Ortho Packrat

Health Maintenance/Orthopedics/Rheumatology 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

Explanations (c) A. Weight bearing exercises are an appropriate adjunct to medication in a patient with osteoporosis. Water aerobics are non-weight bearing. Sun exposure adn vitamin D supplementation are useful in preventing and treating osteomalacia. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

History & Physical/Orthopedics/Rheumatology 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

Explanations (u) A. EMG may be performed in a patient who is being considered for surgery. (u) B. Nerve conduction test may be performed if operative intervention is being planned. (c) C. The Phalen maneuver is used to reproduce the symptoms of carpal tunnel syndrome by flexion of the wrist. (u) D. The Finkelstein test is performed when deQuervain's tenosynovitis is suspected.

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

Explanations (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.

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.

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.

A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is A. methylprednisolone (Medrol) dose pack. B. splint in neutral position. C. observation. D. surgery.

(u) A. A Medrol dose pack will have no affect on carpal tunnel syndrome. (c) B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel. (u) C. Observation will not improve symptoms. (u) D. Surgical intervention is reserved for cases unresponsive to conservative therapy.

Clinical Therapeutics/Orthopedics/Rheumatology 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)

(u) A. Opioid medication is not effective in the treatment of fibromyalgia. (c) B. Amitriptyline is the treatment of choice for fibromyalgia and is typically administered at bedtime. (u) C. Methotrexate is not effective in treating fibromyalgia. (u) D. NSAIDs are generally ineffective in treating fibromyalgia.

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.

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.

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 soleus muscles, and the abductor hallucis and gluteus maximus muscles. (u) D. See C for explanation.

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.

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.

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

Explanations (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

Explanations (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

Explanations (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.

History & Physical/Orthopedics/Rheumatology Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle? Answers A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis

Explanations (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

Explanations (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.

Scientific Concepts/Orthopedics/Rheumatology Which of the following types of hip fracture has the highest risk for avascular necrosis and nonunion? A. Femoral neck B. Intertrochanetric C. Subtrochanteric D. Greater trochanteric

Explanations (c) A. Fractures involving the femoral neck typically disrupt the blood supply to the femoral head and may cause avascular necrosis and nonunion. (u) B. Intertrochanteric fractures usually do not cause avascular necrosis and nonunion due to the capsule and blood supply to the femoral head remaining intact. (u) C. Subtrochanteric fractures usually do not cause avascular necrosis and nonunion due to the capsule and blood supply to the femoral head remaining intact. (u) D. Greater trochanteric fractures usually do not cause avascular necrosis and nonunion due to the capsule and blood supply to the femoral head remaining intact.

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

Explanations (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 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)

Explanations (c) A. NSAIDs, such as indomethacin, are the mainstay of therapy in ankylosing spondylitis (AS). (u) B. Methotrexate is beneficial in treatment of rheumatoid arthritis, but there is little evidence that it changes the course of disease in ankylosing spondylitis. (u) C. Oral prednisone may be used sparingly in ankylosing spondylitis, but is less useful for this condition because of its association with osteoporosis. (u) D. Sulfasalazine is potentially useful in the treatment of spondyloarthropathies but studies suggest that it is minimally effective in patients with axial disease.

Diagnosis/Orthopedics/Rheumatology Topic 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

Explanations (c) A. One of the earliest signs of compartment syndrome is severe pain that occurs with extension of the involved muscles. (u) B. DVT below the knee usually occurs in the posterior compartment and, while potentially painful, should not produce the degree of pain described. (u) C. The pain of osteomyelitis, while potentially severe, should not be greatly exacerbated by manipulation of the overlying muscles. (u) D. Complex regional pain syndrome can present with pain but it is typically a burning pain and often accompanied by vasomotor symptoms.

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

Explanations (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.

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

Explanations (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 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

Explanations (c) A. Rotator cuff tears are associated with full passive range of motion but have pain and weakness during active abduction. (u) B. Subacromial bursitis causes pain with raising hand above head and has mild degree of weakness. (u) C. Adhesive capsulitis (frozen shoulder) causes significant reduction in both active and passive range of motion. (u) D. Of the four rotator cuff muscles, supraspinatus is most likely to strain causing tendonitis. The symptoms cause limited range of motion due to pain but minimal weakness.

