Musculoskeletal Smarty PANCE

1) 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done? A X-ray of the lower leg and ankle. B Doppler studies. C Bone scan. D Compartment pressure 2) 18 year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis? A avascular necrosis B myositis ossificans C compartment syndrome D reflex sympathetic dystrophy 3) A 42 year-old male sustained a closed left tibial fracture in a fall two days ago. He was treated with a cast for immobilization. Acutely, he developed severe pain in his left leg. Examination reveals the anterolateral aspect of the leg to be exquisitely tender to palpation. The patient has extreme pain with plantar flexion. What is the most likely diagnosis? A Compartment syndrome B Deep venous thrombosis C Osteomyelitis D Complex regional pain syndrome

1) Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency 2) Compartment syndrome is characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture.

facts 1

1) Leukocytosis and a low synovial glucose are indicative of septic arthritis. 2) lyme dz = erythema migrans, after the onset of erythema migrans the patients develop a severe headache, mild stiffness of the neck, migratory musculoskeletal pain, arthralgias and profound malaise and fatigue. 3) The scoliotic curve is measured by the Cobb method using AP and lateral x-ray films of the entire length of the spine. 4) Galeazzi's fracture/dislocation involves a fracture of the mid or distal radial shaft with distal radioulnar joint dislocation. 5)1% lidocaine and corticosteroids are most commonly used together for joint injections 6)Lyme disease is a tick-borne illness caused by the spirochete B. burgdorferi. 7) The posterior column affects proprioception (position sense) and vibration sense 8) Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis of the knee that have failed other therapies. Although the onset of action of this medication is slower than injected glucocorticoids, it has a sustained length of activity outlasting the injected glucocorticoids. 9) Lyme dz = Amoxicillin is first line therapy in a patient less than 12 years of age due to the harmful effects of doxycycline on teeth and bones in children. 10) Which of the following leads to retropatellar pain? increased Q angle Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome.

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 a lumbar curvature of 30 degrees E Greater than 70 degrees

20 to 40 degrees Treatment modalities are based on the degree of curvature: 20 degrees or less does not normally require treatment; 20 to 40 degrees is an indication for bracing in an immature child; and 40 degrees and greater is resistant to bracing and requires surgical fixation with spinal fusion, which is best done at special centers. A greater than 70-degree curvature is associated with poor respiratory function in adulthood.

Bone mass measurement should be considered in all women by what age?😨😩😩😨😩😨😨😨😨 A 30 - 35 B 40 - 45 C 50 - 55 D 60 - 65

60 - 65 National Osteoporosis Foundation

Posterior lateral talar tubercle fracture

A 16-year-old female presents to her orthopedic surgeon 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. What is the most likely diagnosis?

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

A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.

A 34 year-old female, with a past medical history of irritable bowel syndrome and migraines, presents with fatigue, generalized aching and stiffness of the trunk, hip, and shoulder girdles. She complains of pain and tightness in the neck and across the upper posterior shoulders. She complains of poor sleep, but denies depression. Physical examination is unremarkable except for numerous tender points on palpation. Laboratory evaluation was unremarkable. Which of the following is the best intervention for this patient? 😨😨😩😩 A corticosteroids B supervised exercise program C hydrocodone (Vicodin) D refer to endocrinologis

A carefully planned and individualized exercise program has been proven effective for the management of fibromyalgia.

A 13 year-old female presents to the office with right knee and thigh pain and the inability to bear weight since waking yesterday morning. The mother states the child had a fever of 100.9 degrees F this morning and continues to be non- weight bearing. Examination reveals a warm, erythematous, swollen knee. Which of the following tests would be most beneficial in the diagnosis and treatment of this patient? A Plain x-ray of the femur B Antistreptolysin O titer C Magnetic resonance imaging (MRI) of the femur D Culture of joint aspirate

A culture of the joint fluid will confirm the diagnosis and offer information regarding infectious agent.

In the neonate, unequal thigh folds may indicate which of the following? A Coxa vara B Legg-Calve-Perthes disease C Developmental hip dysplasia D Slipped capital femoral epiphysis

A dislocated hip displaces proximally in developmental hip dysplasia, causing a shortening of the leg that may present as unequal thigh folds.

