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Board Review. 5. An 18-year-old female basketball player comes to your office the day after sustaining an inversion injury to her ankle. She says she.

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Presentation on theme: "Board Review. 5. An 18-year-old female basketball player comes to your office the day after sustaining an inversion injury to her ankle. She says she."— Presentation transcript:

1 Board Review

2 5. An 18-year-old female basketball player comes to your office the day after sustaining an inversion injury to her ankle. She says she treated the injury overnight with rest, ice, compression, and elevation. You examine her and diagnose a moderate to severe lateral ankle sprain. In addition to rehabilitative exercises, you advise A) a short-term cast B) a posterior splint that allows no flexion or extension C) a semi-rigid stirrup brace (Air-Stirrup) D) an elastic bandage E) no external brace or support

3 ANSWER: C In acute ankle sprains, functional treatment with a semi-rigid brace (Aircast) or a soft lace-up brace is recommended over immobilization. Casting or posterior splinting is no longer recommended. Elastic bandaging does not offer the same lateral and medial support. External ankle support has been shown to improve proprioception.

4 37. A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A pregnancy test is negative, and other blood work is normal. She has no other medical problems and takes no medications. With respect to her amenorrhea, you advise her A) to increase her caloric intake B) that this is a normal response to training C) to begin an estrogen-containing oral contraceptive D) to stop running

5 ANSWER: A Amenorrhea is an indicator of inadequate calorie intake, which may be related to either reduced food consumption or increased energy use. This is not a normal response to training, and may be the first indication of a potential developing problem. Young athletes may develop a combination of conditions, including eating disorders, amenorrhea, and osteoporosis (the female athlete triad). Amenorrhea usually responds to increased calorie intake or a decrease in exercise intensity. It is not necessary for patients such as this one to stop running entirely, however

6 45. A 56-year-old African-American male has pain and tingling in the medial aspect of his ankle and the plantar aspect of his foot. He jogs 3 miles daily and has no history of any injury. The symptoms are aggravated by activity, and sometimes keep him awake at night. The only findings on examination are paresthesias when a reflex hammer is used to tap just inferior to the medial malleolus. This patient probably has A) a stress fracture B) a herniated nucleus pulposus at L5 or S1 C) plantar fasciitis D) diabetic neuropathy E) tarsal tunnel syndrome

7 ANSWER: E Entrapment of the posterior tibial nerve or its branches as the nerve courses behind the medial malleolus results in a neuritis known as tarsal tunnel syndrome. Causes of compression within the tarsal tunnel include varices of the posterior tibial vein, tenosynovitis of the flexor tendon, structural alteration of the tunnel secondary to trauma, and direct compression of the nerve. Pronation of the foot causes pain and paresthesias in the medial aspect of the ankle and heel, and sometimes the plantar surface of the foot. The usual site for a stress fracture is the shaft of the second, third, or fourth metatarsals. A herniated nucleuspulposus would produce reflex and sensory changes. Plantar fasciitis is the most common cause of heel pain in runners and often presents with pain at the beginning of the workout. The pain decreases during running only to recur afterward. Diabetic neuropathy is usually bilateral and often produces paresthesias and burning at night, with absent or decreased deep tendon reflexes.

8 81. A 32-year-old female who is an avid runner presents with knee pain. You suspect patellofemoral pain syndrome. Which one of the following signs or symptoms would prompt an evaluation for an alternative diagnosis? A) Peripatellar pain while running B) Knee stiffness with sitting C) A “popping” sensation in the knee D) “Locking” of the joint E) A positive “J” sign (lateral tracking of the patella when moved from flexion to full extension)

9 ANSWER: D Patellofemoral pain syndrome is a clinical diagnosis and is the most common cause of knee pain in the outpatient setting. It is characterized by anterior knee pain, particularly with activities that overload the joint, such as stair climbing, running, and squatting. Patients complain of “popping,” “catching,” “stiffness,” and “giving way.” On examination there will be a positive “J” sign, with the patella moving from a medial to a lateral location when the knee is fully extended from the 90° position. This is caused by an imbalance in the medial and lateral forces acting on the patella. “Locking” is not characteristic of patellofemoral pain syndrome, so loose bodies or a meniscal tear should be considered if this is found.

10 84. A 22-year-old male with no previous history of shoulder problems is injured in a fall. He has immediate pain and is unable to abduct his arm. He goes to the emergency department and an MRI reveals an acute tear of the rotator cuff. Which one of the following is the best initial treatment for this injury? A) Observation without treatment for 1 month B) Immobilization for 1 month C) Physical therapy for 1 month D) Corticosteroid injection E) Surgical repair

11 ANSWER: E An acute rupture of any major tendon should be repaired as soon as possible. Acute tears of the rotator cuff should be repaired within 6 weeks of the injury if possible (SOR C). Nonsurgical management is not recommended for active persons. Observing for an extended period will likely lead to retraction of the detached tendon, possible resorption of tissue, and muscle atrophy.

