MSK

Question 1

A 12-year-old female athlete and her parents want advice on how to prevent injuries while playing soccer.

What are some of the safety tips recommended by the AAP?

Answer 1

Take time off.
Wear the right gear.
Strengthen muscles.
Increase flexibility.
Use the proper technique.
Take breaks.
Play safe.
Stop the activity if there is pain.
Avoid heat illness.
Explanation
Juvenile athletes are prone to trauma and overuse injuries. Most common injuries are caused by abnormal stress to bone or soft tissue, resulting in a sprain, strain, or fracture. Follow the AAP Sports Injury Prevention Tip Sheet to help prevent sports injuries.

Question 2

What would you recommend regarding sports participation to patients with diabetes mellitus (DM) Type 1?

Answer 2

Most sports are allowed, but watch for any signs of hypoglycemia.
Monitor blood glucose levels before and after activity (even up to 12 hours later).
Explanation
A child with DM Type 1 must be watched for any signs of hypoglycemia, which is the greatest risk for these patients during exercise. Monitor blood glucose levels before and after activity (even up to 12 hours later). Depending on the results, treat with either carbohydrate consumption or insulin dosing. Coaches must be trained to recognize and treat hypoglycemia.

Question 3

What are the clinical findings associated with tibial torsion?

Answer 3

Intoeing due to medial rotation of the tibia
Explanation
Tibial torsion presents with intoeing at the time the child starts walking. On physical examination, the medial malleolus is even with or posterior to the lateral malleolus, and although the toes are rotated medially, the patella faces forward when walking. Most cases spontaneously resolve by school age. Reserve surgery for severe cases that cause functional or cosmetic deformity that persists after 8 years of age.

Question 4

A 12-year-old boy is a pitcher for a junior league baseball team. For the past 2 weeks, he has complained to his parents of right elbow pain, especially after pitching a game. Physical examination reveals no swelling but painful palpation of the right medial epicondyle, worsened with resisted wrist flexion and valgus testing of the right elbow. Plain radiographs of the right elbow are negative for any fracture or dislocation.

What is the sports-related injury in this case?

Answer 4

Answer
Medial elbow apophysitis, a.k.a. Little League elbow
Explanation
Medial elbow apophysitis is inflammation of the growth plate of the medial epicondyle. It occurs in athletes who are skeletally immature, typically 9–14 years of age, and results from the valgus stress placed on the elbow during overhead throwing. Most patients present with medial epicondyle pain that intensifies as the number of throws increases. Physical examination elicits pain to palpation of the medial epicondyle and with valgus maneuvers of the elbow. X-rays are normal. Treatment consists of rest, NSAIDs, and physical therapy.

Question 5

What are the clinical findings associated with a sports-related prepatellar bursitis?

Answer 5

Answer
The prepatellar bursa is palpated and demonstrates warmth, focal tenderness, and swelling. Bursal wall thickening is noticeable when squeezed between the fingertips.
Explanation
Prepatellar bursitis is an inflammation of the bursa that is anterior to the kneecap. It is caused by a fall or direct blow to the anterior knee that can occur in sports such as football and basketball. Symptoms include pain with activity, swelling, and tenderness. Diagnosis is usually made clinically by examining the overlying skin and bursa, which are squeezed between the fingertips to assess for bursal wall thickening. Full range of motion at the knee remains intact.

Question 6

Describe the clinical findings seen with clubfoot.

Answer 6

Plantarflexion and medial rotation of the foot
Explanation
Clubfoot is a congenital defect in which the foot is plantarflexed and medially rotated due to shortened ligaments. Promptly refer to an orthopedist to correct the issue before the child begins walking.

Question 7

A 16-year-old male basketball player has noticed a painless, enlarging mass at his right quadriceps muscle over the past several weeks. He denies fever, weight loss, night sweats, or other constitutional symptoms. He admits to getting hit a lot during his basketball activities. Physical examination reveals a fixed palpable mass in the proximal anterior right thigh but minimal tenderness to palpation. Both hip and knee joints have full range of motion.

What is the likely diagnosis for this condition?

Answer 7

Answer
Traumatic myositis ossificans
Explanation
Traumatic myositis ossificans is characterized by extraskeletal ossification following blunt soft tissue trauma. It typically presents as a painless, enlarging mass, most often located in the quadriceps, brachialis, or deltoid muscles. The mass is typically located away from a joint and is rounded and well circumscribed. Evaluation with plain x-rays reveal mature peripheral ossification with a distinct margin surrounding a radiolucent center of immature osteoid and primitive mesenchymal tissue. This peripheral maturation is the reverse of that seen with a neoplasm. Unlike in neoplasm, the bony mass is always slightly separated from the long shaft of the bone.