Which of the following is the most sensitive to determine whether there is a small effusion in the knee? A Compress the patella and move it against the femur, noting any crepitus B Flex the knee to about 90 degrees and palpate for tenderness over the joint line C Milk the medial aspect of the knee, press lateral margin of the patella, and note a bulge of returning fluid medial to the patella D Force fluid into space between the patella and the femur, tap the patella over the femur to detect a click

A small bulge of returning fluid after milking fluid upward from the knee is useful for detecting small effusions

A 44 year-old female presents with ongoing arthralgias and myalgias with intermittent flares of arthritis. She is found to have a malar rash that worsens with sun exposure. She is known to have progressive renal damage and has recurrent infections that are slow to respond to therapy. She takes ibuprofen (Motrin) as needed for her joint pain and takes no other medication. Which of the following tests would be the initial test recommended to screen for this diagnosis? A Rheumatoid factor B Antihistone antibodies C Anti-Smith (Anti-Sm) antibodies D Anti-nuclear antibodies (ANA)

ANA's are the best screening test used in the evaluation for SLE

Which of the following medications inhibits prostaglandin synthesis in a patient with rheumatoid arthritis?😨😨😨 A Methotrexate B Infliximab (Remicade) C Probenecid (Benemid) D Aspirin

ASA Salicylates inhibit the enzymatic production of prostaglandins by inhibiting cyclooxygenase.

Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle? A Supraspinatus B Infraspinatus C Teres minor D Subscapularis

Abduction against resistance tests the supraspinatus

Which of the following is the treatment of choice for a torus (buckle) fracture involving the distal radius? A Open reduction and internal fixation B Ace wrap or anterior splinting C Closed reduction and casting D Corticosteroid injection followed by splinting

Ace wrap or anterior splinting A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks.

A 67 year-old female presents with progressive pain in her left knee that is worse with activity and relieved with rest. She notes stiffness of the knee that last about 20 minutes after activity is resumed. She exercises regularly. No known drug allergies. On physical exam she is 5' 5", 225 pounds. Her left knee exam reveals mild effusion without erythema or warmth. Radiographs of the left knee reveal medial joint space narrowing and subchondral bone sclerosis. Her sodium is 138 mEq/L, potassium 4.3 mEq/L, bicarbonate 24 mEq/L, chloride 104 mEq/L, BUN 23 mg/dl and creatinine 1.8 mg/dl. Which of the following medications is most appropriate for this patient's worsening pain?😨😨😩😩😨😨😩😩 A naprosyn B prednisone C acetaminophen D methotrexate

Acetaminophen is recommended as first-line pharmacotherapy in patients with osteoarthritis. Naprosyn is contraindicated in patients with abnormal renal function.

A 65-year-old male presents to his primary care physician for stiffness in his arm. He states that he has been having trouble combing his hair and reaching objects that are high on the shelf. The patient has a past medical history of diabetes mellitus type II, obesity, and hypertension. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient admits to leading a sedentary life in which he tends to stay home and watch television. He does not engage in any physical or strenuous activity. On physical exam the patient has decreased passive and active range of motion of his shoulder. Strength of the patient's upper extremity is 4/5. Which of the following is the most likely diagnosis? A Rotator cuff impingement B Adhesive capsulitis C Biceps tendinopathy D Subacromial bursitis

Adhesive capsulitis classically presents in elderly, sedentary patients with a chief complaint of stiffness. On physical exam, the key findings are a loss of active, but more importantly, passive range of motion. It is the loss of passive range of motion that suggests a diagnosis of adhesive capsulitis over rotator cuff injuries, biceps tendinopathy, glenohumeral osteoarthritis, and subacromial bursitis. The diagnosis of adhesive capsulitis is made clinically, however, radiograph, MRI, and ultrasound can be used to rule out other diagnoses. Treatment includes NSAIDs and physical therapy and can include steroids.

Which of the following risk factors is the most predictive for the development of osteoarthritis? A Age B Major joint trauma C Prior inflammatory joint disease D Repetitive stress

Age is the most significant risk factor for osteoarthritis.

Which of the following clinical characteristics is associated with bicipital tendonitis?😨😨😩😩 A Aggravated by resisted supination of the forearm B Bulging appearance to the proximal arm C Weakness of the arm with internal rotation and adduction D Pain that awakens the patient at nigh

Aggravated by resisted supination of the forearm

Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase? A Probenecid (Benemid) B Allopurinol (Zyloprim) C Colchicine D Indomethacin (Indocin)

Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid.

A 25 year-old female with irritable bowel syndrome presents with complaint of upper and lower extremity discomfort. The patient has pinpoint muscle tenderness over the shoulder girdle, low back and hips. Which of the following medications is the most appropriate treatment in this patient? A Hydrocodone (Vicodin) B Amitriptyline (Elavil) C Methotrexate (Rheumatrex) D Naproxen sodium (Naprosyn

Amitriptyline is the treatment of choice for fibromyalgia and is typically administered at bedtime

A 22 year-old male presents to the emergency department complaining of right hand pain after punching a brick wall. His pain is noted at the ulnar aspect of his hand and worsens with touch and movement. On examination, you notice obvious swelling and tenderness over the dorsum of the right hand proximal to the metacarpal phalangeal (MCP) joint of the fifth digit. Skin is intact. X-ray reveals a fracture of the proximal fifth metacarpal with good alignment. Which of the following is the treatment of choice? A Immediate orthopedic consult for surgical fixation B Long finger splint extending beyond the MCP C Ulnar gutter splint to immobilize fracture site D Referral for casting

An ulnar gutter splint is the most appropriate care in the emergency room.