12 131. You see a 5-year-old white female with in- toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with the cosmetic appearance and possible future disability, and request that she be treated. You recommend which one of the following? A) Observation B) Medial shoe wedges C) Torque heels D) Sleeping in a Denis Browne splint for 6 months E) Derotational osteotomy of the femur

13 ANSWER: A There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8–10 years of age who still have cosmetically unacceptable, dysfunctional gaits. Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate treatment for a 5-year-old with uncomplicated anteversion.

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15 169. In a preadolescent athlete, sudden death from a blunt injury to the chest (commotio cordis) is most likely to occur in which one of the following situations? A) A pitcher is struck by a line drive B) A basketball player is struck by the ball C) A chest-to-chest collision occurs during a soccer game D) Hockey players skate into each other E) A football player is struck by the shoulder pad of a lineman

16 ANSWER: A Commotio cordis usually results from impact with a projectile in sports. Children and adolescents may have increased risk due to a compliant chest wall. Ventricular fibrillation is thought to result from the impact. Softer “safety” baseballs are one consideration in primary prevention. Older competitors are at less risk. Large blunt objects or body-to-body contact also carries less risk.

17 216. An overweight 13-year-old male presents with a 3-week history of right lower thigh pain. He first noticed the pain when jumping while playing basketball, but now it is present even when he is just walking. On examination he can bear his full weight without an obvious limp. There is no localized tenderness, and the patella tracks normally without subluxation. Internal rotation of the hip is limited on the right side compared to the left. Based on the examination alone, which one of the following is the most likely diagnosis? A) Avascular necrosis of the femoral head (Legg-Calvé-Perthes disease) B) Osteosarcoma C) Meralgia paresthetica D) Pauciarticular juvenile rheumatoid arthritis E) Slipped capital femoral epiphysis

18 ANSWER: E This is a classic presentation for slipped capital femoral epiphysis (SCFE) in an adolescent male who has probably had a recent growth spurt. Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy. Obese males are affected more often. The pain is typically in the anterior thigh, but in a high percentage of patients the pain may be referred to the knee, lower leg, or foot. Limited internal rotation of the hip, especially with the hip in 90° flexion, is a reliable and specific finding for SCFE and should be looked for in all adolescents with hip, thigh, or knee pain. Meralgia paresthetica is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the femoral head) is more likely to occur between the ages of 4 and 8 years. Juvenile rheumatoid arthritis typically is associated with other constitutional symptoms including stiffness, fever, and pain in at least one other joint, with the pain not necessarily associated with activity.

19 237. A 7-year-old male is brought to your office after hurting his hand when he fell on a wet kitchen floor. He is unable to describe the mechanism of injury. On examination the maximal point of tenderness is at the third metacarpal-phalangeal joint, which also has some generalized swelling but no ecchymosis. Range of motion is limited in this joint due to pain. A radiograph of the hand is shown in Figure 7. Which one of the following is the most likely diagnosis? A) Boxer’s fracture B) Greenstick fracture C) Salter type II fracture D) Spiral fracture E) No abnormality

20 ANSWER: C Recognizing common fracture types is an important part of determining how to proceed when caring for an injured patient. Fractures in children can be different from those in adults for several reasons, including the elasticity of immature bone, the possibility of child abuse, and the presence of growth plates. The radiograph shown with this question is an example of a fracture through the growth plate. Approximately 6%–7% of such fractures will cause a restriction of growth. The Salter classification system was developed to classify fractures into the growth plate and can be used to estimate the risk of growth restriction. The higher the classification, the greater the risk of complications.