Question 8

A 16-year-old boy sustains a mild traumatic brain injury (mTBI; a.k.a. concussion) playing football. He is eager to get back in the game.

Can he return to the game?

Answer 8

No, he cannot return to play that day.
Explanation
No return to play the same day! Rest for 24–48 hours is recommended (including rest from schoolwork and video games). Then, it is recommended that athletes gradually resume activities as symptoms allow. Second impact syndrome is thought to occur when children sustain another injury while still symptomatic from the first.

Question 9

What would you recommend regarding sports participation to patients with epilepsy?

Answer 9

Avoid climbing, hang-gliding, scuba diving.
With proper supervision, above-water sports, horseback riding, harnessed rock climbing, and gymnastics are allowed.
Explanation
Patients with epilepsy must be careful in activities involving heights, water, or horses and must be supervised so that, in the event of a seizure, help is close by.

Question 10

Name the differential diagnosis for hip pain in a child.

Answer 10

Infections
Tumors
Transient synovitis
Legg-Calvé-Perthes disease
Slipped capital femoral epiphysis
Explanation
Any child who presents with pain in the hip, limps, or refuses to bear weight or walk must be evaluated promptly.

Question 11

A 7-year-old boy presents with:

Pain in his left hip and knee
Limping for several days
Plain x-ray of the hip shows a “ratty” appearance of the left femoral head.

What is the most likely diagnosis?

Answer 11

Answer
Legg-Calvé-Perthes disease
Explanation
Legg-Calvé-Perthes disease is a partial or complete idiopathic avascular necrosis of the femoral head. It is most common in boys between 3 and 12 years of age, with a peak incidence at 5–7 years of age. In this case, tell the boy to not bear weight on the affected limb and refer him to an orthopedist. Treat with activity modification and abduction exercises. This disorder typically resolves with time.

Question 12

What would you recommend regarding sports participation to patients with Marfan syndrome?

Answer 12

Low-to-moderate activity/exercise is allowed.
Avoid contact sports and scuba diving.
Explanation
Persons with Marfan syndrome can participate in low-to-moderate activity/exercise, such as golf, bowling, or diving, but must avoid contact sports and scuba diving to minimize the risk of high pressures to the aorta (which is already dilated or aneurysmal in these patients), lens dislocation, and/or pneumothorax.

Question 13

What is the diagnostic approach for the evaluation of hip pain in a child?

Answer 13

Careful history and physical exam
CBC
Acute phase reactants (e.g., ESR and CRP)
Plain radiographs of the hip
Explanation
Any child who presents with pain in the hip, limps, or refuses to bear weight or walk must be evaluated promptly. Potential diagnoses are infections, tumors, transient synovitis, Legg-Calvé-Perthes disease, or slipped capital femoral epiphysis.

Question 14

What is the appropriate diagnostic evaluation for developmental dysplasia of the hip in patients of various ages?

Answer 14

Answer
If < 4–6 months of age, ultrasonography of both hips
If > 6 months of age, plain radiography of both hips
Explanation
Ultrasonography of both hips is the preferred method of evaluation in infants < 4–6 months of age because the femoral head has not yet ossified, and cartilage and soft tissues are better delineated on ultrasound. In older infants and children, plain hip radiography are appropriate because the femoral heads are ossified and no longer cartilaginous.

Question 15

What conditions are most commonly associated with congenital scoliosis?

Answer 15

Answer
Neuromuscular diseases and congenital rib/vertebral anomalies
Explanation
Although most cases of scoliosis are idiopathic, most of the remainder are due to neuromuscular diseases and/or congenital rib/vertebral anomalies. Cardiopulmonary compromise generally occurs if the scoliosis is severe. Ideally, congenital forms of scoliosis are diagnosed early in childhood. If found, bracing usually corrects or limits progression of the curve. Surgical intervention is often required when scoliosis is congenital or caused by neuromuscular weakness

Question 16

A 15-year-old female presents to the emergency department complaining of muscle cramps, nausea, dizziness, and weakness after playing volleyball at the beach all day long. Physical examination reveals dry mucous membranes, skin tenting, and rectal temperature of 101.0°F (38.3°C). The rest of the physical examination is unremarkable.

