterior column function on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion. Complete cord transection would affect motor and sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain with radiculopathy.

Which of the following is the most common cause of impingement syndrome (nerve root compression)? A. Spinal stenosis B. Herniated discs C. Cauda equina syndrome D. Spinal degeneration

B. Herniated discs Impingement pain tends to be sharp, well localized, and can be associated with paresthesia, whereas irritation pain tends to be dull, poorly localized, and without paresthesia. Impingement is associated with a positive straight-leg raising sign, whereas irritation is not. Neurologic deficits and pain radiation below the knee are rarely seen in irritation alone and are most commonly found with impingement. The cause of impingement syndrome is most commonly herniated discs, but it may also be caused by spinal stenosis, spinal degeneration, or cauda equina syndrome.

Which of the following is the most common preoperative diagnosis for adults older than 65 years who undergo spinal surgery? A. Osteoporosis fracture B. Lumbar spinal stenosis C. Compression fracture D. Cervical stenosis

B. Lumbar spinal stenosis

A 26-year-old male was lifting a heavy object two weeks ago when he felt a sudden onset of low back pain. He describes pain in the low mid back at the belt line aggravated with movement. Radicular symptoms are noted in the left buttock down the leg to the dorsal aspect of the foot. He denies any urine or bowel complaints His examination demonstrates an inability to stand on his toes and a positive straight leg raise. Which of the following is most appropriate diagnostic study in this patient? A. Computed tomography (CT) B. Magnetic resonance imaging (MRI) C. Discography D. Electromyogram

B. Magnetic resonance imaging (MRI) MRI is the diagnostic study of choice in a patient with suspected disc herniation.

A six-month-old male presents to the pediatrician for a well-child visit. The patient's mother is concerned about the patient's vision because he often turns his head to the right. She has begun trying to correct the head turn and places him on his back with his head turned in the opposite direction to sleep, but she has not noticed any improvement. She is not certain about when the head-turning began and denies any recent fever. She reports that the patient fell off the bed yesterday but was easily soothed afterward. The patient is otherwise doing well and is beginning to try a variety of solid foods. The patient is sleeping well at night. He is beginning to babble and can sit with support. The patient was born at 37 weeks gestation via cesarean delivery for breech positioning. On physical exam, the patient's head is turned to the right and tilted to the left. There is some minor bruising on the posterior aspect of the head and over the sternocleidomastoid. He has no ocular abnormalities and is able to focus on his mother from across the room. Which of the following is the best next step in management? A. Direct laryngoscopy B. Neck radiograph C. Reassurance and follow-up in one month D. Referral to ophthalmology E. Referral to physical therapy

B. Neck radiograph persistent head turning to the right and head tilt to the left, which suggests a diagnosis of torticollis. The best next step in management is a neck radiograph to rule out acquired etiologies.

A 62-year-old man presents complaining of progressively worse right shoulder pain for 5 weeks. The pain is located anterolaterally and is aggravated by overhead activities. The patient notes significant pain when trying to sleep with his arm in a forward-flexed position and his hand behind his head. The patient notes weakness of the right arm and states that he has noticed that he uses the arm less because of the pain. On physical examination, you elevate the patient's arms to 90 °, abduct to 30 °, and internally rotate the arms with the thumbs pointing downward. You note weakness and drooping of the right arm with this maneuver that is exacerbated when you apply downward pressure to the right arm. On the basis of this presentation, what is the most likely injured structure? A. infraspinatus tendon B. supraspinatus tendon C. teres minor tendon D. subscapularis tendon E. bicipital tendon

B. supraspinatus tendon supraspinatus strength test or the "empty the can" test. Weakness in this maneuver is suggestive of injury to supraspinatus tendon

Patient will present as → a 33-year-old man who complains of left anterior shoulder pain for 4 weeks. The pain is made worse with overhead activities. On examination, you note maximal pain in the shoulder with palpation between the greater and lesser tubercle. Pain in the shoulder is exacerbated when the arm is held at the side, elbow flexed to 90 degrees, and the patient is asked to supinate and flex the forearm against your resistance.

Biceps Tendonitis

Patient will present with → pain at the biceps groove

Biceps Tendonitis

Patient presents as → a 42-year-old who sustained a left finger injury while attempting to catch a baseball for his son. He presents today with left, middle finger pain and an inability to extend his middle finger at the distal interphalangeal joint. A radiograph after closed reduction and splinting is shown here.