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22 5. A 15-year-old white male complains of bilateral foot pain. He does not recall any injury, and the pain improves with rest. Examination reveals tenderness over the lateral and anterior ankle, along with a rigid flatfoot, peroneal tightness, and pain on foot inversion. The most likely diagnosis is A) tarsal coalition B) stress fracture C) plantar fasciitis D) turf toe E) foot sprain

23 ANSWER: A Tarsal coalition is the fusion of two or more of the tarsal bones. It is congenital, and 50% of the time is bilateral. It is asymptomatic until early adolescence. On clinical examination there is tenderness over the subtalar joint (lateral and anterior ankle), rigid flatfoot, limited subtalar motion, peroneal tightness, and pain on foot inversion. Treatment is conservative. A stress fracture would present with pain in the forefoot, warmth, mild swelling, and point tenderness over the affected metatarsals, most commonly the second or third. Radiographs are often negative initially, but a callus is usually evident by the third week of symptoms. Plantar fasciitis presents with pain in the heel or sole of the foot and is most painful with the first step after arising from bed or prolonged sitting. It may be associated with pes planus (flat foot), but in plantar fasciitis the flat foot is flexible, not rigid. Turf toe is inflammation of the first metatarsophalangeal joint due to acute and/or repetitive hyperextension injury resulting from sudden toe-off against an unyielding surface, such as artificial turf. The patient may present acutely with a tender, red, swollen first metatarsophalangeal joint, with pain on passive extension. Others may develop a chronic condition and present with hallux rigidus. Foot sprain is a nonspecific term for an acute ligamentous injury.

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25 8. Which one of the following is characteristic of osteoarthritis of the knee? A) Greater frequency in men than in women B) Increased pain with rest C) A direct correlation between radiographic changes and pain severity D) Reduction of pain with repair of associated meniscal tears E) Reduction of pain with muscle strengthening

26 ANSWER: E Osteoarthritis of the knee is more common in women than in men. Rest improves the pain of osteoarthritis, and increasing muscle strength improves joint stability and reduces pain. Meniscal tears are extremely common in advanced osteoarthritis, but repairing them fails to improve the course of the disease. Radiographic changes correlate poorly with pain severity in osteoarthritis.

27 30. A 62-year-old white female presents to your office with moderately severe knee pain. She has a history of osteoarthritis and is not aware of any recent injury. The pain bothers her both during the day and at night. Examination reveals a moderately obese female with a normal knee examination except for tenderness in the medial tibial plateau region, approximately 3 cm (1½ in) below the medial joint line of the knee. The area of tenderness is about the size of a quarter. All ligaments of the knee are intact on examination. There is no knee effusion. A radiograph is negative except for minimal degenerative changes. Which one of the following should you suspect? A) De Quervain’s tendinitis B) Prepatellar bursitis C) Bursitis of the medial collateral ligament D) Anserine bursitis E) Medial meniscus tear

28 ANSWER: D Anserine bursitis is characterized by pain, particularly at night, that occurs in the medial knee region over the upper tibia. It is located about 2–3 cm below the medial joint line. It can be bilateral. A diagnosis of anserine bursitis requires local tenderness confined to a quarter-sized area of the medial tibial plateau, approximately 3 cm below the medial joint line; a negative valgus stress maneuver, which indicates an intact medial collateral ligament; and a normal radiograph of the tibia indicating no underlying pathology. De Quervain’s tendinitis is located in the wrist region, not the knee. Prepatellar bursitis is characterized by knee swelling and pain over the front of the knee. Bursitis that occurs adjacent to the medial collateral ligament typically presents with tenderness over the medial aspect of the knee. Medial joint line pain is characteristic of osteoarthritis, second and third degree medial collateral ligament injuries, medial meniscal tears, and fractures of the tibial plateau.

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30 49. A 14-year-old male who is active in sports most of the year presents with bilateral anterior knee pain that is worse in the right knee. An examination reveals tenderness and some swelling at the tibial tubercles. Which one of the following is true regarding this patient’s condition? A) It is almost never seen in adults B) Treatment with a straight leg cylinder cast for 6 weeks is often needed C) Corticosteroid injection of the tibial tubercle is a safe and effective treatment D) Radiographs should always be ordered to rule out other conditions E) Bilateral symptoms are unusual

31 ANSWER: A Osgood-Schlatter disease is encountered in patients between 10 and 15 years of age. These patients are often active in sports that involve a lot of jumping. It is thought to be secondary to repetitive microtrauma and traction apophysitis of the tibial tuberosity. Bilateral symptoms are present in 20%–30% of patients. Radiographs may reveal abnormalities, but are rarely indicated in straightforward cases. This condition is usually self-limited, and most patients are able to return to full activity within 2–3 weeks. Treatment includes rest, ice, anti-inflammatory medications, a rehabilitation program, and an infrapatellar strap during activities. Casting and corticosteroid injections are not indicated.