What is the likely cause of this patient’s illness?

Answer 16

Heat illness
Explanation
Heat illness occurs when the body cannot cool itself with the typical sweating mechanism. It usually occurs in hot, humid weather with strenuous activity occurring for a long period of time. Risk factors include young age, old age, illness, being overweight, alcohol consumption prior to activity, and certain medications such as stimulants. Prevention includes staying well hydrated, replenishing salt with sports drinks, and limiting time of activity.

Question 17

A 14-year-old female gymnast presents to the pediatrician’s office for an annual check-up. She states she has missed her period for several months and has lost some weight due to her strict diet. Physical examination reveals a thin, muscular female but nothing else of note. A urine pregnancy test is negative.

What condition is this gymnast likely experiencing?

Answer 17

Answer
Female athlete triad
Explanation
The “female athlete triad” is a combination of energy deficiency (most often from disordered eating), menstrual dysfunction, and decreased bone density. It is especially common in sports where a low body weight is favorable. A history of menstrual dysfunction is the earliest symptom. It should prompt you to get a detailed history of the patient’s diet and exercise. Lab work to test for pregnancy and thyroid dysfunction is usually warranted. Get a bone density study in patients with < 6 menses in 12 months and history of ≥ 2 stress fractures. Treatment requires a multidisciplinary team approach that includes the pediatrician, coach or trainer, nutritionist, and psychologist

Question 18

What are the essential nutritional requirements for hydration and rehydration during sports participation?

Answer 18

Water and electrolytes
Explanation
Hydration, including water and electrolyte replacement, is very important for the athlete. Hydration helps regulate body temperature and replaces losses that occur during exercise. Drink 16 oz water 1 hour prior to exercise and 4–8 oz every 15–20 minutes. Use a sports drink for exertion lasting > 1 hour. Higher environmental temperatures and humidity necessitate more fluids. After exercise, eat recovery foods that contain both carbohydrates and protein to help replenish glycogen to the muscles.

Question 19

A patient presents with knee pain and swelling. The valgus stress test shows medial instability.

What is your diagnosis?

Answer 19

Medial collateral ligament (MCL) injury
Explanation
MCL tears are common injuries among athletes. Such a tear occurs in contact sports when the lateral knee sustains a blow causing valgus stress or in activities that require significant torque of the leg (e.g., basketball, football, tennis). Symptoms include pain, swelling, and instability over the medial knee. Most MCL injuries can be diagnosed clinically, with tenderness to palpation over the MCL and valgus laxity with high-grade injuries. Treatment is usually nonsurgical and includes rest, ice, NSAIDs, bracing, and physical therapy.

Question 20

A 15-year-old male track and field sprinter has broken his running records by several seconds each time he races. In addition, his muscle mass has increased in a short period of time. His coach has become concerned because of his aggressive behavior and fighting in the men’s locker room. His friends have also commented that his eyes “seem yellow.”

What is the appropriate evaluation for this patient given this scenario?

Answer 20

Answer
Screening for performance-enhancing drugs
Explanation
The primary physician must be prepared to identify risk factors, physical signs, and symptoms of performance-enhancing drug use (i.e., doping). Ask appropriate screening questions and perform a thorough physical examination, looking for exaggerated muscle mass, enlarged liver, and rapid heart rate. It is important to emphasize to the athlete the risks involved and healthy alternatives to achieve his goals. Involvement of the coach and counseling are often needed. A drug screen and liver function test are necessary to detect doping. In this case, the patient was taking androgenic steroids.

Question 21

What are the clinical findings seen in kyphosis?

Answer 21

Answer
Spine is angled in the anterior-posterior direction, causing a humped back.
Explanation
Kyphosis is diagnosed when the curves of the spine are greater than normal, causing the spine to be abnormally convex. In kyphosis, the spine is angled in the anterior-posterior direction, giving it a forward flexion. This gives the appearance of a humped back. Kyphosis typically involves the upper thoracic region of the spine and usually does not cause respiratory compromise.

Question 22

A newborn is found to have the following triad:

Short neck
Limited neck motion
Low occipital hairline
These associated findings are noted as well:

Deafness
Macrocephaly
Meningocele
What is the syndrome?

Answer 22

Klippel-Feil syndrome
Explanation
Klippel-Feil syndrome occurs when there is congenital fusion of ≥ 2 of the 7 cervical vertebrae. It presents with the classic triad of short neck, limited neck motion, and low occipital hairline. There are 3 types, differentiated based on the extent of vertebral column malformation. Note that fusion of C2–C3 is autosomal dominant, while C5–C6 is autosomal recessive. Deafness, macrocephaly, hydrocephalus, meningocele, and intellectual disability are common.