A 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the emergency department. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?😨😨😨😩😩😩😩 A Anterior plain film of knee B Sunrise view of the knee C Measurement of compartment pressures D Angiograph

Angiography popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.

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

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 ligamental injury.

A 23 year-old female presents with ongoing arthralgias with intermittent flares of arthritis. She is found to have a malar rash and an abnormal urinalysis. Serum ANA and anti-double-stranded DNA antibodies are present. Which of the following tests should be ordered to assess her risk for thrombotic events and future risk of spontaneous abortion? A complete blood count B PT/INR C bleeding time D anti-phospholipid antibodies

Anti-phospholipid antibodies are present in 25% of SLE patients and may cause thrombotic events and spontaneous abortion.

A 35 year-old female presents with a long standing complaint of dry, scratchy eyes and dry mouth. She also reports dyspareunia. Labs demonstrate a positive anti-nuclear antibody and Anti-La antibodies. The patient has a prolonged Schirmer test. Which of the following classes of medicines should be avoided in treating this condition? A Antimalarials B NSAIDs C Glucocorticoids D Anticholinergics

Anticholinergics should be avoided in a patient with Sjogrens syndrome. All the other medications may be used to treat

Antinuclear Antigen (ANA) is most commonly associated with and monitors progress of which of the following disorders? A Systemic Lupus Erythematosis (SLE) B Rheumatoid arthritis (RA) C Osteoarthritis D Ankylosing spondylitis

Antinuclear Antigen is the most helpful screening tool for SLE

Which of the following interventions is initially indicated for helping to relieve the symptoms of plantar fasciitis? A Steroid injections B Short leg walking cast C Arch supports D Surgical release

Arch supports, NSAIDs and stretching exercises are the initial interventions to help relieve symptoms.

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

Axial loading and rotation most likely result in meniscal injuries.

A 58 year-old male presents complaining of anterior right shoulder pain the day after performing extensive yard work. The pain is localized over the anterior proximal humerus with distinct point tenderness. There are no visible abnormalities. The patient has full range of motion and strength with all shoulder movements. The pain is reproduced by asking the patient to resist the examiner during supination of the right elbow. Which of the following is the most likely diagnosis?😨😨😩😩😨😨 A supraspinatus tendonitis B subacromial bursitis C rotator cuff tear D bicipital tendonitis

Bicipital tendonitis presents with anterior shoulder pain that is reproduced by palpating the tendon in the humeral bicipital groove and through resisted motion of the biceps muscle (elbow flexion or supination).

A patient is 12 hours post-closed reduction of a tibial fracture and is in a long leg cast. Despite pain medication the patient complains of unrelieved pain and cannot move his toes. Which of the following is the most appropriate clinical intervention in this patient?😨😨😨😩 A Elevate the leg B Bivalve the cast C Encourage ambulation D Place on PCA pump

Bivalve the cast he cast for this patient is too tight and the pressure needs to be released. Bivalving the cast is the best option for this patient.

An 80 year-old female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use? 😨 A Calcitonin (Miacalcin) nasal spray B Alendronate (Fosamax) C Raloxifene (Evista) D Combined estrogen and progesterone (Prempro) therap

Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body

A 36 year-old male has a history of recurrent low back pain. When lifting a stack of books yesterday, he experienced sudden, severe pain in the lumbar area. He denies radicular pain. His lower extremity examination is unremarkable, and his back examination is remarkable for paraspinal muscle tenderness and increased pain with flexion at the waist. Which of the following management options should be instituted at this time? A refer the patient to orthopedic surgery B continue ordinary activities as tolerated C confine the patient to bed with traction D recommend sleeping on a softer mattress

Continuation of activities as tolerated is recommended during the acute phase. After symptoms resolve, an exercise program should be initiated to strengthen the back.

A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice? A Open reduction and internal fixation B Continuous extension of the DIP with splinting C Continuous flexion of the PIP with splinting D Application of short arm cast

Continuous extension of the DIP with splinting The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via splinting for 6 to 8 weeks

A 62 year-old female presents to the emergency room with significant back pain without radiation after lifting a box weighing approximately 15 pounds. She denies any previous trauma or injuries. Past history includes hysterectomy at age 42 and a 49 pack year smoking history. Her current weight is 107 pounds. Lumbo-sacral spine film indicates a spinal compression fracture at level L4. Which of the following tests would you perform to further assess the patient's findings? A Computed tomography (CT) of the spine B Magnetic resonance imaging (MRI) of the spine C DEXA scan D Technetium-99m bone scan

DEXA scan Low patient weight, smoking, and early estrogen deficiency are all risk factors for osteoporosis. Spontaneous fractures occurring from lifting with above risk factors should be evaluated for bone density.