32 56. Which one of the following is a contraindication to participation in contact sports? A) A single testicle B) Fever C) Documented scoliosis of 20º D) Sickle cell trait

33 ANSWER: B Having a single testicle is not a contraindication to contact sports, but it does necessitate a discussion regarding the potential risk, as well as the use of a protective cup. A single ovary is not a contraindication because it is well protected. Fever is a contraindication to participation since it increases cardiovascular effort, as well as the potential for heatstroke and orthostatic hypotension and dehydration. The rare possibility of an associated myocarditis also should be taken into account. Carditis may result in sudden death with exertion. Scoliosis should be looked into prior to allowing a child to participate in contact sports, but once the diagnosis is made it is rarely a contraindication unless the curvature is greater than 40º. Sickle cell trait is not a contraindication to contact sports, although sickle cell disease can be a contraindication to strenuous activities or sports associated with significant contact.

34 64. The most effective means of preventing sudden death in high-risk patients with asymptomatic hypertrophic cardiomyopathy is A) amiodarone (Cordarone) B) metoprolol (Lopressor) C) verapamil (Calan, Isoptin) D) chronic dual-chamber pacing E) an implantable cardioverter-defibrillator (ICD)

35 ANSWER: E Many patients with hypertrophic cardiomyopathy (HCM) never have any clinical signs or symptoms. The major cause of mortality is sudden death, which can occur in both asymptomatic and symptomatic patients, often after physical exertion. Patients with HCM should be counseled about the risk of competitive sports and dehydration. Medications such as verapamil, ß-blockers, and diltiazem are used for symptom management, but do not decrease the risk of sudden death. Because of its effects on decreasing dysrhythmias, amiodarone may decrease the risk of sudden death, which is supported by anecdotal data. For most patients with HCM, the annual risk of dying is similar to that of the normal adult population, or 1% per year. Patients most at risk for sudden death include those with ventricular tachycardia on an ambulatory monitor, marked left ventricular hypertrophy, abnormal blood pressure response to exercise, syncope, and a family history of sudden death. At present, the implantable cardioverter-defibrillator (ICD) is the most effective modality for preventing sudden death in high-risk patients with asymptomatic HCM. Pacing does not reduce risk significantly.

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37 75. A 43-year-old house painter presents with chronic pain in the radial aspect of the wrist, radiating down the thumb. Her symptoms are worsened with pinching and with wrist movement. She has had to quit her job due to the severity of symptoms. On examination she has pain in the thumb with opening and closing her hand, and a Finkelstein’s test is positive. The most effective treatment for this patient would be A) rest B) NSAIDs C) splinting D) local corticosteroid injection

38 ANSWER: D The history and physical findings are most consistent with de Quervain’s tenosynovitis, which affects the abductor pollicis longus and the extensor pollicis longus and brevis tendons. Local corticosteroid injection is the most effective treatment. NSAIDs and splinting may be somewhat effective for mild cases, but are less effective than corticosteroids. Rest alone has not been shown to be very helpful.

39 86. A 6-year-old female is brought to your office for recurring limb pain. For the past 2 weeks she has complained of cramping pain in her thighs and calves, which has caused her to awaken at times. Massage and occasional acetaminophen help. In the morning the symptoms are gone and daily activity is unimpaired. Her physical examination is normal. On examination she has no inflammatory signs and no joint or muscle tenderness. Which one of the following would be most appropriate at this point? A) Radiographs of the hips and knees B) An erythrocyte sedimentation rate C) A CBC D) Antinuclear antibody (ANA) testing E) No further testing

40 ANSWER: E This patient is experiencing benign nocturnal pains of childhood, formerly called “growing pains.” These are cramping pains of the thigh, shin, and calf, and affect approximately 35% of children 4– 6 years of age. The pain typically occurs in the evening or at night, may awaken the child from sleep, and disappears by morning. This classic presentation in the absence of other inflammatory or chronic signs and symptoms should reinforce the benign nature of this condition. Physical findings are normal, so in the absence of worrisome complaints or anatomic abnormalities no further diagnostic testing is required. Parents should be reassured that there are no long-term sequelae. If activity is impaired, the physical examination is abnormal, or any constitutional or systemic complaints are present, then further evaluation with additional testing is indicated, and may include an erythrocyte sedimentation rate, CBC, antinuclear antibody, or radiographs of affected bones or joints.

41 90. A 5-year-old male is brought to your office with forearm pain after a fall, and you diagnose a non- angulated buckle fracture of the distal radius and ulna. Which one of the following treatments has the best functional outcome at 3–4 weeks? A) An ACE wrap B) A removable splint C) A long arm cast D) A thumb spica cast E) Surgical reduction and internal fixation

42 ANSWER: B Although casting for 3–4 weeks with a short arm cast has been the traditional treatment for buckle fractures of the wrist, functional outcome in the short term is better with a simple removable splint, and management is easier. Long-term outcomes are good with either treatment. Rigid splinting adds to short-term functional stiffness, and a wet cast or foreign bodies placed between the cast and skin necessitate additional visits. Surgical approaches are contraindicated and would not improve healing or position.

