AAFP: Musculoskeletal Flashcards
Slipped capital femoral epiphysis is most likely in which one of the following patients with no history of trauma?
a. A 3-day-old male with a subluxable hip
b. A 7-year-old male with groin pain and a limp
c. A 13-year-old male with knee pain
d. A 16-year-old female with lateral thigh numbness
c. A 13-year-old male with knee pain
SCFE occurs most commonly during the adolescent growth spurt (11-13 yo for girls, 13-15 yo for boys). Associated features include being overweight. AAs are affected more commonly as well. The pt may present with pain in groin or anterior thigh, but also may present with pain referred to the knee. That is also the case for Legg-Calve-Perthes disease (avascular or aseptic necrosis of the femoral head). This condition most commonly occurs in boys 4-8 yo. Limping is a prominent feature.
Upper thigh numbness in an adolescent female is a classic symptom of meralgia paresthetica, which is attributed to impingement of the lateral femoral cutaneous nerve in the groin, often associated with obesity or wearing clothing that is too tight in the waist or groin.
DDH is identified by a click during a provocative hip exam of the newborn, using both the Barlow and Ortolani maneuvers to detect subluxation or dislocation.
A 36 yo male is dx with midsubstance Achilles tendinopathy. He has had symptoms for approximately 8 weeks. For this patient, which one of the following would be the first-line treatment?
a. Tendon massage
b. Eccentric exercise
c. Iontophoresis
d. Therapeutic U/S
e. Electical stimulation therapy
b. Eccentric exercise
For chronic midsubstance Achilles tendinopathy (sx lasting longer than 6 weeks), the preferred first-line tx is an intense eccentric strengthening program of the gastrocnemius/soleus complex.
Eccentric strengthening: pt should stand on the ball of the injured foot with the calcaneal area of the foot over the edge of a stair step. The ankle is then lowered to full dorsiflexion with the heel below the level of the step.
A 50 yo female reports a 1-month hx of pain in her wrists. She does not recall any injury. On exam, both wrists are warm but not red, feel boggy on palpation, and lack 30 degrees of both flexion and extension. No other joints are affected. She feels fatigued and unwell, but attributes this to her busy schedule. Radiographs of the wrists are normal. Laboratory findings are unremarkable except for a mildly elevated ESR and a negative Rh factor. Which one of the following is the most likely dx?
a. Rheumatoid arthritis
b. Osteoarthritis
c. Inapparent injury
d. Fibromyalgia
e. Lyme disease
a. Rheumatoid arthritis
RA is most often symmetric at presentation and particularly affects the wrists and other extremity joints that have a high ratio of synovium to articular cartilage. Rh factor is often negative in the early months of the disease, although it may be psoitive later.
Osteoarthritis of the wrists usually invovles the carpal-metacarpal joint of the thumb primarily, and the joint would be red if there were an injury.
Fibromyalgia usually involves the soft tissue of the trunk, and there is no evidence of inflammation.
Lyme disease can cause a variety of joint diseases, but not chronic symmetric arthritis.
A 37 yo graphic designer presents to your office with a hx of several months of radial wrist pain. She does not recall any specific trauma but notes that it hurts to hold a coffee cup. Finkelstein’s test is positive and a grind test is negative, and there is tenderness to palpation over the radial tubercle. Which one of the following would be most appropriate at this point?
a. Plain radiography focusing on the scaphoid
b. Rest and a thumb spica wrist splint
c. MRI of the wrist
d. Short arm cast
b. Rest and a thumb spica wrist splint
This patient has de Quervain’s tenosynovitis. Finkelstein’s test has good sensitivity and specificity in patients with a negative grind test. A positive grind test would be more consistent with scaphoid fracture.
A short arm cast may be appropriate for forearm/wrist fractures.