Question 23

What are the most likely ankle injuries to occur in a prepubescent child?

Answer 23

Ankle sprains with fractures
Explanation
The cartilaginous growth plate is the “weak link” in the growing child. Thus, injury to the physis or fracture is the most likely ankle injury in the prepubescent child. In adults, ankle sprains are more likely, due to the mature skeleton.

Question 24

What steps prevent overuse injuries in child athletes?

Answer 24

Limit the number of teams an athlete is on in one season.
Do not allow an athlete to play one sport year-round.
Explanation
Overuse injuries can affect bones, growth plates, and soft tissues. Due to the fact that these structures grow at an uneven rate, children are at increased risk for these types of injuries. Overuse injuries are increasing in frequency due to the competitive nature of youth sports and the year-round playing of a single sport. This puts repetitive stress on specific areas of the body without allowing for adequate rest. The main symptom is pain that is not due to an acute injury and that increases with activity. Rotation of the types of sports throughout the year allows other bones and muscle groups to be used instead of stressing the same structures for a single sport.

Question 25

What is the proper management for the 2 types of bone cysts?

Answer 25

Unicameral: serial plain films, observation, and fracture prevention
Aneurysmal: surgical excision
Explanation
Bone cysts are either fluid filled (unicameral) or blood filled (aneurysmal) within a bone. Both are noncancerous, typically solitary, and occur in children and young adults. Unicameral bone cysts are often observed with serial plain films, and activity is restricted to prevent fracture. Unicameral bone cysts often resolve spontaneously. Aneurysmal bone cysts are more aggressive in growth and require surgical treatment.

Question 26

A 14-year-old male hurt his left ankle playing basketball. He recalls stumbling onto the floor in pursuit of the ball and twisting his ankle. He is able to bear weight on it, but it is painful. Examination of the ankle reveals soft tissue swelling, warmth, and slight tenderness over the lateral malleolus. There is full but painful range of motion of the ankle. Plain radiographs of the left ankle are negative for fracture.

What is the sport injury in this patient?

Answer 26

Ankle sprain
Explanation
Ankle sprains occur when the ankle is pushed past its normal range of motion, leading to stretching or tearing of the involved ligament. Lateral ankle sprain, caused by inversion of the foot, is more common than medial. Symptoms include pain, swelling, decreased range of motion, and inability to bear weight. Diagnosis is made by physical exam and possibly x-rays to rule out fracture; in the skeletally immature athlete, the growth plate can get injured before the ligaments do. Treat with bracing, rest, ice, compression, and elevation (RICE). Strengthening and stretching exercises are necessary, and physical therapy may be needed as well.

Question 27

What are some of the clinical findings associated with the use of androgenic steroids as performance-enhancing drugs?

Answer 27

Acne, muscle mass increase, gynecomastia, small testicles, hypertension, aggressive behavior, inhibited growth, elevated liver enzymes, cholestatic jaundice, hirsutism
Explanation
The highly competitive nature of sports results in many athletes looking for an advantage over their opponents. Unfortunately, many of these athletes turn to performance-enhancing drugs (i.e., athletes who engage in “doping”) and they do not take into consideration the risks of using these substances.

Question 28

A 15-year-old girl joined her high school cross-country/track team. She has been running several miles per day for the past several weeks but increased her running mileage in preparation for a track meet next month. Since then, she has noticed her right knee “giving out” during her runs, along with pain at the anterior portion of her kneecap. Physical examination reveals tenderness on palpation of the patella, but there is no swelling or effusion of the knee joint. There is full range of motion of both knees, but pain of the right knee is noted with squatting.

What is the sports-related injury in this case?

Answer 28

Patellofemoral syndrome (PFS)
Explanation
PFS is the most common cause of anterior knee pain in young athletes, particularly females. Pain occurs especially with prolonged sitting, running, or activities that require bending of the knees. The pathophysiology seems to be related to overuse and joint malalignment. In PFS, the patella does not track straight down the middle but instead rubs against the inner or outer femur, resulting in the patellofemoral joint becoming inflamed and painful. If the condition progresses, the articular cartilage on the underside of the patella softens, causing decay. This syndrome is chondromalacia patella. Diagnosis of PFS is made based on history and physical examination findings of patellar pain with movement

Question 29

Identify the cardiac conditions that would limit sports participation and require further cardiac evaluation.