Boutonniere Deformity - Tear at PIP joint (jammed finger)

Patient presents as → a 29-year-old man who arrives at the emergency department with a swollen right hand. According to the patient's girlfriend, he punched a wall after having an argument. On physical exam, there is marked swelling over the ulnar side of his right hand with limited movement of the 5th metacarpophalangeal joint due to pain. Radiographs reveal a fracture of the 5th metacarpal neck of the right hand.

Boxer's Fracture

The presence of a "bamboo spine" on spine radiographs, elevated ESR, and a positive test for HLA-B27 support the diagnosis of A. Multiple myeloma B. Reiter's syndrome C. Ankylosing spondylitis D. Rheumatoid arthritis E. Pott's disease

C. Ankylosing spondylitis

What spinal nerve root is most likely affected in a patient with weak wrist extension, thumb and index finger paresthesias and diminished triceps reflex? A. Cervical 4 B. Cervical 5 C. Cervical 6 D. Cervical 7

C. Cervical 6 - cervical 5 would be associated with deltoid and biceps weakness and diminished biceps reflex - cervical 7 would result in triceps weakness and paresthesias in the middle finger and diminished brachioradialis reflex.

Which of the following is most suggestive of cauda equina syndrome? A. Low back pain without a clear precipitating event B. Presence of other systemic symptoms (eg, fever, weight loss, dysuria) C. New-onset bowel or bladder dysfunction D. Straight-leg test results indicating pain radiating to below the knee, not merely in the back or hamstrings

C. New-onset bowel or bladder dysfunction Any history of new-onset bowel or bladder dysfunction (eg, urinary hesitancy, overflow incontinence) with back pain is suggestive of cauda equina syndrome. This is particularly true if other, new neurologic deficits are also present.

A 65-year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected? A. L3-L4 B. L4-L5 C. L5-S1 D. S1-S2

C. L5-S1 The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles.

Which of the following is indicated in appropriateness criteria from the American College of Radiology (ACR)? A. All patients with acute lower back pain and/or radiculopathy should undergo imaging studies B. In patients with a history of osteoporosis, initial evaluation with CT scanning is indicated C. MRI is the imaging procedure of choice in patients suspected to have cord compression or spinal injury D. Patients with recurrent low back pain and history of prior surgical intervention should be evaluated initially with radiography

C. MRI is the imaging procedure of choice in patients suspected to have cord compression or spinal injury

Which of the following is the most common symptom in patients with lumbar spinal stenosis? A. Bladder difficulties B. Cauda equina syndrome C. Radiating leg pain D. Bowel difficulties

C. Radiating leg pain constellation of symptoms that include lower back pain, radiating leg pain (unilateral or bilateral), and possible bladder and bowel difficulties. The classic presentation is radiating leg pain (with or without a numbness and tingling sensation) associated with walking that is relieved by rest (neurogenic claudication). When patients bend forward, the pain diminishes.

A 21 year old who is training for his first half marathon progressively develops worsening pain in his right foot. At first it was relieved with rest but now it persis. Examination reveals pain with pressure applied to the fifth metatarsal. Which of the following is the best test to confirm the suspected diagnosis? A. CT B. MRI C. bone scan D. x-ray

C. bone scan Bone scan is the most sensitive test for stress fracture. It will demonstrate uptake in the area of the stress fracture before it would appear on x-ray

Patient presents as → a 39-year-old woman complaining of pain and numbness in her hand. The patient reports that the pain is most severe during hours of sleep and that the pain can sometimes wake her up at night and she feels as if her thumb is falling asleep. To relieve the pain she shakes her hand or places it under warm running water. She says her symptoms mainly affect the first 3 digits of her hand. She denies any recent injury to or pain in the hand or neck. On physical exam, she has normal range of motion of the neck and arm. She has 2+ bilateral biceps, triceps, and brachioradialis reflexes. She has a positive Phalen and Tinel test.