43 96. A healthy 25-year-old female runner presents with a complaint of right heel pain for 2 months. The pain is most pronounced with the first steps of the day or after periods of rest, and is located around the medial calcaneal tuberosity. Which one of the following is NOT recommended for acute treatment? A) Extracorporeal shock wave therapy B) Prefabricated insoles (heel pad) C) Night splints D) Corticosteroid iontophoresis E) NSAIDs

44 ANSWER: A These findings are classic for plantar fasciitis. Treatments in the acute phase include insoles, night splints, corticosteroid iontophoresis, and NSAIDs. Based on current evidence, extracorporeal shock wave therapy is recommended only after 12 months of symptoms.

45 99. A 10-year-old male is brought to your office with pain and swelling of the knee after falling out of a tree. A physical examination is notable for point tenderness and swelling at the proximal tibia. A radiograph shows a displaced fracture of the proximal tibia through the physis and epiphysis. The most appropriate management is A) a long leg cast B) a rigid knee immobilizer C) a functional (hinged) knee immobilizer D) orthopedic referral

46 ANSWER: D Physeal injuries are unique to children, and account for approximately one-fourth of all pediatric fractures. This child has a Salter-Harris fracture that requires referral to an orthopedist. Salter-Harris type I injury is a fracture through the hypertrophic cartilage that causes widening of the physeal space. These fractures are difficult to diagnose radiographically, but their clinical hallmark is point tenderness at the epiphyseal plate. Type II fractures are the most common, and extend through both the physis and metaphysis. Although these fractures may result in some shortening, they rarely cause functional deformities. Type III injuries extend through the physis and epiphysis, disrupting the reproductive layer of the physis. These injuries may cause chronic sequelae because they disrupt the articular surface of the bone, but they do not produce deformities and generally have a good prognosis. Type IV injuries cross through the epiphysis, physis, and metaphysis. These fractures are also intra-articular, increasing the risk for chronic disability. They can disrupt the proliferative zone, leading to early fusion and growth deformity. Type V fractures are the least common but most difficult to diagnose, and have the worst prognosis. The classic mechanism of injury is an axial force that compresses the epiphyseal plate without an overt fracture of the epiphysis or metaphysis.

47 105. A 76-year-old male has fallen twice as a result of buckling of the left knee during ambulation. Neither fall resulted in injury, and he is advised to use an offset walking cane. The patient is left hand– dominant and has normal strength in all four extremities. Crepitus is present in both knees, but is much more pronounced in the left knee. Which one of the following describes the best method for use of a cane by this patient? A) Place the cane in the left hand and advance it at the same time as the left leg B) Place the cane in the left hand and advance it at the same time as the right leg C) Place the cane in the right hand and advance it at the same time as the left leg D) Place the cane in the right hand and advance it at the same time as the right leg E) Switch the cane between hands at intervals of several hours to distribute the load equally

48 ANSWER: C The standard walking cane generally is designed as a tool to aid in balance and, to a lesser degree, reduce weight bearing on a specific leg. The offset cane design results in the downward force vector being placed directly over the shaft, making this choice ideal where improved balance and reduction of weight bearing on a particular leg is desired. Mechanical advantage produces maximum benefit when the cane is placed in the hand opposite the most severely affected leg, and the movement of the cane tracks the movement of the affected leg, consistent with normal gait.

49 122. Little League elbow refers to a problem located over the A) medial epicondyle B) lateral epicondyle C) olecranon D) capitellum E) ulnar groove

50 ANSWER: A Little League elbow is an apophysitis of the medial epicondyle of the elbow. It occurs in throwing athletes between 9 and 12 years of age, and causes elbow pain during throwing. It may also affect velocity and control. It may cause pain and swelling in the arm and/or elbow, but the diagnosis should be considered in throwing athletes with elbow pain even if symptoms are minimal.

51 127. A 72-year-old white female is experiencing pain due to a vertebral compression fracture. Pain control with opioid analgesics and calcitonin therapy is not adequate. Which one of the following would make vertebroplasty an appropriate option? A) Fracture duration <6 months B) Degree of vertebral collapse 80% C) Radiologic evidence of destruction of the posterior vertebral wall D) New-onset bladder dysfunction thought to have a neurologic etiology E) New-onset bilateral lower-extremity paresis

52 ANSWER: A Vertebroplasty is a reasonable therapeutic consideration for vertebral compression fractures if pain is not adequately controlled with analgesics and conservative therapy. Some studies indicate a better response with less chronic fractures. Treatment of fractures less than 6 months old is acceptable. More prolonged conservative therapy with an inadequate response is not appropriate. Neurologic dysfunction, including bladder dysfunction, paralysis, and sensory deficits, is a relative contraindication to vertebroplasty. Spinal cord compression requires other treatment, and high degrees of compression (>67%) are not amenable to this therapy. Destruction of the posterior wall is a contraindication to this therapy because the injected polymethyl methacrylate should not directly contact the spinal cord. Coagulopathies and infectious processes are also contraindications.

