Musculoskeletal (PANCE)

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Scientific Concepts/Orthopedics/Rheumatology 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

(c) A. 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. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Diagnostic Studies/Orthopedics/Rheumatology An x-ray reveals a break in the cortex of one side of the ulna shaft without a separation or break of the opposite cortex describes what type of fracture? A. greenstick B. transverse C. torus (buckle) D. epiphyseal

(c) A. A greenstick fracture is a break in the cortex of one side of bone shaft without a break in the opposite cortex. (u) B. A transverse fracture is a complete fracture of both cortices. (u) C. A torus fracture is a bowing, bending, or buckling without a break in the cortex. (u) D. Epiphyseal fracture occurs at the growth plate.

History & Physical/Orthopedics/Rheumatology 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

(c) A. Abduction against resistance tests the supraspinatus. (u) B. Lateral rotation against resistance tests the infraspinatus and teres minor. (u) C. See B for explanation. (u) D. Medial rotation against resistance tests the subscapularis.

Health Maintenance/Orthopedics/Rheumatology 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

(c) A. Age is the most significant risk factor for osteoarthritis. Prevalence and severity increase with age. Ninety percent of people greater than the age of 40 have degenerative changes of the weight bearing joints. Major joint trauma, prior inflammatory joint disease, and repetitive stress are additional risk factors but not as predictive as age. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Therapeutics/Orthopedics/Rheumatology 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) therapy

(c) A. Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body. (u) B. Alendronate is effective in building new bone for a patient with osteoporosis but has no associated analgesic effect. (u) C. Raloxifene is a selective estrogen receptor modulator and has positive effects on bone density when used to treat osteoporosis. Raloxifene, however, has no analgesic properties. (u) D. Combined hormonal therapy may have positive effects on bone density but it has no analgesic properties.

Diagnosis/Orthopedics/Rheumatology A 14 year-old patient, who fell on his outstretched hand, complains of pain along his entire arm. There is point tenderness and swelling over the midshaft of the radius. There is significant pain with limited flexion of the elbow joint. An x-ray will most likely show which of the following fractures? A. Galeazzi's B. Scaphoid C. Colles' D. Smith's

(c) A. Galeazzi's fracture/dislocation involves a fracture of the mid or distal radial shaft with distal radioulnar joint dislocation. (u) B. A scaphoid fracture is a fracture of the scaphoid bone and would not cause pain in the elbow joint. (u) C. A Colles' fracture of the distal radius has a characteristic "silver fork" deformity, but does not involve the elbow joint. (u) D. A Smith's fracture is the reverse of a Colles' fracture, with volar angulation of the distal radius, but does not involve the elbow joint.

Clinical Therapeutics/Orthopedics/Rheumatology 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

(c) A. Hydroxychloroquine is associated with macular damage, rash and diarrhea. (u) B. Hydroxychloroquine is not associated with hepatoxicity of hemolytic anemia. (u) C. Hydroxychloroquine lacks renal toxicity. (u) D. Mouth sores may be a sign of agranulocytosis in patients on hydroxychloroquine, but retinopathy occurs more commonly.

Scientific Concepts/Orthopedics/Rheumatology Which of the following is the underlying pathogen for the development of Lyme disease? A. Borrelia burgdorferi B. Bartonella henselae C. Rickettsia rickettsii D. Coxiella brunetti

(c) A. Lyme disease is a tick-borne illness caused by the spirochete B. burgdorferi. (u) B. Bartonella henselae is the spirochete that causes cat scratch fever. (u) C. Rickettsia Rickettsii is the spirochete that causes Rocky Mountain Spotted Fever. (u) D. Coxiella brunetti is the spirochete that causes Q fever.

Health Maintenance/Orthopedics/Rheumatology 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

(c) A. 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). (u) B. Although patients with osteoarthritis may have neck pain and stiffness, there is no predilection for the atlantoaxial joints. (u) C. Patients with gout are likely to have involvement of peripheral joints rather than spinal joints. (u) D. Patients with pseudogout are more likely to have involvement of the knees, wrist, shoulder, ankle, elbow, and hands rather than the cervical spine.

Scientific Concepts/Orthopedics/Rheumatology Which of the following leads to retropatellar pain? A. increased Q angle B. increased quadriceps tone and strength C. Osgood-Schlatter Disease D. hamstring stretching

(c) A. Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome. (u) B. Quadriceps strengthening aids in restoring patellofemoral tracking. (u) C. Osgood-Schlatter disease involves the tibial tubercle, not the patellofemoral joint. (u) D. Hamstring stretching aids in restoring patellofemoral tracking.

Health Maintenance/Orthopedics/Rheumatology 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 monthly

(c) A. Patients with osteoarthritis who exercise are able to maintain range of motion, strengthen periarticular muscles, and improve physical fitness. (u) B. Bracing or resting of the affected joint in a patient with osteoarthritis may limit joint motion and restrict mobility, which may negatively impact the disease. (u) C. See B for explanation. (u) D. Steroid injection into the affected joint may decrease pain but injections are limited to not more than three per year.

Clinical Intervention/Orthopedics/Rheumatology 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

(c) A. Rest and NSAID is the most appropriate initial intervention in a patient with olecranon bursitis. (u) B. Surgical excision is reserved for chronic bursitis and is not indicated in this acute initial presentation. (u) C. Incision and drainage is not recommended as it may cause a chronic drainage sinus tract. (u) D. Aspiration of the bursa and corticosteroid injection are second-line therapy in a patient with olecranon bursitis who fails rest and NSAIDs.