Answer 29

Hypertrophic cardiomyopathy, prolonged QT interval, aortic stenosis, coronary artery anomalies, myocarditis, uncontrolled stage 2 hypertension
Explanation
History and physical examination are always important in assessing an athlete prior to sports participation. If an athlete has ever experienced chest pain and/or dizziness, then further cardiac evaluation is warranted (e.g., ECG, echocardiogram). The listed cardiac conditions pose serious and possibly life-threatening complications and therefore restrict sports participation

Question 30

What are the physical examination findings in patients with femoral anteversion?

Answer 30

Medial orientation of both the toes and patella when walking
Increased internal rotation with decreased external rotation bilaterally of the hips (patient lying prone with knees bent)
Explanation
Femoral anteversion is due to medial rotation of the femur and presents in preschool-aged children (3–6 years of age). These children find the “W” sitting position comfortable. Most cases spontaneously resolve by 11 years of age; surgery is reserved for severe cases that interfere with ambulation.

Question 31

What is the most common etiology of acquired torticollis?

Answer 31

Answer
Injury or inflammation of neck muscles
Explanation
Acquired torticollis is most commonly caused by injury or inflammation of the sternocleidomastoid or trapezius muscle. Serious causes of torticollis include retropharyngeal abscess, suppurative jugular thrombophlebitis (Lemierre syndrome), cervical spine injury, or central nervous system tumors, which need referral. Treat acute bacterial infection with antibiotics, treat muscular spasm with NSAIDs and muscle relaxants

Question 32

What would you recommend regarding sports participation to patients with Down syndrome?

Answer 32

Most sports are allowed but first assess for any signs and/or symptoms of atlantoaxial (C1–C2) instability.
Explanation
Persons with Down syndrome have a predisposition to atlantoaxial (C1–C2) instability and must be examined for this. If exam results are abnormal and/or patients are symptomatic, cervical imaging and a pediatric neurosurgeon or orthopedist consult are warranted.

Question 33

What are some of the common overuse injuries in athletes?

Answer 33

Sever disease, Osgood-Schlatter disease, patellofemoral syndrome, iliotibial band syndrome, medial apophysitis, lateral epicondylitis, osteochondritis dessicans, stress fractures, spondylolysis/spondylolisthesis
Explanation
Overuse injuries can affect bones, growth plates, and soft tissues. Due to the fact that these structures grow at an uneven rate, children are at increased risk for these types of injuries. Overuse injuries are increasing in frequency due to the competitive nature of youth sports and the year-round playing of a single sport. This puts repetitive stress on specific areas of the body without allowing for adequate rest.

Question 34

What is the recommended treatment for prepatellar bursitis?

Answer 34

Answer
Treatment consists of rest, ice, elevation, and NSAIDs. If there is no improvement with time and treatment, needle aspiration of the bursa is sometimes needed.
Explanation
Prepatellar bursitis is an inflammation of the bursa that is anterior to the kneecap. It is caused by a fall or direct blow to the anterior knee that can occur in sports such as wrestling and basketball. Symptoms include pain with activity, swelling, and tenderness. In chronic cases, bursal wall thickening can be demonstrated by palpation of a fluid-filled mass anterior to the patella or the patellar tendon. Diagnosis is usually made clinically

Question 35

A 15-year-old boy presents after colliding with another player during a soccer game. He complains of knee pain, and his right knee is slightly swollen. You perform the duck walk test (patient is asked to squat down and walk like a duck), which causes reproducible pain in the medial joint line.

What is your diagnosis?

Answer 35

Meniscal tear
Explanation
Meniscal injuries are common, and tears usually occur due to twisting injuries while the foot is planted. Often symptoms are nonspecific. Isolated meniscal tears usually cause localized pain and moderate effusion, whereas more diffuse pain and significant effusion occur if there is an associated injury to a cruciate ligament or a fracture. Diagnosis is made by eliciting joint line tenderness, asking the patient to do the duck walk; repeated passive knee flexion and extension with tibial internal and external rotation will produce pain and possible “clicking.” Note that x-rays of the knee are normal, but these injuries are clearly visible on MRI.

Question 36

A 13-year-old boy who plays basketball presents with:

Pain in his left knee
A swollen, tender tibial tubercle with a bump that is painful with palpation
Plain film shows fragmentary ossification of the tibial tubercle.