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

Explanations (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? Answers A. Shin splint B. Stress fracture C. Osgood-Schlatter disease D. Patellofemoral pain syndrome

Explanations (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.

History & Physical/Orthopedics/Rheumatology 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

Explanations (c) A. Spinal stenosis typically presents as back pain and thigh pain aggravated by ambulation and relieved by sitting. (u) B. Spinal stenosis is gradual in onset and is improved by sitting. (u) C. Spinal stenosis, unlike polymyalgia rheumatic, does not have associated shoulder or neck pain. (u) D. True claudication will have thigh pain similar to spinal stenosis but can be differentiated by absence of pulses. Spinal stenosis preserves distal pulses.

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

Explanations (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.

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 Answers A. lateral. B. oblique. C. anteroposterior. D. odontoid.

Explanations (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

Explanations (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

Explanations (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

Explanations (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 splints B. corticosteroid injection C. surgical referral D. propoxyphene (Darvocet)

Explanations (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.

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? Answers A. Wrist splint for 2-6 weeks B. Corticosteroid injection C. Surgical referral D. Darvocet

Explanations (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.

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

Explanations (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.

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

Explanations (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.

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

Explanations (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

Explanations (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

Explanations (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

Explanations (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

Explanations (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

Explanations (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 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

Explanations (u) A. CT of the spine should be reserved for fractures that remain symptomatic or progress after treatment. (u) B. MRI is a good tool in evaluation of union versus non union fractures and should be reserved for fractures that remain symptomatic or progress after treatment. (c) C. 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. (u) D. Technetium-99m bone scan is useful in the evaluation of active bone formation (or lack of) and is reserved for fractures that remain symptomatic or progress after treatment.

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 Answers A. carpal tunnel syndrome. B. radial tunnel syndrome. C. tenosynovitis. D. gamekeeper's thumb.

Explanations (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

Explanations (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

Explanations (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 Therapeutics/Orthopedics/Rheumatology 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)

Explanations (u) A. Corticosteroid use is recommended after initial treatment is unsuccessful. (u) B. Surgical intervention is reserved for patients not responsive to initial/conservative treatment. (c) C. Splinting the affected wrist is the initial treatment choice and maintains a neutral position of the wrist. (u) D. Gabapentin is not indicated in the management of carpal tunnel syndrome.

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

Explanations (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

Explanations (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.

History & Physical/Orthopedics/Rheumatology A 14-year old male active in sports, has been complaining of intermittent anterior right knee pain for several months. He denies any specific injuries. On examination, there is no erythema, swelling, deformities, joint laxity, or crepitus. Palpation reveals tenderness over the tibial tubercle and bursa of the right knee. This finding is characteristic of which of the following disorders? A. Discoid meniscus B. Osgood-Schlatter disease C. Chondromalacia patella D. Osteochondritis dissecans

Explanations (u) A. Discoid meniscus causes clicking over the lateral meniscus during flexion. This disorder is mostly painless and occasionally may cause mild aching or effusion. (c) B. Osgood-Schlatter disease causes pain at the tibial tubercle and it is caused by fragmentation of the tip of the proximal tibial physis. (u) C. Chondromalacia patella may demonstrate exaggerated knee valgus and subluxation. (u) D. Osteochondritis dissecans in older children may have effusions, pain, and locking of the joint caused by a portion of the joint surface softening and a shearing leading to a loose fragment.

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

Explanations (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.

Clinical Intervention/Orthopedics/Rheumatology 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

Explanations (u) A. Fixation is warranted for displaced fractures, angulated fractures beyond 40 degrees, or extensor lag. (u) B. A long finger splint would not immobilize the joint above and below and may not offer enough immobilization. (c) C. An ulnar gutter splint is the most appropriate care in the emergency room. (u) D. Although you will eventually refer the patient for casting, the choice treatment initiated in the emergency room should be immobilization.