Diagnosis/Orthopedics/Rheumatology 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? A. shin splint B. stress fracture C. Osgood-Schlatter disease D. patellofemoral pain syndrome

(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture. (u) B. See A for explanation. (u) C. Osgood-Schlatter disease is an injury occurring at the insertion of the patellar tendon on the tibial tuberosity in a younger age group. (u) D. Patellofemoral pain syndrome is the most common cause of chronic anterior knee pain, more commonly seen in females.

Diagnosis/Orthopedics/Rheumatology 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

History & Physical/Orthopedics/Rheumatology 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 night

(c) A. Supraspinatus tendonitis will be aggravated by resisted supination of the forearm. (u) B. Biceps rupture may present with a bulging appearance of the proximal arm. (u) C. Weakness of the arm with internal rotation and adduction is characteristic of pectoralis major rupture or tear. (u) D. Night pain is characteristic of rotator cuff tear or tendonitis.

History&Physical/Orthopedics/Rheumatology 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-C7

(c) A. Symmetric joint swelling associated with stiffness, warmth, tenderness, and pain are characteristic of rheumatoid arthritis. (u) B. Heberden's nodes, or bony enlargements of the DIP joints, are seen in osteoarthritis, not rheumatoid arthritis. (u) C. Morning stiffness lasting less than 15 minutes is more characteristic of osteoarthritis. The morning stiffness typically seen with rheumatoid arthritis lasts longer than 1 hour and is a distinguishing feature between the two types of arthritis. (u) D. Cervical spondylosis occurs with osteoarthritis. RA is associated with C1-C2 subluxation.

Diagnosis/Orthopedics/Rheumatology 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

(c) A. The distinctive feature of Ewing sarcoma is the radiographic appearance of a periosteal "onion skin" reaction. (u) B. This benign tumor typically presents as a painless mass and appears in plain film radiographs as a stalk or broad-based projection from the surface of the bone. (u) C. The classic radiographic appearance of multiple myeloma is a lytic lesion but this is a condition that is seen in a much older population and is more likely to present with back pain. (u) D. Although the presentation may be similar to Ewing's sarcoma, the radiographs in osteoid osteoma typically show a round lucency surrounded by sclerotic bone.

Diagnostic Studies/Orthopedics/Rheumatology 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.

(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology. (u) B. The oblique view is usually not included in the initial set of x-rays taken. Bilateral supine oblique is a view that may be ordered if all seven cervical vertebrae are not seen on the lateral view. (u) C. Anteroposterior view shows < 1% of significant injuries. (u) D. The odontoid view reveals 10% of significant injuries.

Diagnosis/Orthopedics/Rheumatology 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

(c) A. The 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. (u) B. Prepatellar bursitis causes swelling in the prepatellar area and is worse with kneeling. The prepatellar bursa is superficial and is located over the inferior portion of the patella. (u) C. The infrapatellar bursa is deeper and lies beneath the patellar ligament before its insertion on the tibial tubercle. It has a midline location rather than the medial surface as described in the question. (u) D. Trochanteric bursitis causes hip pain rather than knee pain.

History & Physical/Orthopedics/Rheumatology 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

(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance. (u) B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is more commonly injured in proximal humeral fractures and anterior shoulder dislocations. (u) C. Injury to the long thoracic nerve causes winging of the scapula due to its innervation of the serratus anterior muscle. (u) D. Injury to the subscapular nerve results in weakness and pain of the infraspinatus muscle; this injury is commonly seen in volleyball players from repetitive stress.

Diagnostic Studies/Orthopedics/Rheumatology The most accurate way to determine the exact degree of spinal curvature in a child with scoliosis is by which of the following? A. Calculation of the Cobb angle B. Measurement of waist asymmetry C. Measurement of rib hump deformity D. Calculation using a scoliometer

(c) A. The scoliotic curve is measured by the Cobb method using AP and lateral x- ray films of the entire length of the spine. (u) B. While waist asymmetry and rib hump deformity may be observed on physical examination of the patient with scoliosis, none of them can be used to determine the exact degree of the spinal curvature. (u) C. See B for explanation. (u) D. A scoliometer or inclinometer measures distortions of the torso and is good for screening angle of rotation, but is not exact to determine exact degree of curvature.

Clinical Intervention/Orthopedics/Rheumatology 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 splint for 2-6 weeks B. Corticosteroid injection C. Surgical referral D. Darvocet

(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve. (u) B. Corticosteroid injections and surgery are indicated only after a trial of the wrist splint provides no relief. (u) C. See B for explanation. (u) D. Darvocet has no role in the treatment of carpal tunnel syndrome.

ClinicalIntervention/Orthopedics/Rheumatology 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)

Diagnosis/Orthopedics/Rheumatology A mother brings her 14 month-old son to your clinic. Earlier today she lifted her son by grabbing him by the wrists and pulling him up off the floor. The child is sitting in his mother's lap with his left forearm is extended and in pronation. He is refusing to move the left arm, forearm or wrist. The arm and joints appear normal with no noted deformities, edema or erythema. Distal pulses and capillary refill are normal and he can move his fingers. Which of the following is the most likely diagnosis? A. Nursemaid's elbow B. Fractured left wrist C. Osteochondritis dissecans D. Child abuse

(c) A. This clinical history is classic for radial head dislocation or nursemaid's elbow. (u) B. There is no edema, deformity or erythema to suggest a fractured wrist. (u) C. Osteochondritis dissecans is avascular necrosis of subchondral bone, most commonly seen during adolescence. (a) D. Although child abuse could be suspected the clinical history best describes nursemaid's elbow.