A 4 yo male is brought to your office by his parents who are concerned that his is increasingly “knock-kneed.” His uncle required leg braces as a child, and the parents are worried about long-term gait abnormalities. On exam, the patient’s knees touch when he stands and there is a 15 degree valgus angle at the knee. He walks with a stable gait. Which one of the following should you do now?
a. Refer to orthopedics for therapeutic osteotomy
b. Refer to physical therapy for customized bracing
c. Prescribe quadriceps-strengthening exercises
d. Provide reassurance to the patient and his family
d. Provide reassurance to the patient and his family
This case is consistent with physiologic genu valgus, and the parents should be reassured. Toddlers under 2 years of age typically have a varus angle at the knee (bowlegs). This transitions to physiologic genu valgus, which gradually normalizes by around 6 years of age.
A 54 yo male presents with progressively worsening pain just below his right knee. He describes the pain as deep and aching, and says it is always present throughout the day, even while he is at rest, and worsens at night. Weight bearing intensifies the pain, as does heat. The patient does not recall any injury or other reason for the leg to hurt. He has not had any fever. His family hx is positive for osteoarthritis in both parents when they were older, and an uncle has had a knee replacement. A physical exam is negative except for some varus deformity of the right lower tibia. His alkaline phosphatase level is elevated but his GGT level is normal. CMP is normal. CBC, including WBC count and differential is normal.
a. Osteoarthritis
b. Osteoporosis
c. Osteomyelitis
d. Paget’s disease of bone
e. Seronegative spondyloarthritis
d. Paget’s disease of bone
- Continuous pain
- Pain increases with rest (unlike osteoarthritis), with heat, and at night
- AP is elevated
What are FABER and FADIR tests sensitive for?
FABER (flexion, adbduction, external rotation)
FADIR (flexion, adduction, internal rotation)
These are impingement tests that are sensitive for labral tears.
A 17 yo female presents to your office with anterior knee pain. She tells you she recently started a running program. She says the pain is worse running down hills, and is vaguely localized just medial to the patella. Examination of the knee shows no effusion or instability, and there is no joint-line pain or patellar tenderness. McMurray’s maneuver is negative. Plain radiographs of the knee appear normal. Which one of the following would be most appropriate at this point?
a. MRI of the knee
b. Modification of her running program and a quadriceps and hip strengthening program
c. Static stretching of the quadriceps and hamstrings prior to running
d. Corticosteroid injection in the area of the pes anserine bursa
b. Modification of her running program and a quadriceps and hip strengthening program
This patient is suffering from PFPS, which causes anterior knee pain that is worse with running downhill. PFPS can be treated with exercises to strengthen the quadriceps and hips, and by using a knee sleeve with a doughnut-type cushion that the patella fits into.
Pes anserine bursitis usually causes pain and tenderness medially, below the joint line.
An 18 yo football player injured the middle finger of his right hand. During the game, he grabbed the jersey of an opposing player as he attempted to tackle him. When you examine him, he cannot flex the affected finger at the DIP joint. Radiographs show a bony fragment at the volar surface of the proximal distal phalanx. Which one of the following would be the most appropriate mgmt?
a. Referral to a hand surgeon
b. Splinting the DIP joint in flexion for 4-6 weeks
c. Splinting the DIP joint in extension for 4-6 weeks
d. Buddy taping the affected finger to the adjacent finger
a. Referral to a hand surgeon
This patient’s injury is commonly referred to as “jersey finger,” a flexor digitorum profundus avulsion fracture that results from forced hyperextension of a flexed DIP joint. On exam, the patient will be unable to flex the finger at the DIP joint. Because the risk of the tendon retraction is high, patients with these fractures should be referred to a hand surgeon as soon as the diagnosis is made.