Carpal Tunnel Syndrome

Patient presents as → a 27-year old male who was involved in a minor motor vehicle accident. He was restrained at the time of impact. On arrival in the emergency room, he is alert and oriented, airway is stable, and has a normal blood pressure and heart rate. Physical exam shows a laceration over his forehead. He has 5/5 strength in his upper and lower extremities with normal sensation and reflexes. The patient is discharged home.

Cervical Spine Strain

Patient will present as → a 57-year old male with right arm pain of 4 weeks duration. He reports the pain began following a tennis match and has not improved with time. He describes the pain as an aching sensation that affects his lateral forearm that improves when he abducts the shoulder. He also describes a sensation of numbness in this right thumb. The reflex exam shows he has 1+ right biceps reflexes and 2+ right triceps reflexes which are both symmetric with the left side. A sensory exam shows paresthesias in the distribution of the right thumb. Motor exam shows no evidence of radial deviation with active wrist extension. Motor exam on the right shows 5/5 deltoid, 5/5 elbow flexion with the palms facing upward, 4/5 wrist extension, and 5/5 elbow extension, and 5/5 wrist flexion.

Cervical herniated disk The clinical presentation is most consistent with C6 radiculopathy. This would be caused by a paracentral cervical disc herniation at C5/6. Buzz numbness in right thumb, lateral forearm, 1+ right biceps reflexes, paresthesias in distribution of right thumb, 4/5 wrist extension

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

Clavicle Fracture Buzz -swelling, erythema, tenderness on anterior aspect of right shoulder

Patient presents as → a 73-year-old female who tripped while getting out of the car and fell onto her outstretched right hand. She experiences immediate pain and swelling over her right wrist. On exam, the patient has a dinner-fork deformity of the wrist and exquisite pain with passive motion. A radiograph is shown, which reveals a dorsally angulated distal radius fracture.

Colles Fracture - Distal Radial Fracture (Posterior Angulation)

Patient will present as→ a 54-year-old male presents with a slowly enlarging mass on the dorsum of his left wrist which has been present for 3 years. He denies any significant symptoms. Physical exam shows a 1 cm palpable mass which transilluminates.

Ganglion cyst

Patient will present as → a 33-year-old man who has undergone ORIF of the left tibia. Fifteen hours postoperatively, the patient complains of increased pain and swelling of his left leg. His pain is unrelieved by medication, he is experiencing numbness, tingling, and loss of function in the extremity. Physical examination demonstrates decreased sensation and painful paralysis of his toes along with diminished pedal pulses on the affected side and coolness with a loss of color in the area.

Compartment Syndrome

Patient will present → after sustaining an injury from the inside (varus stress)

LCL injury

Patient presents as → a 45-year-old secretary complaining of weakened grip along with pain and numbness over the small finger and ulnar half of 4th finger and ulnar dorsum of the hand. Her symptoms often wake her at night and are exacerbated when she talks on her cell phone.

Cubital/Ulnar Tunnel Syndrome

In which of the following disks is spur formation most common? A. C1-2 B. C3-4 C. C4-5 D. C6-7

D. C6-7 With aging, the intervertebral disk degenerates and collapses, leading to spur formation. This most commonly occurs at C5-6 and C6-7. A relative decrease in spinal motion occurs at these levels, with a concomitant increase in spinal motion at C3-4 and C4-5. The spine responds to physiologic stresses with bone growth at the superior and inferior margins of the vertebral body (osteophytes).

Which of the following is not generally considered a routine and common finding upon physical examination of hip fracture? A. Limited range of motion (especially internal rotation) B. Pain upon passive hip motion C. Tenderness to palpation over the femoral neck D. Ecchymosis overlying the affected area

D. Ecchymosis overlying the affected area

Which of the following statements about scoliosis is true? A. The most common form is congenital B. The patient has a normal Adam's test C. Patients with abnormalities > 5 degrees should be referred to an orthopaedist D. Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left E. Syringomyelia is not associated with scoliosis

D. Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left

ou are evaluating a 13-year-old male for progressively worsening thoracic pain that has been present for the past 6 months. The patient characterizes the pain as a dull ache that is present all of the time. If he tries to lean backward and extend his upper back, the pain will become sharp. His parents have noticed that his upper back has been becoming progressively more rounded over the past several years. Radiographs (x-rays) of the thoracic spine reveal anterior wedging of four adjacent thoracic vertebrae, the degree of wedging ranges from 7 to 10 degrees. What is the most likely cause of his pain? A. Ankylosing spondylitis B. Postural kyphosis C. Thoracic scoliosis D. Scheuermann kyphosis E. Thoracolumbar scoliosis

D. Scheuermann kyphosis Scheuermann kyphosis is most common in boys and is diagnosed radiographically a kyphotic curve with anterior wedging of more than 5 degrees in a minimum of three successive vertebrae. Postural kyphosis is more common in girls and the patient is able to correct the curvature voluntarily. Ankylosing spondylitis results in straightening and fusion of the involved spinal segment. Scoliosis is the term used to describe a lateral curvature of the spine.