Clinical Therapeutics/Orthopedics/Rheumatology 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)

(c) A. This patient has polymyalgia rheumatica and treatment with glucocorticoids can relieve discomfort and prevent the associated ischemic temporal arteritis, which threatens vision. (u) B. Cyclophosphamide is an immunosuppressant used in the treatment of acute leukemia. (u) C. Methotrexate is a folate inhibitor used to treat rheumatoid arthritis, not polymyalgia rheumatica. (u) D. Azathioprine is an immunosuppressant that is used to treat rheumtatic disease and inflammatory bowel disease, not polymyalgia rheumatica.

Diagnostic Studies/Orthopedics/Rheumatology 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

(c) A. 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. (u) B. Irregularity and fragmentation of the joint space is associated with avascular necrosis of the femoral head as seen in Legg-Calve-Perthes disease. This typically occurs in a younger male population and is not associated with the classic externally rotated hip with ambulation seen in SCFE. (u) C. Capsular swelling of the joint may be seen in transient synovitis of the hip but is not associated with SCFE. (u) D. Hip dislocation at this age is associated with major trauma, such as that sustained in a fall from height or dashboard injury. SCFE does not lead to hip dislocation.

History&Physical/Orthopedics/Rheumatology Which of the following is an extra-articular manifestation of rheumatoid arthritis? A. Vasculitis B. Malar rash C. Coronary artery aneurysms D. Periorbital xanthelasma

(c) A. Vasculitis affecting any organ system is seen in patients with severe rheumatoid arthritis. (u) B. A malar rash is frequently seen in systemic or discoid lupus. (u) C. Coronary artery aneurysms are frequently a manifestation of Kawasaki's disease. (u) D. Xanthelasma is a skin finding that occurs in hyperlipidemia.

Clinical Intervention/Orthopedics/Rheumatology A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory deficits and weakness along with decreased rectal sphincter tone. Which of the following is the most appropriate intervention? A. Epidural steroids B. Oral NSAIDs C. Physical therapy D. Surgery

(h) A. While epidural steroids can be effective in treating lumbar disc herniation, in the case of cauda equina syndrome, immediate surgical decompression is mandatory. (h) B. NSAIDs may be beneficial in some cases of lumbar muscle strain and disc herniation. They are not appropriate for management of cauda equina syndrome, immediate surgical decompression is mandatory. (h) C. Physical therapy may be beneficial in some cases of lumbar muscle strain and disc herniation but it is not appropriate for management of cauda equina syndrome. (c) D. Cauda equina syndrome is a rare but serious surgical emergency because the duration of nerve compression is inversely correlated with the likelihood of full neurologic recovery.

Scientific Concepts/Orthopedics/Rheumatology 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 D. Thoracic outlet obstruction

(u) A. Acute cervical muscle strain might result from the mechanism of injury described but symptoms would not quickly resolve. (u) B. Concussion involves generalized symptoms such as loss of consciousness but would not affect one limb exclusively. (c) C. 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. (u) D. Thoracic outlet syndrome is most commonly caused by cervical rib and is usually only symptomatic when the arm is elevated.

Diagnostic Studies/Orthopedics/Rheumatology 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

(u) A. Although electromyography and nerve conduction studies would be helpful in localizing the nerves involved, this is not an appropriate first-line diagnostic test. (u) B. Although there is pain in the shoulder, this patient presents with cervical radiculopathy and shoulder studies are not appropriate. (c) C. 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. (u) D. Although there is pain in the shoulder, this patient presents with cervical radiculopathy and shoulder studies are not appropriate.

Diagnosis/Orthopedics/Rheumatology 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

(u) A. Anterior cruciate ligament injury would have a positive drawer test and mechanism of injury can be due to a direct blow to the knee or as a result of sudden deceleration and rotation of the knee. (c) B. 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. (u) C. A tibial stress fracture is more likely to present without acute injury and with tenderness over the tibia rather than the lateral aspect of the leg. (u) D. A contusion does not cause pain with weight bearing.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. Antibiotic treatment would be appropriate if the skin was broken and the injury was sustained in a fist fight with the potential for introduced oral flora. (u) B. Reduction followed by splinting is recommended for fifth metatarsal fractures with angulation of 15-40 degrees. (c) C. Open reduction is indicated with angulation of greater than 40 degrees. (u) D. With angulation of greater than 15 degrees, reduction should be performed prior to splinting.

Diagnosis/Orthopedics/Rheumatology An 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

(u) A. Avascular necrosis is a late complication of fracture resulting from disruption of the blood supply to the bone. (u) B. Myositis ossificans occurs primarily in muscles post- traumatically and may not arise for several months after an injury. (c) C. 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. (u) D. Reflex sympathetic dystrophy is characterized by painful wasting of muscles that may be secondary to injury and could occur as a late complication.

Diagnostic Studies/Orthopedics/Rheumatology 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

(u) A. CBC may reveal anemia, leukopenia and thrombocytopenia, but these are not the cause of thrombotic events and spontaneous abortion in SLE. (u) B. The PT/INR should not be altered in SLE. (u) C. Bleeding time measures platelet function, not risk for thrombosis. (c) D. Anti-phospholipid antibodies are present in 25% of SLE patients and may cause thrombotic events and spontaneous abortion.