A 65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine? A Radiolucent lesions B Demineralization C Chondrocalcinosis D Subperiosteal resorption

Demineralization Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X- ray findings demonstrate demineralization in the spine and pelvis

Which of the following groups is most likely to present with Duchenne's muscular dystrophy? A Adolescent females B Middle-aged males C Infant females D Toddler-aged males

Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males.

A 13 year-old girl reports two weeks of worsening right knee pain with no history of antecendent injury or recent trauma. She reports frequent episodes of nighttime awakening with knee pain in the past two weeks. Examination of the knee reveals edema and a tender mass over the anterior proximal right tibia. Her knee exam is otherwise within normal limits. Radiographs of the right knee show a lytic mass with a multi-laminated periosteal reaction involving the proximal anterior tibia. What is the most likely diagnosis?😨😨😩😩 A Ewing sarcoma B Osteochondroma C Multiple myeloma D Osteoid osteoma

Ewing sarcoma The distinctive feature of Ewing sarcoma is the radiographic appearance of a periosteal "onion skin" reaction.

Which of the following fractures is associated with the greatest risk of avascular necrosis of the femoral head? and nonunion? A intertrochanteric B femoral neck C subtrochanteric D pelvic rim

Femoral neck fractures lead to the greatest disruption of arterial blood supply to the femoral head.

During the stages of fracture healing which of the following is responsible for producing collagen? A Osteoclasts B Chondrocytes C Glycosaminoglycans D Fibroblasts

Fibroblasts produce collagen during the inflammation stage of healing.

A 30 year-old male sustains a blow to his right lateral leg during a soccer game. He complains of pain with weight bearing. Examination reveals tenderness along the lateral aspect of the right lower leg, but no point tenderness over the tibia. There is full active range of motion at the ankle, knee, and hip joints. There is no swelling or tenderness of the ankle or knee joints. Which of the following is the most likely diagnosis?😨😨 A Anterior cruciate ligament tear B Fractured fibula C Tibial stress fracture D Gastrocnemius contusion

Fractured fibula Isolated fibular fractures can occur with direct or indirect trauma to the fibular shaft. X-ray films of the leg are mandatory for any patient with a history of trauma and pain on ambulation to rule out this potentially overlooked injury.

A 55 year-old female presents with complaints of stiffness, aching, and pain in the muscles of her neck, shoulders, lower back, hips, and thighs. There is no associated weakness associated with the stiffness and achiness. Laboratory evaluation shows an elevated C reactive protein and erythrocyte sedimentation rate. Which of the following medications is used to treat this condition immediately and will also serve to prevent a known complication from this disorder? A Glucocorticoids B Cyclophosphamide (Cytoxan) C Methotrexate (Rheumatrex) D Azathioprine (Imuran

Glucocorticoids dx: polymyalgia rheumatica and treatment with glucocorticoids can relieve discomfort and prevent the associated ischemic temporal arteritis, which threatens vision.

Which of the following histories best describes spinal stenosis? A Gradual onset of back and thigh pain exacerbated by walking and alleviated by sitting B Acute onset of low back pain with radiation of pain to right foot, aggravated by sitting C Aching in bilateral buttocks with associated pain felt in shoulder or neck D Thigh pain aggravated by walking and absence of pedal pulses

Gradual onset of back and thigh pain exacerbated by walking and alleviated by sitting Spinal stenosis typically presents as back pain and thigh pain aggravated by ambulation and relieved by sitting.

A 4 year-old boy presents to the ED after sustaining a crush injury to his distal third phalanx. Physical exam reveals an associated nail bed injury. Which of the following is the appropriate management? A Rest, ice, elevation B Immobilize, antibiotics, orthopedics referral C Splint for 48 hours, aspirin, ice D Surgical referral for amputation of digit

Immobilize, antibiotics, orthopedics referral

A 35 year-old patient with lupus is being treated for mild arthralgias and rash with hydroxychloroquine. Which of the following clinical manifestations is the most common side effect of this medication?😨😨😨😨😨😨 A impaired night vision B jaundice C proteinuria D mouth sores

Impaired night vision Hydroxychloroquine is associated with macular damage, rash and diarrhea

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

Impingement of the shoulder is most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa.

Which of the following histories is most consistent with rheumatoid arthritis (RA)? A Acute onset, morning stiffness, monoarticular joint swelling and tenderness B Insidious onset, morning stiffness, symmetrical joint swelling and tenderness C Insidious onset, morning stiffness, monoarticular joint swelling and tenderness D Acute onset, morning stiffness, symmetrical joint swelling and tenderness

Insidious onset, morning stiffness, symmetrical joint swelling and tenderness Rheumatoid arthritis has an insidious onset, morning stiffness is typically longer than 30 minutes, and is typically symmetrical in presentation.