Which of the following is not associated with greater treatment effects of surgery for spinal stenosis? A. Neuroforaminal stenosis B. Predominant leg pain C. Neurologic deficit D. Smoking habit

D. Smoking habit

Patient presents as → a 63-year-old man with palmar contractures. He reports that his hand appears "deformed" and denies any pain. His past medical history is significant for alcoholic cirrhosis. Physical exam reveals thickened skin on his palms, contractures of his fourth and fifth fingers bilaterally, and several non-tender palmar nodules. He is counseled on this condition and he opts to try injected collagenase.

Dupuytren Contracture: AKA Claw Hand

Patient presents as → a 32-year-old secretary presents with pain over the radial side of her right wrist. She denies any history of wrist trauma. Her pain is aggravated by carrying her 3-month-old son. She is swollen and tender over the radial styloid. Finkelstein test is positive. Radiographs are normal without signs of osseous abnormalities.

De Quervain's Tenosynovitis

A 33-year-old man complains of left anterior shoulder pain for 4 weeks. The pain is made worse with overhead activities. On examination, you note maximal pain in the shoulder with palpation between the greater and lesser tubercle. Pain in the shoulder is exacerbated when the arm is held at the side, elbow flexed to 90 ° and the patient is asked to supinate and flex the forearm against your resistance. On the basis of this presentation, what is the most likely diagnosis? A. rotator cuff tendonitis B. myocardial infarction C. anterior shoulder dislocation D. rotator cuff tear E. bicipital tendonitis

E. bicipital tendonitis Bicipital tendonitis is an inflammation of the long head of the biceps tendon and the tendon sheath causes anterior shoulder pain that resembles and often accompanies coexisting rotator cuff tendonitis. Tenderness with bicipital tendonitis is reproduced with Yergason test. During Yergason test, the shoulder pain is exacerbated when the arm is held at the side, elbow flexed to 90 °, and the patient asked to supinate and flex the forearm against your resistance. Rotator cuff injuries often accompany bicipital tendonitis, and bicipital tendonitis can occur secondary to compensation for rotator cuff disorders or labral tears. In this case, the pain is clearly reproduced in a pattern suggestive of bicipital tendonitis. Myocardial infarction can present as shoulder pain and should always be considered in patients, especially those with known cardiac risk factors.

Patient presents as → a 23-year-old male with severe left arm pain. One hour prior to presentation, he was climbing a tree to retrieve a kite and fell 6 feet onto the ground. He landed on his pronated outstretched left arm and developed immediate-onset pain and swelling. On exam, he is tender to palpation with a notable deformity characterized by radial wrist angulation. The distal ulna is palpable. Radiographs demonstrate a fracture of the distal radial diaphysis with associated dislocation of the distal radioulnar joint.

Galeazzi Fracture

13-year old with severe pain in left mid forearm after falling awkwardly on an outstretched left arm, unable to move left arm without significant pain (watch video)

Forearm Fx

Patient will present as → a 67-year-old female with a severe throbbing headache and visual impairment in the left eye. The patient describes worsening of pain with chewing or combing her hair. Lately, she reports feeling very weak and tired especially in the mornings. At times she cannot even raise her arms to reach the cabinets in her kitchen. On physical exam, she has decreased visual acuity of the left eye, scalp tenderness on the left, and an absent pulse in the left temporal area. Laboratory testing is significant for an elevated erythrocyte sedimentation rate. She is admitted and immediately started on systemic glucocorticoids.

Giant Cell Arteritis

Patient will present as → a 66-year-old male with chronic right shoulder pain and crepitus. On physical exam his rotator cuff strength is 5/5. He has pain with both passive and active range of motion. Radiographs are shown here and here. An MRI is performed and shows no evidence of a rotator cuff tear.