Health Maintenance/Orthopedics/Rheumatology 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)

(u) A. Calcitonin does not have any estrogen effects on the body and serves as an analgesic when used in the management of vertebral fractures. (u) B. Alendronate is a bisphosphonate that does not have any hormonal effects on the body. (u) C. Estrogen/progesterone replacement has the benefit of maintaining bone and decreasing vertebral fractures but it would improve perimenopausal hot flashes. (c) D. Raloxifene 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.

Clinical Therapeutics/Orthopedics/Rheumatology 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)

(u) A. Calcium-channel blockers, such as diltiazem, are not associated with increased risk of hyperuricemia and gout. (c) B. Thiazide diuretics, such as hydrochlorothiazide, are associated with increased risk of hyperuricemia and gout. (u) C. ACE inhibitors, such as lisinopril, are not associated with increased risk of hyperuricemia and gout. (u) D. Beta-blockers, such as metoprolol, are not associated with increased risk of hyperuricemia and gout.

Diagnosis/Orthopedics/Rheumatology 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.

(u) A. Carpal tunnel is diagnosed by a positive Tinel's or Phalen's maneuver. (u) B. Radial syndrome is demonstrated by simultaneously extending the patient's wrists and fingers while the examiner passively flexes the patient's long finger, which causes pain. (c) C. 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. (u) D. Gamekeeper's thumb is the most common injury to the metacarpophalangeal collateral ligaments, causing a sprain.

Diagnosis/Orthopedics/Rheumatology A 41 year-old female complains of 3 weeks of gradually worsening pain at the base of the thumb and radial aspect of the wrist. She and her husband have been renovating their home for the past 2 months and it has become increasingly difficult for her to hold a hammer. She denies numbness or tingling. She denies any history of previous trauma to the wrist. On examination, there is tenderness over the distal radial styloid and pain reproduced with ulnar deviation of a fist clenched over the abducted thumb. Which of the following is the most likely diagnosis? A. Carpal tunnel syndrome B. deQuervain's tenosynovitis C. Ganglion cyst D. Volar flexor tenosynovitis

(u) A. Carpal tunnel syndrome typically presents with pain and paresthesias in the median nerve distribution. (c) B. deQuervain's tenosynovitis typically results from repetitive activity involving pinching the thumb while moving the wrist. There is often pain and tenderness over the radial styloid and Finkelstein's is positive in this patient. (u) C. Ganglion cysts classically present with a visible or palpable, usually painless swelling over the dorsum of the wrist. (u) D. With volar flexor tenosynovitis, pain is expected with extension of the fingers and localized tenderness of the volar tendon sheaths.

Clinical Therapeutics/Orthopedics/Rheumatology 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

(u) A. Casting the foot in a patient with Morton's neuroma is not effective therapy. (u) B. Physical therapy has not been shown to be of benefit in treating Morton's neuroma. (c) C. Steroid injection is the treatment of choice for Morton's neuroma when conservative measures fail. (u) D. Surgical excision is recommended for treatment of Morton's neuroma only if conservative measures and steroid injection have failed.

Clinical Intervention/Orthopedics/Rheumatology 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 endocrinologist

(u) A. Corticosteroids have no role in the management of fibromyalgia. (c) B. A carefully planned and individualized exercise program has been proven effective for the management of fibromyalgia. (u) C. Opioids are not first-line agents in the treatment of fibromyalgia. (u) D. One-third of patients with fibromyalgia are found to have deficiency of growth hormone, but referral to endocrinology is not indicated at this time.

History & Physical/Orthopedics/Rheumatology 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

(u) A. Coxa vara is a hip deformity that would present with a decrease in the hip angle and a shift of the femoral shaft medially. (u) B. Legg-Calve-Perthes disease presents with a painless limp in children ages 4-10 due to avascular necrosis of the femoral head. (c) C. A dislocated hip displaces proximally in developmental hip dysplasia, causing a shortening of the leg that may present as unequal thigh folds. (u) D. A slipped capital femoral epiphysis is primarily an adolescent disorder with decreased range of motion in abduction and internal rotation of the hip on physical examination.

History & Physical/Orthopedics/Rheumatology 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

(u) A. Crepitus without pain is not significant and does not indicate an effusion. (u) B. Tenderness over the joint line indicates a meniscal injury, but does not demonstrate an effusion. (c) C. A small bulge of returning fluid after milking fluid upward from the knee is useful for detecting small effusions. (u) D. Ballottement of the patella against the femur is useful for detecting large effusions, but not small ones.

Diagnostic Studies/Orthopedics/Rheumatology 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

(u) A. Electroencephalogram (EEG) cannot detect or diagnose spina bifida occulta. (u) B. Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neural tube defect, such as spina bifida. (u) C. Folic acid has been shown to decrease the incidence of neural tube defects, not as an aid in diagnosis of the defect. (c) D. X-ray or MRI is the definitive test to diagnose spina bifida occulta, showing the vertebral bony defect.

History&Physical/Orthopedics/Rheumatology 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 shortened

(u) A. Failure of the planes of the fingernails in the partially closed hand to line up indicates rotational misalignment. (u) B. Fingernails of the open hand normally form an asymmetric arc. (c) C. All fingernails should point to the same spot when the hand is closed. Overlapping of one finger over the other indicates rotational misalignment. (u) D. Shortening of a finger does not indicate rotational misalignment.

Diagnosis/Orthopedics/Rheumatology 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.