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

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 soles muscles, and the abductor hallucis and gluteus maximus muscles.

Which of the following is an established risk factor for osteoporosis? A Parity status B Carbohydrate intake C Lactation history D Low body weight

Low body weight Established risk factors for osteoporosis include low body weight, female sex, advanced age, Caucasian race, and bilateral oophorectomy before menopause without estrogen replacement.

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 Magneti resonance imaging (MRI) C Discography D Electromyelogram

MRI is the diagnostic study of choice in a patient with suspected disc herniation

Which of the following medications is the initial treatment of choice for suppressing the progression of rheumatoid arthritis (RA)? A Naproxen sodium (Naprosyn) B Prednisone C Methotrexate (Rheumatrex) D Gold salts

Methotrexate (Rheumatrex)

Which of the following medications used to treat rheumatoid arthritis is contraindicated in patients with chronic hepatitis? A Sulfasalazine B Methotrexate C Minocycline D Infliximab

Methotrexate is contraindicated in patients with chronic hepatitis

Which of the following treatment strategies is most likely to promote optimal health and limit the morbidity and mortality associated with rheumatoid arthritis? A meningococcal vaccination B NSAIDs C methotrexate D corticosteroids

Methotrexate is the most commonly prescribed DMARD for RA and has been proven to induce remission in some patients.

A 43-year-old female presents with a two-year history of frequent episodes of pain and morning stiffness in both hands and wrists. She experiences some symptomatic relief with ibuprofen but feels that the episodes are becoming more frequent and severe. On examination, you observe joint swelling of several MCP joints on both hands. X-ray of the hands shows joint space narrowing of the MCP joints. In addition to NSAIDs, what is the most appropriate first-line long-term medication to treat this patient? A Prednisone (Deltasone) B Infliximab (Enbrel) C Methotrexate (Rheumatrex) D Sulfasalazine (Azulfidine)

Methotrexate is the standard first-line medication in the treatment of rheumatoid arthritis. This DMARD is generally effective, well-tolerated, and affordable

Physical exam findings in a 4 year-old child that include blue sclerae and recurrent fractures indicates which of the following? A Ehlers-Danlos syndrome B Marfan syndrome C Achondroplasia D Osteogenesis imperfecta

Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.

A 57 year-old male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. Which of the following is the treatment of choice for this patient? A Corticosteroids B Colchicine C Allopurinol D Non-steroidal antiinflammatory agent

NSAID medications are the treatment of choice for acute gouty attacks

A 27 year-old male presents with gradually worsening low back pain and stiffness for the past two years. His symptoms are worse upon awakening and gradually improve throughout the day. Lumbosacral flexion is less than 50%. Lumbosacral spine films show erosions in the joint line of both sacroiliac joints. HLA-B27 test is positive. Which of the following is the most appropriate first-line medication for this patient? A Indomethacin (Indocin) B Methotrexate (Rheumatrex) C Prednisone (Medrol dose pack) D Sulfasalazine (Azulfidine)

NSAIDs, such as indomethacin, are the mainstay of therapy in ankylosing spondylitis (AS)

Which of the following x-ray views will show the presence of a "Scotty dog" deformity seen with spondylolysis? A Lateral B Oblique C Anteroposterior D Open-mouth odontoid

Oblique Spondylolysis results from a defect through the pars interarticularis, which is seen as a defect in the neck of the "Scotty dog" on the oblique view.

A 22 year-old male presents several hours after sustaining a hand injury when he punched a wall. X-rays of the hand demonstrate fracture of the fifth metacarpal neck with 65 degrees dorsal angulation and a claw hand. What is the most appropriate intervention? A Antibiotic treatment and ulnar gutter splint immobilization B Closed reduction and ulnar gutter splint immobilization C Open reduction and ulnar gutter splint immobilization D Ulnar gutter splint immobilization only

Open reduction and ulnar gutter splint immobilization Open reduction is indicated with angulation of greater than 40 degrees

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

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

A 30 year-old diabetic female complains of persistent numbness in her right thumb and forefinger that has been awakening her from sleep for the past week. She is right hand dominant and denies any history of activities involving repetitive motion of the hands. Which of the following is the next step in the evaluation of this patient? A Electromyogram (EMG) B Nerve conduction velocity (NCT) C Phalen maneuver D Finkelstein test

Phalen maneuver is used to reproduce the symptoms of carpal tunnel syndrome by flexion of the wrist.