53 138. A high-school gymnast presents to your office with a history of back pain for the past 3–4 weeks. She reports that symptoms are worse with any hyperextension activity. Examination demonstrates a hyperlordotic posture with mild tenderness in the lower lumbar spine. Radiographs demonstrate the classic “Scotty dog with a collar” appearance of spondylolysis. Which one of the following statements about this diagnosis is true? A) Most athletes can resume full activity in 4–6 weeks B) Spondylolisthesis >25% requires referral to a spine surgeon C) Inadequate treatment can lead to complete fracture and spondylolisthesis with prolonged disability D) Adolescents should be followed with serial CT every 6 months until they reach skeletal maturity

54 ANSWER: C Complete fracture and spondylolisthesis with prolonged disability may occur if spondylolysis is not diagnosed early and treated appropriately. Most athletes respond to conservative management and return to full activity approximately 6 months after diagnosis. Treatment for low- grade spondylolisthesis (up to 50% slippage) is similar to treatment for spondylolysis. Patients should be followed with serial radiographs at 6-month intervals until they reach skeletal maturity. Patients with a high-grade slippage (>50%) may need to be comanaged by an orthopedic or spine surgeon to guide treatment and assist in return-to-play decisions.

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57  Graded according to its degree of severity. The Myerding grading system measures the percentage of vertebral slip forward over the body beneath. The grades are as follows:  Grade 1: 25% Grade 2: 25% to 49% Grade 3: 50% to 74% Grade 4: 75% to 99% Grade 5: 100%*

58 143. A 70-year-old retired farmer presents with an angulated right knee and a painful hip. He asks you about the possibility of “getting a new knee,” although he is not eager to do so. You would advise him that the major indication for knee replacement is A) severe joint pain at rest B) marked joint space narrowing seen on radiologic studies C) destruction and loss of motion of the contralateral joint D) an acutely infected joint

59 ANSWER: A The major indication for joint replacement is severe joint pain, usually pain at rest. Loss of joint function and radiographic evidence of severe destruction of the joint may also be considered in the decision. The appearance of the joint and the status of the contralateral joint may be minor considerations. Surgical insertion of a foreign body into an infected joint is contraindicated.

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61 155. You see a 16-year-old white female for a preparticipation evaluation for volleyball. She is 183 cm (72 in) tall, and her arm span is greater than her height. She wears contacts for myopia. Which one of the following should be performed at this time? A) An EKG B) Echocardiography C) A stress test D) A chest radiograph E) Coronary MRI angiography

62 ANSWER: B Marfan’s syndrome is an autosomal dominant disease manifested by skeletal, ophthalmologic, and cardiovascular abnormalities. Men taller than 72 in and women taller than 70 in who have two or more manifestations of Marfan’s disease should be screened by echocardiography for associated cardiac abnormalities. Any of these athletes who have a family history of Marfan’s syndrome should be screened, whether they have manifestations themselves or not. If there is no family history, echocardiography should be performed if two or more of the following are present: cardiac murmurs or clicks, kyphoscoliosis, anterior thoracic deformity, arm span greater than height, upper to lower body ratio more than 1 standard deviation below the mean, myopia, or an ectopic lens. Patients with Marfan’s syndrome who have echocardiographic evidence of aortic abnormalities should be placed on beta-blockers and monitored with echocardiography every 6 months.

63 174. A 16-year-old male comes to your office after suffering an eversion injury to his ankle while being tackled in a football game 3 days ago. He was not able to bear weight after the injury and now has tenderness at the distal tibiofibular joint with no swelling. Compression of the fibula against the tibia at the mid-calf elicits pain anterior to the lateral malleolus and proximal to the ankle joint. Stabilizing the leg and rotating the foot externally elicits pain at the same location. Radiographs are negative. Which one of the following would be most appropriate at this point? A) Application of an elastic wrap to the ankle for 2 weeks B) Therapeutic ultrasound C) Stress radiographs D) A CT scan E) Long-term semirigid support