(u) A. Genu valgum is a knock-knee deformity of the knees and would be detected on physical examination. (u) B. Legg-Calve-Perthes presents in a younger population. (u) C. Osgood-Schlatter disease is characterized by local pain, swelling, and tenderness to palpation overlying the tibial tubercle, and x-ray findings of tibial tubercle prominence, with or without free bony fragments. (c) D. 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.

Diagnosis/Orthopedics/Rheumatology A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical exam the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis? A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis

(u) A. Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis. (u) B. See A for explanation. (u) C. Acute rheumatic fever commonly involves multiple joints. (c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.

Diagnosis/Orthopedics/Rheumatology A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical examination the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis? A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis

Clinical Therapeutics/Orthopedics/Rheumatology When injecting a corticosteroid into a joint to help relieve pain, which of the following would most commonly be mixed in the syringe? A. Hyaluronic acid B. Ketorolac C. Chondroitin sulfate D. Lidocaine

(u) A. Hyaluronic acid is usually injected by itself in patients with osteoarthritis. (u) B. Ketorolac is an NSAID that is given orally and not intra-articularly. (u) C. Chondroitin sulfate is taken orally and thought to improve symptoms in osteoarthritis. (c) D. 1% lidocaine and corticosteroids are most commonly used together for joint injections.

History & Physical/Orthopedics/Rheumatology 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

(u) A. Hyperextension injuries usually result in ACL and PCL injuries. (c) B. Axial loading and rotation most likely result in meniscal injuries. (u) C. Hyperflexion injuries result in PCL injuries. (u) D. Valgus force to the lateral knee more than likely results in medial collateral ligament injuries.

History & Physical/Orthopedics/Rheumatology 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 abduction

(u) A. Hypothenar atrophy may occur with aging and disuse but it is not part of the median nerve involvement that occurs with carpal tunnel syndrome. (u) B. Finger abduction weakness is associated with ulnar nerve injury, which does not occur with carpal tunnel syndrome. (u) C. Radial nerve injury causes weakness of wrist extension and this is not part of carpal tunnel syndrome. (c) D. 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.

Scientific Concepts/Orthopedics/Rheumatology T 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

(u) A. Long bones are most commonly affected with osteomyelitis in children. (u) B. See A for explanation. (c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection (u) D. See A for explanation.

Clinical Therapeutics/Orthopedics/Rheumatology Which of the following medications inhibits prostaglandin synthesis in a patient with rheumatoid arthritis? A. Methotrexate B. Infliximab (Remicade) C. Probenecid (Benemid) D. Aspirin

(u) A. Methotrexate inhibits the enzyme dihydrofolate reductase. (u) B. Infliximab (Remicade) neutralizes cytokine tumor necrosing factor. (u) C. Probenecid blocks the tubular reabsorption of filtered urate and is used to reduce serum uric acid. (c) D. Salicylates inhibit the enzymatic production of prostaglandins by inhibiting cyclooxygenase.

Clinical Therapeutics/Orthopedics/Rheumatology 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

(u) A. Naprosyn is contraindicated in patients with abnormal renal function. (u) B. Oral prednisone is not appropriate for the long-term management of osteoarthritis. (c) C. Acetaminophen is recommended as first-line pharmacotherapy in patients with osteoarthritis. (u) D. Methotrexate is not indicated for the treatment of osteoarthritis.

Scientific Concepts/Orthopedics/Rheumatology During the stages of fracture healing which of the following is responsible for producing collagen? A. Osteoclasts B. Chondrocytes C. Glycosaminoglycans D. Fibroblasts

(u) A. Osteoclasts are responsible for removing necrotic bone. (u) B. Chondrocytes make up the articular cartilage. (u) C. Glycosaminoglycans help form the osteon or vascular canal. (c) D. Fibroblasts produce collagen during the inflammation stage of healing.

Diagnosis/Orthopedics/Rheumatology 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. Which of the following is the most likely diagnosis? A. Osteosarcoma B. Legg-Calve-Perthes disease C. Osgood-Schlatter disease D. Osteoid osteoma

(u) A. Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy. (u) B. Legg-Calve-Perthes disease is avascular necrosis of the hip affecting boys ages 4-10. (u) C. Osgood-Schlatter disease is inflammation of the tibial tuberosity affecting mainly boys in the ages of 10-15. Commonly associated bilaterally and due to jumping. (c) D. Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin.

Diagnostic Studies/Orthopedics/Rheumatology 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

(u) A. Paget's disease of bone presents with bone pain, kyphosis, bowed tibias, large head, and deafness. The initial lesions are destructive and radiolucent. Paget's disease has a normal serum calcium and phosphate, but the serum alkaline phosphatase is elevated. (c) B. 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. (u) C. Chondrocalcinosis is the presence of calcium- containing salts in articular cartilage and is commonly seen in hyperparathyroidism, diabetes, hypothyroidism, and gout. (u) D. Hyperparathyroidism is frequently asymptomatic. Serum parathyroid hormone and serum calcium are elevated. X-ray findings include demineralization, subperiosteal resorption of bone especially in the radial aspects of the fingers.

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

(u) A. Parity status and lactation history have been shown to be poor predictors of bone mass; therefore, they do not have an established role in the prediction of increased risk for development of osteoporosis. (u) B. Carbohydrate intake has no association to the development of osteoporosis. (u) C. See A for explanation. (c) D. Established risk factors for osteoporosis include low body weight, female sex, advanced age, Caucasian race, and bilateral oophorectomy before menopause without estrogen replacement.

History & Physical/Orthopedics/Rheumatology 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.