The neuromuscular hallmark of polymyalgia rheumatica is A asymmetric muscle pain and stiffness. B distal paresthesias. C muscle weakness. D proximal muscle pain and stiffness.

Proximal symmetric muscle pain and stiffness, particularly involving the shoulder, neck and pelvic girdle, is the musculoskeletal hallmark of polymyalgia rheumatica.

A 22 year-old female complains of worsening pain, swelling, and tenderness in her left heel for 1 week. She sustained a penetrating injury to the heel two weeks ago when she stepped on a nail while running in tennis shoes. Examination reveals a draining puncture wound with surrounding erythema and exquisite tenderness. X-ray of the left foot demonstrates periosteal reaction associated with the wound. Which organism is classically responsible for this infection? A Escherichia coli B Streptococcus pyogenes C Pseudomonas aeruginosa D Staphylococcus aureus

Pseudomonas aeruginosa frequently associated with osteomyelitis involving puncture wounds of the foot. This is believed to result from direct inoculation with P. aeruginosa via the foam padding found in tennis shoes.

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

RICE (rest, ice, compression and elevation). Corticosteroid injections, moist heat, and a walking cast provide no benefit. Surgical intervention for repair of a ruptured ligament is only necessary in chronically unstable joints.

A 74 year-old male presents with one month history of right shoulder pain without any known precipitant. His pain involves an area from the right paraspinous musculature to the right deltoid with occasional radiation down the arm. Pain is worse with movement of the shoulder and is not relieved by acetaminophen. He reports numbness of the right index finger and thumb. Physical examination of the shoulder is limited by pain. There is decreased grip strength and absent pinprick sensation in the index finger and thumb. Relexes are normal. What is the most appropriate initial study to obtain?😨😨😨😨😨😨😩😩😩 A EMG with nerve conduction B MRI of the right shoulder C Radiographs of the neck D Radiographs of the right shoulder

Radiographs of the neck Cervical radiculopathy may be due to intervertebral foraminal osteophytes which will be identified on plain film radiographs of the neck making this the appropriate first step in evaluation.

Which of the following preventive strategies against osteoporosis-associated vertebral fractures has a known side effect of increasing the incidence of hot flashes when used in a perimenopausal female?😨😩😩😨 A Calcitonin (Miacalcin) nasal spray B Alendronate (Fosamax) C Estrogen/progesterone (Prempro)replacement D Raloxifene (Evista)

Raloxifene (Evista) has effects on bone turnover and bone mass and has been shown to decease vertebral fractures. It has anti-estrogen effects on the non-skeletal portions of the body and increases hot flashes in perimenopausal females.

A 53 year-old female massage therapist presents with new onset of sudden swelling involving the right elbow. She denies previous episodes similar to this. On physical examination, the patient is afebrile. There is a 4 cm fluid-filled mass that is tender to palpation overlying the tip of the elbow with no evidence of erythema or warmth. Which of the following is the most appropriate intervention? 😨😨😨😩😩😩 A Rest and NSAIDs B Surgical excision C Incision and drainage D Aspiration and corticosteroid injection

Rest and NSAID is the most appropriate initial intervention in a patient with olecranon bursitis.

Endotracheal intubation should be performed with caution in patients with which of the following underlying conditions due to the propensity to cause subluxation of C1 on C2?😨😨😨😨😨😨😩 A Rheumatoid arthritis B Osteoarthritis C Gout D Pseudogout

Rheumatoid arthritis Patients with advanced rheumatoid arthritis will have synovitis of the atlantoaxial joint (C1-C2) which may damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation).

A 60 year-old right hand dominant male presents to your office complaining of right shoulder pain and progressively worsening arm weakness. His symptoms are aggravated when working above the shoulder level. On physical examination, there is no evidence of muscle atrophy. He has strong (5/5) adduction of his right shoulder but considerable weakness (1/5) with abduction when raising his arm above his head. Passive range of motion is intact. Which of the following is the most likely diagnosis? A Rotator cuff tear B Subacromial bursitis C Adhesive capsulitis D Supraspinatus tendonitis

Rotator cuff tears are associated with full passive range of motion but have pain and weakness during active abduction.

The most reliable site from which to identify the causative organism in cases of osteomyelitis is the A base of ulcer. B blood C sinus tract. D bone

Samples from needle aspiration of pus in the bone, or from a bone biopsy, are essential to determine the exact causative agent.

A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is the most striking and consistent abnormality of which of the following?😨😨 A Spondylolysis B Spondolisthesis C Scoliosis D Herniated disc

Scoliosis

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

Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels. patient's signs and symptoms are most consistent with septic arthritis. IV drug abuse places this patient at even greater risk.

A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis? A Shin splint B Stress fracture C Osgood-Schlatter disease D Patellofemoral pain syndrome A 20 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on during practice. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis?