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.

Explanations (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.

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

Explanations (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

Explanations (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

Explanations (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 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

Explanations (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

Explanations (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

Explanations (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? Answers A. Radiolucent lesions B. Demineralization C. Chondrocalcinosis D. Subperiosteal resorption

Explanations (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.

Diagnosis/Orthopedics/Rheumatology 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

Explanations (u) A. Plain x-rays may aid in diagnostic suspicion, usually after a week or two, but do not aid in treatment choice. (u) B. ASO titer is not indicated in a patient with osteomyelitis. (u) C. MRI will detect the early inflammation of osteomyelitis but does not aid in the treatment choice. (c) D. A culture of the joint fluid will confirm the diagnosis and offer information regarding infectious agent.

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? Answers A. Rest, ice, elevation B. Immobilize, antibiotics, orthopedics referral C. Splint for 48 hours, aspirin, ice D. Surgical referral for amputation of digit

Explanations (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.

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

Explanations (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.

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

Explanations (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

Explanations (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.

Diagnostic Studies/Orthopedics/Rheumatology 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

Explanations (u) A. See B for explanation. (c) B. MRI is the diagnostic study of choice in a patient with suspected disc herniation. (u) C. See B for explanation. (u) D. See B for explanation.

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

Explanations (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

Explanations (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

Explanations (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

Explanations (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.

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.

Explanations (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.

Clinical Intervention/Orthopedics/Rheumatology 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

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Tenderness in the snuff box should be treated as a 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. (u) D. See C for explanation.

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

Explanations (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.

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

Explanations (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? Answers A. Spondylolysis B. Spondolisthesis C. Scoliosis D. Herniated disc

Explanations (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.

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

Explanations (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.

Diagnosis/Orthopedics/Rheumatology 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

Explanations (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? Answers A. Abduction stress test B. Anterior drawer sign C. Lachman test D. McMurray test

Explanations (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

Explanations (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

Explanations (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.

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

Explanations (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

Explanations (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

Explanations (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.

Health Maintenance/Orthopedics/Rheumatology A 23 year-old male presents to the emergency department with severe right shoulder pain. He is holding his shoulder in internal rotation. Which of the following would increase your suspicion that he has a posterior glenohumeral dislocation? A. History of a direct posterior blow to the humerus B. History of seizure C. Palpable mass in the anterior axilla D. Palpable space beneath the acromion

Explanations (u) A. This is a common mechanism for anterior glenohumeral dislocation. (c) B. Tonic-clonic seizures can create severe contraction of the internal rotator muscles of the shoulder. (u) C. This is a classic finding associated with anterior dislocation. The mass is the humeral head outside of the glenoid. (u) D. This is also a classic finding associated with anterior dislocation and the space is where the humeral head should be in a non-dislocated shoulder.

Clinical Intervention/Orthopedics/Rheumatology 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

Explanations (u) A. This measure may be used while the necessary equipment is obtained to bivalve the cast, but it will not treat the underlying condition. (c) B. The cast for this patient is too tight and the pressure needs to be released. Bivalving the cast is the best option for this patient. (u) C. The cast for this patient is too tight and the pressure needs to be released. Ambulation is not appropriate in this patient. (u) D. Increasing the patient's pain medication will not treat the underlying condition.

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

Explanations (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

Explanations (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.

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? Answers 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.

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

Explanations (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.

Scientific Concepts/Orthopedics/Rheumatology 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

Explanations (u) A. Medial collateral ligament injuries often occur with rotational injuries or direct impact to the lateral knee. Tenderness medially with laxity with valgus (medial) stress is noted. (u) B. Lateral collateral ligament injury causes pain mostly on the lateral aspect of the knee and patients can experience knee buckling with normal gait. Tenderness laterally with laxity with varus (lateral) stress is noted. (u) C. Posterior cruciate ligament injuries occur with an outside directed force, often a posterior directed force such as a knee striking a dashboard. The patients often do not hear a pop. A posterior drawer test or posterior sag test can be useful in the diagnosis. (c) D. 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.