(u) A. Polymyalgia rheumatica is associated with pain and stiffness but typically occurs in a symmetric distribution. (u) B. Peripheral neurons are unaffected by polymyalgia rheumatica and is not associated with neuropathic symptoms. (u) C. Although patients may appear to have proximal muscle weakness, this is usually related to pain and is not true measurable weakness. (c) D. Proximal symmetric muscle pain and stiffness, particularly involving the shoulder, neck and pelvic girdle, is the musculoskeletal hallmark of polymyalgia rheumatica.

Clinical Therapeutics/Orthopedics/Rheumatology Topic: 6a Author: Jonathan Bowser 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)

(u) A. Prednisone can produce impressive clinical improvement in rheumatoid arthritis but the side effects associated with their long-term use limit their utility. (u) B. Tumor necrosis factor inhibitors, such as infliximab, are very effective disease modifying antirheumatic drugs (DMARDS). This class of medication is inappropriate as a first-line medication due to very high cost. (c) C. Methotrexate is the standard first-line medication in the treatment of rheumatoid arthritis. This DMARD is generally effective, well-tolerated, and affordable. (u) D. Sulfasalazine is inexpensive but associated with potentially serious hematologic side effects and is considered a second-line DMARD.

Health Maintenance/Orthopedics/Rheumatology 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

(u) A. RA patients are at increased risk of infection and should receive influenza and pneumococcal vaccines, not meningococcal. (u) B. NSAIDs provide only symptomatic therapy and do not stop the disease progression of RA. (c) C. Methotrexate is the most commonly prescribed DMARD for RA and has been proven to induce remission in some patients. (u) D. Chronic corticosteroid use is associated with greater toxicity than DMARDs and should be used only for symptomatic therapy.

Clinical Therapeutics/Orthopedics/Rheumatology 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)

(u) A. Raloxifene, calcitonin, and teriparatide lack significant drug-drug or drug-food interactions. (c) B. Fosamax should not be coadministered with any other medication or food. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. Rest, ice, and elevation are only palliative measures and not appropriate management (c) B. Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered "open" and the patient should be given antibiotics and follow-up with ortho in one week. (u) C. The digit must be immobilized until seen by ortho. Aspirin is not an appropriate analgesic for children. (u) D. See B for explanation.

Diagnosis/Orthopedics/Rheumatology A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh that he noticed about 3 days ago. Physical exam reveals a large annular lesion with a bright red outer border and partial central clearing. Which of the following is the most likely diagnosis? A. Rheumatoid arthritis B. Kawasaki disease C. Lyme disease D. Nongonococcal arthritis

(u) A. Rheumatoid arthritis is a symmetrical arthritis that commonly affects the proximal interphalangeal and metacarpophalangeal joints. It is not associated with the rash of erythema migrans. (u) B. Kawasaki disease is an acute febrile, multisystem disease of children. It is characterized by unresponsiveness to antibiotics, nonsuppurative cervical adenitis, and changes in the skin and mucous membranes such as edema, erythema of the lips and palms, and desquamation of the skin of the fingertips. (c) C. After an incubation period of 3 to 32 days, erythema migrans develops at the site of the tick bite. Within days or weeks 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. (u) D. Nongonococcal arthritis occurs in patients with an underlying predisposition such as rheumatoid arthritis. The common presentation is involvement of a single joint.

Diagnosis/Orthopedics/Rheumatology A 53 year-old patient presents with severe pain at the base of the thumb and no other finger involvement. The pain is worse with activity and lasts a short period of time following rest. There is no specific history of trauma to the thumb but the patient admits working with her hands as a typist. Which of the following is the most likely diagnosis? A. Rheumatoid arthritis B. Osteoarthritis C. Hemochromatosis D. Pseudogout

(u) A. Rheumatoid arthritis typically involves the MCP and PIP joints of the digits for the second through fifth fingers. The thumb is classically spared. (c) B. The base of the thumb is typically involved with osteoarthritis as are the DIP joints of the other fingers. (u) C. Hemochromatosis classically involves the MCP joints of the second through fifth fingers. (u) D. Pseudogout joint involvement is typically the MCP joints of the second through fifth fingers.

Diagnosis/Orthopedics/Rheumatology 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 lymphocytes, 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

(u) A. Rheumatoid arthritis usually involves more than one joint, primarily affecting metacarpophalangeal and wrist joints initially. Synovial fluid analysis would show moderate leukocytosis (< 50,000) with higher glucose levels. (c) B. Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels. (u) C. Although gout presents as monarticular process, it usually presents acutely without previous migratory arthralgias. Crystals are usually found in synovial analysis. (u) D. Osteoarthritis effusions may be normal or show mild elevations of WBCs in the fluid analysis, but it is rarely monarticular.

Diagnostic Studies/Orthopedics/Rheumatology 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)

(u) A. Rheumatoid factor is most commonly performed in the assessment of rheumatoid arthritis and not suspected systemic lupus erythematosus. (u) B. Antihistone antibodies are seen in drug-induced SLE rather than in spontaneously occurring SLE. (u) C. Anti-Smith antibodies and antibodies to the double stranded DNA are fairly specific to SLE but their role is for confirmation rather than screening for SLE. (c) D. ANA's are the best screening test used in the evaluation for SLE.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. See B for explanation. (c) B. 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. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Therapeutics/Orthopedics/Rheumatology Which of the following is the treatment of choice for stage one Lyme disease in a patient less than 12 years of age? A. doxycycline B. amoxicillin C. chloramphenicol D. azithromycin

(u) A. See B for explanation. (c) B. 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. (u) C. Chloramphenicol is only indicated in disseminated disease with known drug resistance. It is not indicated as first line therapy due to its tendency to cause aplastic anemia. (u) D. Azithromycin is not as effective as doxycycline or amoxicillin.