Glenohumeral Joint Osteoarthritis Buzz -shoulder pain, crepitus, rotator cuff strength is 5/5, pain, PROM & AROM

Gonococcal arthritis may present in what two forms?

Gonococcal arthritis may present in two forms: asymmetric polyarthritis, often with tenosynovitis and dermatitis, usually in the knee or wrist; or purulent monoarthritis.

Septic arthritis in YA?

Gonorrhea - treat with ceftriaxone

Osteophytes found at the *distal interphalangeal joints* in osteoarthritis

Heberden nodes (think HD TV - Haberdeen = distal)

Patient will present as → 45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. The patient is unable to tiptoe.

Herniated nucleus pulposus Buzz -radiates, straight leg raise +

Patient presents as → a 73-year-old female who arrives at the emergency room with left arm pain after tripping and falling on the sidewalk. She developed immediate pain throughout her arm. The patient has a history of osteoporosis for which and has been on bisphosphonate therapy for 12 months. Radiographs of her left arm demonstrate a spiral midshaft humeral fracture. She is given appropriate analgesia and placed in a coaptation splint.

Humerus Fx

Patient presents as → a 45-year-old woman with elbow pain. She reports that the pain began a few weeks ago and affects the lateral aspect of the left elbow. The pain improves with rest and is aggravated while playing tennis or holding a cup of coffee. On physical exam, there is tenderness upon palpation of the lateral epicondyle. Pain is elicited with resisted wrist extension while the elbow is fully extended.

Lateral Epicondylitis (Tennis elbow)

Patient will present as→ a 25-year-old woman with a painful middle finger. She obtains regular manicures, changing colors every 2 weeks. She recently had one a week ago and started feeling pain near the nail on her left middle finger. Her current medications include isotretinoin for the treatment of acne. Physical exam reveals an erythematous proximal nail fold of the middle finger. When applying pressure to the nail plate, some pus drains from the nail. She is prescribed frequent warm soaks with chlorhexidine and oral antibiotics.

Infections of the hand

Patient will present → after a high impact trauma cannot extend the knee

Knee dislocation

Patient presents as → a 48-year-old male with a complaint of lower back pain that has developed over the past week. He works in construction but cannot recall a specific injury or incident that could have led to this pain. He denies any pain, weakness, or change/loss of sensation in his legs. The patient also reports no episodes of incontinence and confirms that he has not noted any changes in his bowel movements or urination. Vital signs are as follows: T 37.2 deg C, HR 74 bpm, BP 122/70 mmHg, RR 12, SpO2 100% RA. Physical examination is negative for any focal spine tenderness and demonstrates 5/5 strength and intact sensation to light touch throughout the bilateral lower extremities.

Lower Back Pain Buzz -denies nay pain, weakness, change/loss of sensation in legs, episodes of incontinence, not noted an bowel movement or urination changes

Patient will present as → a 35-year-old male presents with a three-month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the dorsal aspect of his foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MRI images are obtained.

Lumbar herniated disk The clinical presentation is consistent with a lumbar disc herniation with symptoms of a combined L5 and S1 radiculopathy Buzz -pain and paresthesias localized to buttock, lateral and posterior calf, dorsal aspect of foot, 4/5 plantar-flexion & 4+/5 ankle dorsiflexion

Patient presents as → a 42-year-old who sustained a left finger injury while attempting to catch a baseball for his son. He presents with left, long finger pain and an inability to extend his middle finger at the distal interphalangeal joint. A radiograph after closed reduction and splinting is shown here.

Mallet (BASEBALL) finger - Tear at DIP joint

What is the cause of osteoarthritis?

Mechanical wear and tear leading to articular cartilage destruction

Patient presents as → a 47-year-old man with right-sided elbow pain. He describes the pain as sharp and worsens when performing arm curls or playing golf. He denies any direct trauma to the elbow. On physical exam, there is tenderness upon palpation of the medial elbow. Pain is elicited with resisted wrist flexion while the elbow is fully extended.