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

A 14 year-old male who is overweight presents with complaints of left knee and anteromedial thigh pain for the past month. He states the pain gets better with rest and denies any known trauma. On examination of the gait, a slight limp is noted. X-ray films of the left knee are normal. The most likely diagnosis is A genu valgum. B Legg-Calve-Perthes disease. C Osgood-Schlatter disease. D slipped capital femoral epiphysis

Slipped capital femoral epiphysis is most common in overweight adolescent males who present with complaints of pain that is referred to the thigh or medial side of the knee associated with a limp. X-ray films of the knee are normal since the condition involves the hip.

A 30 year-old female presents with left wrist pain after slipping on the ice while walking to her car. On examination, pain is noted on palpation over the anatomical snuff box. X-ray of her wrist shows no identifiable fracture. Which of the following is the most appropriate treatment in this patient? A No treatment necessary B ACE wrap application C Splint application D Immediate orthopedic referral

Splint application dx: suspected scaphoid fracture The patient should be treated as if it is fractured and placed in a splint with a referral to an orthopedic specialist for further evaluation and repeat imaging.

A 44 year-old female hairdresser presents to the clinic with a two-month history of pain and numbness of her left hand that awakens her from sleep. Your exam reveals electric tingling sensations with percussion over the volar surface of the wrist just proximal to the palmar crease and paresthesias noted within 15 seconds of passively flexing the wrist. Which of the following would be the best initial treatment in this patient? A Corticosteroid injection B Surgical intervention C Nocturnal splinting D Gabapentin (Neurontin)

Splinting the affected wrist is the initial treatment choice and maintains a neutral position of the wrist.

The most important preventive medicine recommendation for patients with osteoarthritis is which of the following? A Start an exercise program B Brace the affected joint C Rest the joint D Inject steroids monthl

Start an exercise program to maintain range of motion, strengthen periarticular muscles, and improve physical fitness.

A 42 year-old female experiences pain on the plantar surface of her left foot in the area of the third metatarsal head. The pain is associated with wearing tight shoes and is relieved by removing shoes. Examination reveals a palpable mass and reproduction of pain with deep palpation of the third intermetatarsal space. The patient has tried wearing wider shoes with metatarsal cushions and taking NSAIDS but her symptoms persist. What is the best therapeutic option at this point? A Casting of the involved foot B Physical therapy C Steroid injection D Surgical excision

Steroid injection is the treatment of choice for Morton's neuroma when conservative measures fail.

A football player complains of burning pain, numbness, and tingling extending from the left shoulder down into the hand after he tackled a player. These symptoms resolved spontaneously in minutes. Following resolution of the symptoms, he has full strength and normal sensation in the left arm. What is the most likely etiology of his symptoms? A Acute muscle strain B Mild concussion C Stretching of nerve roots and brachial plexus y D Thoracic outlet obstruction

Stretching of nerve roots and brachial plexus y Brachial plexus neurapraxia, commonly called "stinger" injuries, results from stretching of the cervical nerve roots and brachial plexus by a mechanism such as that described in this question.

An x-ray taken on a patient complaining of wrist pain after being hit by a baseball reveals a non-displaced mid-shaft ulnar fracture. Which of the following splints is most appropriate for treatment? A Thumb spica B Sugar tong C Cock-up wrist D Short arm gutter

Sugar tong splints are best used to immobilize the elbow, wrist and forearm

Which of the following clinical manifestations is commonly seen in a patient with rheumatoid arthritis? A symmetric joint swelling B presence of Heberden's nodes C morning stiffness lasting less than 15 minutes D cervical spondylosis of C3-C

Symmetric joint swelling associated with stiffness, warmth, tenderness, and pain are characteristic of rheumatoid arthritis.

A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has A carpal tunnel syndrome. B radial tunnel syndrome. C tenosynovitis. D gamekeeper's thumb.

Tenosynovitis is diagnosed using Finkelstein maneuver. The patient's thumb is placed in the palm of the hand and the wrist is abruptly deviated to the ulnar aspect of the wrist, causing pain on the radial aspect.

A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexion and external rotation at the hip. Which of the following knee maneuvers does this represent?😩 A Abduction stress test B Anterior drawer sign C Lachman test D McMurray test

The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 15 degrees of flexion and external rotation of the hip.

A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 20 degrees of flexion and the tibia is forced forward while the femur is stabilized. Which of the following knee maneuvers does this represent? A abduction stress test B anterior drawer sign C Lachman test D McMurray test

The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 20 degrees of flexion

A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered? A Inability to extend the wrist against resistance B Numbness over the deltoid muscle in the shoulder C Winging of the scapula D Weakness of the rotator cuff

The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.