Scientific Concepts/Orthopedics/Rheumatology Which of the following fractures is associated with the greatest risk of avascular necrosis of the femoral head? A. intertrochanteric B. femoral neck C. subtrochanteric D. pelvic rim

(u) A. See B for explanation. (c) B. Femoral neck fractures lead to the greatest disruption of arterial blood supply to the femoral head. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Therapeutics/Orthopedics/Rheumatology Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions? A. Rheumatoid arthritis of the knee B. Osteoarthritis of the knee C. Olecranon bursitis D. Gouty arthritis

(u) A. See B for explanation. (c) B. 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. (u) C. Treatment of olecranon bursitis may include incision and drainage but not hyaluronic acid injections. (u) D. Gout is treated with anti-inflammatory medications.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. See B for explanation. (c) B. The majority of ankle sprains are treated with 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. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. See B for explanation. (c) B. 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. (u) C. See B for explanation. (u) D. Short arm casting is indicated in wrist and metacarpal injuries but not in DIP extensor injuries.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures. (u) D. See C for explanation.

History & Physical/Orthopedics/Rheumatology 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

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. 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. (u) D. See C for explanation.

Diagnostic Studies/Orthopedics/Rheumatology Which of the following views on plain films is preferred to identify spondylolysis? A. Anterior B. Posterior C. Oblique D. Lateral

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films. (u) D. See C for explanation.

DiagnosticStudies/Orthopedics/Rheumatology 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.

(u) A. See C for explanation. (u) B. While blood cultures are indicated in acute cases of osteomyelitis, they are only positive in 25-50% of pediatric hematogenous osteomyelitis and 10% of other forms of bone infection. (u) C. Taking specimens for culture from a sinus tract or the base of an ulcer correlate poorly with organisms infecting the bone. (c) D. Samples from needle aspiration of pus in the bone, or from a bone biopsy, are essential to determine the exact causative agent.

Diagnostic Studies/Orthopedics/Rheumatology 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. Angiography

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery. (c) D. The 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.

Health Maintenance/Orthopedics/Rheumatology Bone mass measurement should be considered in all women by what age? A. 30 - 35 B. 40 - 45 C. 50 - 55 D. 60 - 65

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. According to the National Osteoporosis Foundation, all women should have a bone mass measurement by age 60 - 65.

Clinical Therapeutics/Orthopedics/Rheumatology 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

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Anticholinergics should be avoided in a patient with Sjogrens syndrome. All the other medications may be used to treat the systemic symptoms of Sjogrens.

Health Maintenance/Orthopedics/Rheumatology 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

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males.

History & Physical/Orthopedics/Rheumatology 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 most consistent with which of the following? A. spondylolysis B. spondylolisthesis C. scoliosis D. herniated disc

(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles. (u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis. (c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis. (u) D. Herniated disc presents with lumbar muscle spasm and a positive straight leg test.

History & Physical/Orthopedics/Rheumatology 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

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. Steroid injections can be used to relieve symptoms but may be harmful by causing rupture if given in the plantar tendon greater than 3 or 4 times. (u) B. Short leg walking cast may be used for severe cases refractory to initial treatment. (c) C. Arch supports, NSAIDs and stretching exercises are the initial interventions to help relieve symptoms. (u) D. Surgical release of the plantar tendon is usually reserved for patients who fail all therapies.

Clinical Therapeutics/Orthopedics/Rheumatology 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

(u) A. Sulfasalazine is a second line medication that can cause neutropenia and thrombocytopenia. (c) B. Methotrexate is contraindicated in patients with chronic hepatitis. (u) C. Minocycline is used for early rheumatoid arthritis with minimal adverse effects. (u) D. Infliximab is a tumor necrosing factor inhibitor and should be used cautiously in patients with heart failure.

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

(u) A. Supraspinatus tendonitis, subacromial bursitis and rotator cuff tear usually present with pain in the area of the deltoid muscle, limited abduction and are reproduced through impingement tests that narrow the space between the acromium and the humerus thereby impinging the supraspinatus tendon. (u) B. See A for explanation. (u) C. See A for explanation. (c) D. 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).

History & Physical/Orthopedics/Rheumatology 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

(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress. (u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, hips and knees flexed, and feet are flat on the table. (c) C. 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. (u) D. The McMurray test is performed to evaluate medial and lateral meniscal tears while rotating the lower leg internally and externally.

History&Physical/Orthopedics/Rheumatology 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

(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress. (u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, hips and knees flexed, and feet are flat on the table. (c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 20 degrees of flexion. (u) D. The McMurray test is performed to evaluate medial and lateral meniscal tears while rotating the lower leg internally and externally.

Clinical Intervention/Orthopedics/Rheumatology A 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

(u) A. The dorsal forearm splint is best used as an alternative to the ulnar or radial gutter splint for protection of fractures of metacarpals two through five. (u) B. Ulnar gutter splints are best for treatment of stable fractures and dislocations of the ulnar wrist and metacarpals. (c) C. The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures and is the splint of choice for Colles' fracture. (u) D. A volar splint with thumb spica is used to immobilize the first metacarpophalangeal joint and is useful for scaphoid fractures.