Medial Epicondylitis (Golfer's/Pitcher's elbow)

Patient will present as → a 33-year-old female involved in a motor vehicle accident in which she is rear-ended in slow-moving traffic at less than 10 MPH. She presents to the ER complaining of localized neck stiffness and pain. On physical exam, she has paraspinal tenderness in the cervical region. She has limited motion secondary to pain. Her motor, sensory, and reflex exam are normal in her upper and lower extremities. Radiographs are obtained and show normal cervical spine AP and lateral radiographs.

Neck Trauma Buzz - involved MVC -localized neck stiffness & pain -limited motion

Patient presents as → an otherwise healthy 30-year-old male who sustained a left forearm injury as a result of a fall from a 15-foot ladder. Initial examination in the emergency room reveals a clean 2-centimeter laceration over the volar forearm, pain and swelling of the affected arm along with decreased active and passive range of motion. Radial and ulnar pulses are intact. Radiographs are performed and are shown here.

Nightstick Fracture (Isolated fracture of the ulna)

Patient will present → after a fall directly on the knee

PCL injury

Patient will present as → a 3-year-old boy is brought to the clinic because of left elbow pain. The father of the patient says that after picking up the boy from daycare, he noticed his son was not moving his elbow and complained of pain. Patient is holding his left elbow flexed and pronated. Physical examination shows tenderness over the lateral aspect of the left elbow joint on palpation.

Nursemaid's Elbow

Patient presents as → a 49-year-old computer programmer with right elbow swelling for the past few months. The swelling has worsened and became more painful over the last week. He works 12 hours a day and spends a lot of time at his desk keyboarding and working with his mouse. On examination, he has no fever. There is a red and tender swelling of the left posterior elbow.

Olecranon Bursitis (Scholar's Elbow)

Patient presents as → a 10-year-old man who arrives at your ED complaining of severe right elbow and forearm pain after sustaining a blunt injury to his right arm. On examination, the affected arm is swollen and tender around his elbow. Radiographs demonstrate a displaced fracture of the proximal ulnar diaphysis and radial head dislocation.

Proximal ulnar shaft fracture with radial head dislocation Monteggia Fracture

What health maintenance test should be performed on patients with scoliosis?

Pulmonary function tests to determine whether the scoliosis is affecting breathing. Will demonstrate a restrictive airway pattern.

Patient presents as → a 35-year-old concert cellist presents after falling onto a pronated, outstretched hand this morning. She complains of lateral elbow pain. Examination reveals lateral elbow tenderness, and an 80-degree arc of flexion-extension and a 60-degree arc of prono-supination, with extremes of motion limited by pain. There is no bony block to motion. Radiographs of her injury are performed and reveal a Mason Type I radial head fracture.

Radial Head Fracture

Patient presents as → a 4-year-old boy with elbow pain. He was forcefully pulled onto the curb by his mother after a close call with an oncoming car. Since the incident, the child has presented with right elbow pain and has refused to move his right arm. Examination reveals an irritable child cradling his right upper limb with his left hand. The affected limb is pronated with the elbow slightly flexed. Radiographs reveal subluxation of the radial head but are otherwise negative for a fracture.

Radial head subluxation (Nursemaid's elbow)

Patient will present as → a 30-year-old male arrives at the emergency room after a motor vehicle accident. Upon arrival, he has difficulty breathing and reports shoulder pain. On physical exam, he has decreased breath sounds on the right side and significant tenderness of his right shoulder. There is overlying ecchymosis, swelling, and erythema over his right scapula and limited range of motion.

Shoulder Fractures

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

Rotator cuff tendinopathy/tear

Patient presents as → a 16-year-old cross country runner trips during a track meet and lands on his outstretched left hand. He experiences immediate-onset, severe left wrist pain and inability to flex or extend his wrist. On exam, he has point tenderness dorsally over the anatomic snuffbox. A radiograph of his left wrist demonstrates a fracture of the proximal pole of the scaphoid.

Scaphoid Fracture (Snuffbox tenderness)

Septic arthritis carries a high risk of what?

Septic arthritis carries a high risk of joint destruction and is considered a medical emergency.

Patient will present as → an 80-year-old woman arrives at the emergency room with severe right shoulder pain and immobility. She fell down the steps outside her house and landed on her right side two hours prior to presentation. On exam, her right arm is abducted and externally rotated. She has decreased sensation to touch over the lateral aspect of her right shoulder. Radiographs demonstrate an anterior shoulder dislocation.