60 year-old female injured her right wrist when she slipped and fell onto her outstretched hand. Radiographs show a fracture through the metaphysis of the distal radius with dorsal displacement and angulation. Which of the following splints is the best method of temporary immobilization? A Dorsal forearm B Ulnar gutter C Volar forearm D Volar with thumb spica

The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures and is the splint of choice for Colles' fracture.

A 52 year-old male presents with a severely painful, swollen right great toe. He denies recent trauma, but reports several similar episodes of toe pain and swelling over the past two to three years. He has a history of alcohol abuse and hypertension, for which he "takes medication" of unknown type. Examination reveals bright erythema and edema associated with the right first MCP joint. Which of the patient's antihypertensive medications may be contributing to this condition? A Diltiazem (Cardizem) B Hydrochlorothiazide (HCTZ) C Lisinopril (Prinivil) D Metoprolol (Lopressor)

Thiazide diuretics, such as hydrochlorothiazide, are associated with increased risk of hyperuricemia and gout.

An obese 15 year-old male presents with complaint of a limp and right knee pain for two weeks. He denies recent trauma or history of previous injury. Physical examination of the right knee is unremarkable. Examination of the right hip reveals pain with passive range of motion and limited internal rotation and abduction. Flexion of the hip results in external rotation of the thigh. Gait is antalgic with the right hip externally rotated. Which of the following radiographic findings supports the most likely diagnosis? A Displacement of the femoral epiphysis B Irregularity and fragmentation of the joint space C Capsular swelling of the joint D Dislocation of the hip

This patient has slipped capital femoral epiphysis (SCFE) and the classic x-ray findings will demonstrate displacement of the femoral head rotation of the femoral neck anteriorly.

Which of the following is an extra-articular manifestation of rheumatoid arthritis? A Vasculitis B Malar rash C Coronary artery aneurysms D Periorbital xanthelasma

Vasculitis affecting any organ system is seen in patients with severe rheumatoid arthritis

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

Vertebral spine -------------------------------------------------------------------- Femur, humerus, tibia Long bones are most commonly affected with osteomyelitis in children.

A 55 year-old secretary presents with ongoing pain and numbness in her hand. These symptoms are worse at night and she must shake her hand to regain feeling in it. Which of the following physical examination signs will be present? A Hypothenar atrophy B Weakness of finger abduction C Inability to maintain wrist extension against resistance D Weakness of thumb abductio

Weakness of thumb abduction Median nerve injury causes weakness of thumb abduction (measured by thumb opposition strength) along with thenar atrophy. Tinel's and Phalen's signs will also be positive with carpal tunnel syndrome.

A 56-year-old white post-menopausal female had a recent surveillance DEXA bone densitometry. The T-score is -2.7 for her right hip. In counseling this patient, in addition to medications, which of the following would you recommend? A Weight bearing exercises B Water aerobics C Limit sun exposure D Daily red wine consumption

Weight-bearing exercises are an appropriate adjunct to medication in a patient with osteoporosis. Water aerobics are non-weight bearing. Sun exposure and vitamin D supplementation are useful in preventing and treating osteomalacia

Spina bifida occulta is usually detected by which initial diagnostic evaluation?😨😨😩😩😩 A Electroencephalogram B Alpha-fetoprotein levels C Folic acid levels D X-ray of the spine

X-ray or MRI is the definitive test to diagnose spina bifida occulta, showing the vertebral bony defect.

Which of the following osteoporosis therapies is so poorly absorbed that it must be taken alone and on an empty stomach?😨😨 A raloxifene (Evista) B alendronate (Fosamax) C calcitonin (Miacalcin) D teriparatide (Forteo)

alendronate (Fosamax) Fosamax should not be coadministered with any other medication or food ----------------------------------------------------------------- Raloxifene, calcitonin, and teriparatide lack significant drug-drug or drug-food interactions.

A 43 year-old male with a history of a right medial meniscectomy and a strong family history of osteoarthritis presents to the clinic for a routine physical exam. He states he is very active and runs 20-25 miles a week and competes routinely in 5 km races. He is 5' 10" and 160 lbs, BP is 128/76 and P 72. His physical examination is unremarkable. Which of the following would you recommend to this patient to delay the onset of osteoarthritis? A weight loss B corticosteroid injections C 1500 mg of calcium daily D consider swimming or biking instead of running

consider swimming or biking instead of running

In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is A lateral. B oblique C anteroposterior D odontoid

lateral view It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.

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

pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults.

Which of the following would demonstrate rotational misalignment in a patient with a fracture of the fourth metacarpal? A base of the ring fingernail and index fingernail line up in the partially closed hand B fingernails of the open hand form an asymmetric arc C ring finger of the closed hand overlaps the little finger D ring finger of the open hand is shortene

ring finger of the closed hand overlaps the little finger

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

thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.

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

wrist splints dx: carpal tunnel syndrome