A 35 yo male with a 4-month history of pain in the medial aspect of his right knee sees you for follow-up. He has been doing physical therapy for the past month with minimal benefit. A plain radiograph is negative and MRI shows a tear in the medial meniscus. Which one of the following is most likely to yield the best long-term result?
a. Referral for meniscectomy
b. Corticosteroid injection
c. Hylan GF 20 (Synvisc) injection
d. Continued physical therapy
d. Continued physical therapy
Arthroscopic partial meniscectomy is the most common orthopedic procedure performed in the U.S. For patients without osteoarthritis of the knee, studies show meniscectomy for a tear of the meniscus is no more beneficial than conservative therapy in terms of functional status at 6 mo.
The optimal approach in patients with a degenerative tear of the meniscus is a physical therapy and exercise regimen.
A 39 yo female presents with lower abdominal/pelvic pain. On exam, with the patient in a supine position, you palpate the tender area of lower abdomen. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies. Which one of the following is the most likely dx?
a. Appendicitis
b. Hematoma within the abdominal wall musculature
c. Diverticulitis
d. PID
e. Ovarian cyst
b. Hematoma within the abdominal wall musculature
A reduction of the pain caused by abdominal palpation when the abdominal muscles are tightened is known as Carnett’s sign. If the cause of the pain is visceral, the taut abdominal muscles may protect the locus of pain. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.
A 17 yo football player presents to your office with a right knee injury. He injured the knee when an opposing player fell against the knee from the front while the patient had his right foot planted. He was unable to bear weight after the injury, and noted immediate swelling of the knee. A positive result with which one of the following would indicate an ACL tear?
a. Ballottement test
b. Lachman test
c. McMurray test
d. Posterior drawer test
e. Thessaly test
b. Lachman test
A positive Lachman test indicates that the ACL may be torn.
Posterior drawer test evaluates PCL stability. McMurray and Thessaly assessments test for meniscal tears. The ballottement test is for detecting intra-articular knee effusion.
A 3 yo female is brought to your office for evaluation of mild intoeing. The child’s patellae face forward, and her feet point slightly inward. Which one of the following would be most appropriate?
a. Reassurance and continued observation
b. Foot stretching exercises
c. Orthotics
d. Night splints
e. Surgery
a. Reassurance and continued observation
Intoeing is usually caused by internal tibial torsion. This problem is believed to be caused by sleeping in the prone position and sitting on the feet. In 90% of cases, internal tibial torsion gradually resolves without intervention by the age of 8. Avoiding sleeping in a prone position enhances resolution of the problem.
A 44 yo AA female reports diffuse aching, especially in her upper legs and shoulders. The aching has increased, and she now has trouble going up and down stairs because of weakness. She has no visual symptoms, and a neurologic exam is normal except for proximal muscle weakness. Laboratory tests revealed elevated levels of serum CK and aldolase. Her symptoms improve significantly when she is treated with corticosteroids. Which one of the following is the most likely dx?
a. Duchenne’s muscular dystrophy
b. Myasthenia gravis
c. ALS
d. Aseptic necrosis of the femoral head
e. Polymyositis
e. Polymyositis
Proximal muscle involvement and elevation of serum muscle enzymes such as CK and aldolase are characteristic. Corticosteroids are the accepted tx of choice.
It is extremely unlikely that Duchenne’s muscular dystrophy would present after age 30. In ALS, an abnormal neurologic exam with findings of UMN dysfunction is characteristic. Pts with MG typically have optic involvement, often presenting as diplopia.
Which one of the following medications used in the treatment of osteoporosis can also be used to treat the pain associated with acute and chronic vertebral compression fractures?
a. Calcitonin-salmon (Miacalcin)
b. Raloxifene (Evista)
c. Risedronate (Actonel)
d. Teriparatide (Forteo)
e. Zoledronic acid (Reclast)
a. Calcitonin-salmon (Miacalcin)
Calcitonin is an antiresorptive agent that has been shown to decrease the risk of vertebral fractures, but it is not considered first-line treatment for osteoporosis because there are more effective agents. However, it does have modest analgesic properties that make it useful in the treatment of the pain associated with vertebral fractures.