Shoulder Dislocation Buzz - severe right shoulder pain & immobility, her right arm is abducted & externally rotated

Can pt have pulse & compartment syndrome?!

YES

Patient presents as → a 73-year-old woman arrives at the emergency department following a fall in her home. She tripped over a throw rug, fell forward and landed with her arms extended and hands flexed. She presents complaining of left wrist pain. On x-ray, you note an extra-articular metaphysical fracture of the radius with volar angulation and displacement.

Smith Fracture - Distal Radial Fracture (Anterior Angulation)

Patient will present as → a 65-year-old male complaining of low back pain radiating to the left buttock, posterior thigh and lateral leg. The pain is worse when walking downhill or standing upright, and was relieved when he sits or uses his walker. Examination reveals normal reflexes, reduced sensation over the left lateral and posterior leg, and weak big toe dorsiflexion. Pain on the left is made worse with back extension. Straight leg raise was 30 degrees on the left and 90 degrees on the right. Dorsalis pedis and posterior tibial pulses were normal. Xray showed disc degeneration at the L4-L5 level and facet joint hypertrophy at that level.

Spinal Stenosis Buzz -low back pain radiating to left booty, posterior thigh, lateral leg, worse when walking downhill, relieved when he sits or uses his walker, reduced sensation, left lateral posterior leg, weak big toes dorsiflexion, worse with back extension, straight leg raise was 30 degrees on left, dis degeneration at l4-5, facet joint hypertrophy

Patient will present as → 45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g., pushing a grocery cart).

Spinal Stenosis Buzz -prolonged standing & walking, relieved by sitting & leaning forward

What is the most common cause of septic arthritis in children and adults?

Staphylococcus aureus

What is the second most common cause of septic arthritis after S. aureus?

Streptococci spp.

Patient presents as → a 35-year-old triathlete who reports an insidious onset of localized aching pain, swelling and tenderness at the end of activity. Now after several weeks the pain has become more severe and is tender throughout his runs. Her pain improves with rest. She denies any trauma to her foot or history of fracture. On physical exam, there is pain upon palpation of the second and third metatarsal bone of the right foot. Her X-Ray is seen here.

Stress Fracture buzz -pain improves w/ rest, 2nd & 3rd metatarsal bone of right foot

Patient will present as → a 42-year-old man with complaints of right shoulder pain. He does not remember any specific injury but has been playing a lot of tennis during the past 4 months. He tells you that "opposing players no longer fear my serve." It has become difficult and painful for him to reach overhead and behind him. Even rolling onto his shoulder in bed is painful. On examination of the right shoulder, there is full range of motion in all planes with obvious discomfort at end ranges of flexion, abduction, and internal rotation. There is significant pain when you place the shoulder in a position of 90 degrees flexion and then internally rotate. There is also moderate weakness with abduction and external rotation of the shoulder. The rest of the musculoskeletal examination is normal.

Subacromial Bursitis BUzz -difficult & painful for him to reach overhead, rolling onto his shoulder in bed is painful, discomfort at end ranges of flexion, abduction, internal rotation, 90 degrees flexion & internally rotates

Patient will present as → a 70-year-old male with an insidious onset of left shoulder pain that is exacerbated by overhead activities and while lifting objects away from his body. He is a retired mechanic of 35 years. The patient reports that over the last several months he has been having difficulty sleeping because of the pain. On physical examination, there is notable tenderness over the left anterolateral shoulder and passive forward flexion >90° causes severe pain. An x-ray reveals proximal migration of the humeral head and calcification of the coracoacromial ligament.

Subacromial Impingement -insidious onset of left shoulder pain, excerbated by overhead activites, passive forward flexion >90 causes severe pain, proximal migration of humeral head

Patient presents as → a 7-year-old girl who fell from a jungle gym and lands on her outstretched left hand. She develops immediate-onset left elbow pain and swelling. On exam, her arm is held in 30 degrees of extension and she is unable to move her elbow due to pain. A radiograph is shown here and demonstrates a dorsally displaced supracondylar humerus fracture.

Supracondylar Fracture

Does the synovial fluid analysis in osteoarthritis reveal low or high levels of white blood cells?