History & Physical/Orthopedics/Rheumatology Topic: 2 Author: Christine Bruce A patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of the following portions of the spinal column are most likely affected? A. Lateral spinothalamic tract B. Ventral spinothalamic tract C. Posterior column D. Transection of the cord

(u) A. The lateral spinothalamic tract affects pain and temperature sensation. (u) B. The ventral spinothalamic tract affects pressures and touch sensations. (c) C. The posterior column affects proprioception (position sense) and vibration sense. (u) D. Patients with transection of the cord will have loss of sensation distal to the area of injury along with paralysis and hyperactive reflexes in the area distal to the transection.

Diagnostic Studies/Orthopedics/Rheumatology 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

(u) A. The lateral view is the most appropriate for evaluation of the possible presence of spondylolisthesis, not spondylolysis. (c) B. 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. (u) C. Anteroposterior views will show the alignment of the spinous processes, but not a defect in the pars interarticularis. (u) D. The open-mouth odontoid view is used to visualize the odontoid process and the relationship between the C1 and C2 vertebrae.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. The patient can be managed conservatively by a primary care provider since there are no neurological deficits. (c) B. Continuation of activities as tolerated is recommended during the acute phase. After symptoms resolve, an exercise program should be initiated to strengthen the back. (u) C. Traction is an outdated method of treatment, while bed rest for more than a few days will cause muscle atrophy. (u) D. Management for low back strain includes using a firm mattress.

Health Maintenance/Orthopedics/Rheumatology 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

(u) A. The patient's BMI is 23. Obesity is not a contributing factor for this patient. (u) B. Corticosteroid injections may be used for symptomatic treatment but are not used for prevention. (u) C. Calcium supplementation is indicated for osteoporosis prevention. (c) D. Swimming and biking would promote excellent joint motion and muscle strength and void the high-impact of competitive short-distance running.

Diagnostic Studies/Orthopedics/Rheumatology A 26 year-old male who is an avid swimmer has been experiencing right shoulder pain for the past month. On examination, pain is elicited with palpation below the anterior acromion. Anterior shoulder pain is also reported when the patient flexes and extends his arm. Which of the following diagnostic tests is most appropriate at this time? A. Shoulder x-ray B. Shoulder arthroscopy C. Shoulder MRI D. Subacromial lidocaine injection

(u) A. This patient is experiencing mild impingement syndrome and, although plain films may demonstrate bone spurs on the undersurface of the acromion, his age and relatively recent onset of symptoms suggest that this study would likely be normal. (u) B. Arthroscopy is not indicated unless less invasive modalities fail to aid in the diagnosis and symptoms of impingement persist despite therapy. (u) C. While MRI would likely support the diagnosis, it is an expensive modality and not necessary to diagnose mild impingement. (c) D. Subacromial injection of lidocaine leading to a transient but dramatic improvement in pain with shoulder extension makes the diagnosis of impingement highly likely.

Clinical Intervention/Orthopedics/Rheumatology 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

(u) A. Thumb spica splints are used for scaphoid fractures. (c) B. Sugar tong splints are best used to immobilize the elbow, wrist and forearm. (u) C. Cock-up wrist splints may be useful in some situations unrelated to fractures, such as to immobilize the wrist for tendinitis or to support it in the case of wrist drop due to radial nerve palsy but not to be used in wrist fractures. (u) D. Short arm gutter splints immobilize only the wrist and the ulnar or radial half of the hand.

Scientific Concepts/Orthopedics/Rheumatology 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

(u) A. While gram negative enteric organisms can be a cause of osteomyelitis, E. coli is rarely seen outside of the neonatal period. (u) B. Streptococcus pyogenes is an uncommon (~10 %) cause of acute osteomyelitis. The mechanism of injury suggests a different pathogen. (c) C. Pseudomonas aeruginosa is 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. (u) D. Staphylococcus aureus is the most common infecting organism in cases of acute osteomyelitis, however, the mechanism of injury in this case suggests P. aeruginosa.

Diagnosis/Orthopedics/Rheumatology 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

(u)A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint. (c) B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head. (u) C. A Colles' fracture is a fracture of the distal radius with dorsal displacement of the radial head. (u) D. A Smith fracture is a fracture of the distal radius with ventral displacement of the radial head.

History & Physical/Orthopedics/Rheumatology 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

Explanations (u) A. Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitral valve prolapse, and associated degenerative arthritis. (u) B. Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity and dislocations. (u) C. Children with achondroplasia are below normal standards on growth charts. They have difficulty balancing their large heads when beginning to walk. (c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.

Clinical Therapeutics/Orthopedics/Rheumatology 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)

Explanations (u) A. Probenecid is a uricosuric medication that helps to increase the excretion of uric acid but it does not prevent the formation of uric acid making it less beneficial in chronic gout therapy. It is also not effective in patients with chronic renal disease. (c) B. 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. (u) C. Colchicine treatment is recommended only in patients who have tophaceous deposits in the skin and is used in the acute rather than the chronic setting of gout. (u) D. Indomethacin is used in the acute management of gout but is not effective in decreasing monosodium urate deposition in the joints.

Diagnostic Studies/Orthopedics/Rheumatology A 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

Explanations (u) A. X-rays of the lower leg and ankle will only determine bone placement. (u) B. Doppler studies will confirm the presence of a decreased pulse. (u) C. A bone scan is not indicated in the evaluation of compartment syndrome. (c) D. Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.

Musculoskeletal (PANCE)

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