64 ANSWER: E Syndesmotic (high ankle) sprains account for as many as 11% of ankle sprains. The mechanism of injury is dorsiflexion and/or eversion of the ankle, most commonly in contact sports. The syndesmotic structures include the anterior, posterior, and transverse tibiofibular ligaments, as well as the interosseous membrane. These injuries can cause chronic ankle instability, resulting in recurrent sprains and hypertrophic ossification. The diagnosis can be made by several tests. The squeeze test can be performed by compressing the fibula against the tibia at mid-calf. A positive test occurs when this elicits pain in the region of the anterior tibiofibular ligament. A positive external rotation stress test causes pain at the same site. It is performed by stabilizing the leg and externally rotating the foot. The crossed-leg test can also detect this injury. The patient places the involved ankle on the opposite knee and pressure is applied to the medial side of the involved ankle, which causes pain at the syndesmosis. While ankle support is often useful for less serious sprains, a Cochrane review showed that semirigid supports are better than elastic bandages. Therapeutic ultrasound has not been shown to have any value for ankle sprains. The injury can be confirmed with an MRI. Indications for referral to an orthopedic surgeon include fracture, dislocation or subluxation, syndesmotic injury, tendon rupture, and uncertain diagnosis.

65 179. A 35-year-old male complains of 2 months of right shoulder pain. He does not recall an injury, but says it is painful to lie on his right side or to work with his right hand above his head. On examination, the shoulder appears normal and there is no pain with external rotation of the shoulder, bringing the arm across the body (scarf test), or attempted external and internal rotation of the shoulder against resistance. Lowering the arm from full abduction (painful arc), attempted abduction above 45º against resistance, and elevating the internally rotated arm above 90º against resistance are all painful. The most likely diagnosis is A) subdeltoid bursitis B) adhesive capsulitis C) impingement syndrome D) glenohumeral osteoarthritis E) acromioclavicular osteoarthritis

66 ANSWER: C The combination of a painful arc and pain on use of the supraspinatus muscle indicates impingement syndrome, which is due to irritation of the rotator cuff under the coracoacromial arch. It is by far the most common cause of shoulder pain seen by family physicians. Subdeltoid bursitis is a much more acute problem, and impairs shoulder mobility in all directions. Adhesive capsulitis produces loss of external rotation. Glenohumeral arthritis produces pain with external rotation, and variable amounts of impaired mobility, depending on progression of the problem over time. Acromioclavicular joint arthritis produces a positive scarf sign, and often a visible bump over the joint, since it lies so close to the skin surface.

67 195. A 65-year-old female presents with a complaint of slowly increasing discomfort in her knees of 3 years’ duration. An examination and radiograph are consistent with noninflammatory osteoarthritis. She says that the pain is well-controlled with acetaminophen, but she wants to know what can be done to prevent further damage to the joint. You recommend A) referral to a rheumatologist for disease-modifying agents such as methotrexate B) hyaluranon injections to preserve cartilage C) corticosteroid injections D) symptomatic measures only

68 ANSWER: D Osteoarthritis is a common finding in older people; some studies show that 25% of patients over age 65 have osteoarthritic changes. Unfortunately, no pharmacologic treatments have been found to prevent the progression of joint destruction. Maintaining ideal weight and avoiding excessive use of the knees, including deep knee bends, running, and stair climbing, does lessen destructive forces on the joint. A reasonable walking program can improve both pain and joint function. Acetaminophen is the first choice for joint pain in someone with noninflammatory osteoarthritis. NSAIDs provide better pain relief but can cause renal damage, fluid retention, and GI bleeding, and are therefore reserved as a second-line treatment. Narcotics usually are reserved for short-term use during flares of arthritis. Studies show that injections of corticosteroids or hyaluranons improve symptoms for some, but have not been shown to lessen joint destruction. Disease-modifying agents, such as methotrexate, can help inflammatory arthritic joints, as in psoriatic arthritis and rheumatoid arthritis, but have not been shown to be of benefit in osteoarthritis.

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70 202. A positive Lachman test indicates injury to the A) medial collateral ligament B) posterior cruciate ligament C) medial meniscus D) anterior cruciate ligament E) lateral collateral ligament

71 ANSWER: D The Lachman test is performed with the knee flexed to 25º- 30º while the examiner grasps the distal femur in one hand and the proximal tibia in the other. While the femur is held stationary, the tibia is pulled anteriorly, using a “shucking” action. If a distinct end point is reached, as if a piece of loose rope suddenly becomes taut, the test is negative or normal. A soft or indistinct end point, as if stretching an elastic band, is a positive or abnormal test that indicates a ruptured anterior cruciate ligament. In this case, the anterior drawer test would also be positive, but it is not as specific as the Lachman test. Injuries to the other structures listed are diagnosed using other maneuvers, and are not associated with a positive Lachman test.