Synovial fluid analysis in osteoarthritis reveals low levels of white blood cells.

A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected?

T 10

Patient presents as → a 17-year-old female complaining of foot pain. She states that yesterday, while at cheerleading practice, she was dropped after being thrown in the air. She states that she landed on her right foot and she immediately had pain. Today, she has noticed significant swelling of her right foot behind her ankle. On physical examination, she has excruciating posterolateral pain in her right ankle with plantar flexion and flexion of her great toe. She also has decreased range of motion in her subtalar joint. Ankle radiographs are shown here.

Talus Fx Buzz -significant swelling of right foot behind ankle

Patient presents as → a 46-year-old woman presents with a chief complaint of burning and tingling on the plantar aspect of the right foot. She has a history of recurrent ankle sprains on the same foot. The area has reduced sensitivity to light touch. Tinel sign is present at the posterior tibial nerve adjacent to the medial malleolus.

Tarsal Tunnel Syndrome Buzz burning and tingling on the plantar aspect of the right foot. recurrent ankle sprains on the same foot. reduced sensitivity to light touch. Tinel sign

Patient presents as → a 35-year-old male presents with new-onset lower back pain. His symptoms began approximately 3 weeks ago and have not subsided. The patient was playing tennis when he set up for a service and immediately while tossing the ball began to have pain. The pain in pain does not radiate. He denies night sweats, unexpected weight loss, bowel, or bladder symptoms. He does not use illicit drugs and does not smoke. On physical exam, no saddle anesthesia, muscle weakness, or sensory changes are noted. There is tenderness over the iliolumbar ligament.

Thoracic Pine Strain

Patient will present as → a 39-year-old man presents with difficulty grasping his golf club. The patient reports difficulty with maintaining a strong grip in various situations. This symptom is accompanied by numbness and tingling. On physical exam, there is atrophy of his intrinsic hand muscles.

Thoracic outlet syndrome buzz -difficulty grasping golf club, difficulty maintaining strong grip in various situations, numbness & tingling, atrophy of intrinsic hand muscles

What is the best initial step in the management of new torticollis?

The best initial step in the management of new torticollis is neck radiograph to rule out acquired causes including retropharyngeal abscess and atlantoaxial subluxation.

Which joint is most commonly affected by septic arthritis?

The knee is the joint most commonly - affected by septic arthritis; affected joints appear swollen, red, and painful.

Patient presents as → a 35-year-old who arrives at your clinic complaining of pain and swelling at the ulnar aspect of her thumb at the MCP joint. The patient reports that she took a heavy fall while skiing over the weekend. As she grabbed her poles to stand up her thumb was very sore. As the day progresses her thumb became swollen, very painful and now it is very difficult to move her thumb. She had trouble driving to today's appointment. On physical examination, you note laxity and pain with valgus stress and a painful palpable mass along the ulnar aspect of the MCP joint. You note instability in 30° of flexion.

Thumb Collateral Ligament Injury - Gamekeeper's Thumb & Skier's Thumb

Patient presents as → a 43-year-old male falls 15 feet from a ladder while working. He complains of ankle pain, inability to bear sustained the isolated, closed injury shown here. He is otherwise healthy, but routinely smokes 30 cigarettes per day.

Tibial Plafond Fx (Fracture of the distal tibia from impact with talus, interrupting the ankle joint space from a forceful axial load,)

Patient will present as → a 28-year-old man who arrives in your ER complaining of severe right knee pain after falling from a ladder. The patient arrives in a wheelchair and physical exam is extremely difficult secondary to pain. AP, lateral and oblique radiographs are performed.

Tibial Plateau Fractures Buzz -knee pain after falling from ladder -AP, lateral, & oblique

Patient will present as → a child injured in a motor vehicle accident

Tibial plateau fractures

Patient will present as → a 3-day-old boy is evaluated in the newborn nursery for a neck contortion. He was born at 38 weeks gestation and was noted at birth to have bilateral clubfeet. On exam, the top of his head is tilted to the right and his chin is rotated to the left. His left sternocleidomastoid muscle is dystonically contracted. An ultrasound of his neck demonstrates no masses or cysts.

Torticollis Buzz -sternocleidomastoid muscle dystonically contracted

Is osteoarthritis more common in men or women?

Women