72 207. A 16-year-old high-school basketball player is struck on the end of her long finger by the ball. Her finger was fully extended and the result was a forced flexion injury of the proximal interphalangeal (PIP) joint. She is unable to actively extend the PIP joint, although passive extension is possible. She is tender over the dorsal aspect of the middle phalanx. Radiographs are negative. Which one of the following is true regarding this injury? A) Immediate referral to an orthopedist is indicated B) Buddy taping to the adjacent ring finger is the only treatment necessary C) Any splint (fashioned aluminum splint, stack splint, ring splint) would be adequate D) Splinting should be continued for 2 weeks E) A boutonniere deformity may result

73 ANSWER: E An injury to the central extensor slip can occur when the proximal interphalangeal (PIP) joint is forcibly flexed while the digit is actively extended. The injury is evaluated by holding the joint in a position of 15º–30º of flexion. The patient will not be able to actively extend the joint, but passive extension should be possible. There will be tenderness over the dorsal aspect of the middle phalanx. Delay or improper treatment may result in a boutonniere deformity, which usually develops over several weeks but can occasionally develop acutely. Treatment consists of splinting the PIP joint in full extension for 6 weeks. The stack splint should only be used to treat injuries of the distal interphalangeal joint.

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75 Mallet finger Tx - Stack splint for 6 weeks Boutonnière deformity Tx: PIP joint splint for 6 weeks

76 229. A 25-year-old runner complains of non-focal knee pain. She does not remember any specific injury. You suspect patellofemoral pain syndrome. Which one of the following would be most consistent with this diagnosis? A) Pain with prolonged sitting B) Swelling C) Locking D) Giving way

77 ANSWER: A Patellofemoral pain syndrome causes nonfocal or anterior knee pain, and is often seen in runners. Common symptoms include stiffness, pain with prolonged sitting, and pain with climbing or descending stairs. Rarely is there swelling, locking, or giving way; these symptoms are more likely to be associated with more profound problems such as a ligament or cartilage tear.

78 233. A 53-year-old Hispanic male presents with a 3-day history of right shoulder pain. The pain started shortly after he caught himself when he fell coming down his front steps. Radiographs of the shoulder are normal. Which one of the following, if present, would be most suggestive of a rotator cuff tear? A) Inability to flex at the elbow against resistance B) Signs of decreased arterial perfusion of the hand C) Swelling of the acromioclavicular joint D) Weakness in external rotation of the shoulder

79 ANSWER: D Shoulder pain after a fall may result from a strained muscle or ligament, an exacerbation of a smoldering subacromial bursitis or tendinitis, or a tear of the rotator cuff. Often there is a combination of two or three of these conditions. If the rotator cuff tear is small, treatment is similar to that recommended for the other conditions. However, if a significant rupture has occurred, immobilization and/or surgical consultation is appropriate. On physical examination, a painful arc of abduction above 90º and weakness in external rotation would be expected with a torn rotator cuff. Of these two, weakness in external rotation is much more specific.

80 238. A 32-year-old male comes to your office for the second time for wrist pain following a fall on the ice 10 days ago. At his first visit, examination of the wrist showed no deformity or swelling, but extension was decreased and he had diffuse tenderness over the dorsum of the wrist, particularly just distal and dorsal to the radial styloid. A radiograph is shown. Which one of the following do the radiographs reveal? A) A dislocated lunate B) A fracture of the scaphoid C) A hamate fracture D) A scapholunate dislocation

81 Metacarpal Anatomy

82 ANSWER: B A dorsiflexion injury will typically cause a scaphoid fracture in a young adult, resulting in tenderness to palpation over the anatomic snuffbox. Often the plain posterior-anterior wrist radiograph is normal. However, a special view with the wrist prone in ulnar deviation elongates the scaphoid, often demonstrating subtle navicular fractures. Hook of the hamate fractures cause tenderness at the proximal hypothenar area 1 cm distal to the flexion crease of the wrist. When this fracture is suspected, carpal tunnel and supinated oblique view radiographs should be obtained. A scapholunate dislocation can be identified with a “clenched-fist” view and the supinated view in ulnar deviation.

83 Scapholunate dislocation Normal

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85  A knee xray series is indicated for any of these  Age 55 years or older  Tenderness at head of fibula  Isolated tenderness of patella  Inability to flex knee to 90 degrees  Inability to walk four weight-bearing steps immediately after the injury and in the emergency department


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