What is the most likely diagnosis?

Answer 36

Osgood-Schlatter disease
Explanation
Osgood-Schlatter disease occurs when overuse in running and jumping sports causes traction apophysitis at the patellar tendon insertion onto the tibial tubercle. Most commonly, it is seen during the adolescent growth spurt. You may see fragmented ossification of the tibial tubercle on plain films. It is usually self-limited and often resolves once the growth plate ossifies. Treat with NSAIDs, ice, and physical therapy (quadriceps, hamstring, and calf stretching). Continuation of play is permissible if the pain is tolerable and there is no limp.

Question 37

What is the best advice for athletes who experience sprains and strains?

Answer 37

Answer
Rest, ice, compression, elevation (RICE), then strengthening exercises and rehabilitation (if needed)
Explanation
Soft tissue can be injured from trauma or twisting. A sprain is tearing of a ligament while a strain is tearing of muscle fibers or tendon. Patients present with pain of affected area, and diagnosis is typically made clinically by history and examination. Treatment consists of rest, ice, compression, and elevation (RICE) in the acute phase, followed by strengthening exercises. Note that adequate rest and rehabilitation of a current injury is key in the prevention of future injury.

Question 38

What is the appropriate clinical evaluation and management of scoliosis?

Answer 38

Identify the type of scoliosis. Perform a back examination and order plain radiographs to determine the degree of curvature, which will dictate management.
Explanation
Idiopathic scoliosis is the most common and is divided into 3 categories: infantile, juvenile, and adolescent. Depending on the age and sex of the child, most cases are detected by a simple back examination with forward flexion and plain radiographs. Most scoliosis cases are asymptomatic. In milder cases (< 20°) of curvature, particularly with limited symptoms, encourage activity without restrictions. For skeletally immature curves between 25° and 45°, use bracing to prevent or minimize curve progression. Curves > 45° to 50° frequently require spinal fusion or the placement of a Harrington rod.

Question 39

A 13-year-old boy presents with severe nighttime pain in his proximal femur. It gets markedly better with nonsteroidals but not with acetaminophen. Plain x-ray of the femur shows a sharp, round lesion 1 cm in diameter with a 1- to 2-mm peripheral radiolucent zone surrounding a homogeneous dense center.

What is the most likely diagnosis?

Answer 39

Answer
Osteoid osteoma
Explanation
Osteoid osteoma presents as described. The key is that it responds to salicylates and NSAIDs but not acetaminophen. The plain film findings are classic (a well-circumscribed lytic lesion with sharp sclerotic borders). Do not think this represents a neoplastic lesion!

It is important to image children who have nighttime, unilateral bony pain.

Question 40

A 4-year-old boy presents with:

Bilateral thigh and calf pain that is worse in the evening and occasionally awakens him from sleep
No fever
No limping
No mobility problems
No joint involvement
What is the most likely diagnosis?

Answer 40

Answer
Growing pains
Explanation
This is the classic presentation for growing pains. The key is that this is muscle pain, not joint pain. Even though it awakens the child from sleep, it is not an unusual finding. The pain is typically worse in the afternoon or evening. There are no systemic symptoms, so there is no fever. Limping and other mobility problems are not associated with this disorder. Labs are generally not necessary but should be ordered if there is something atypical about the findings to exclude possible organic etiologies before making the diagnosis of benign leg pain.

Question 41

What are the clinical findings associated with an anterior cruciate ligament (ACL) injury?

Answer 41

Knee pain, popping, swelling, difficulty bearing weight, anterior translation of the tibia on the femur
Explanation
ACL tears are more common in female athletes and usually occur in sports that require jumping, sudden stops, or quick changes in direction. The most sensitive and specific test for an ACL tear is the Lachman test, which evaluates the anterior translation of the tibia on the femur. This translation, associated with a soft endpoint, is indicative of a positive test. A difference of > 2 mm of anterior translation, when compared to the uninvolved knee, is diagnostic of an ACL tear, as is ≥ 10 mm of total anterior translation. Diagnosis is usually made clinically. MRI is useful to show the associated meniscus, collateral ligament injuries, and bone bruises. Surgical reconstruction is required in most cases to allow return to cutting and jumping sports.

Question 42

A 15-year-old Black patient with obesity presents with a limp. He complains of pain in his left hip and knee. Plain x-rays show the epiphysis has moved when compared to the metaphysis.

What is the most likely diagnosis?

Answer 42

Slipped capital femoral epiphysis
Explanation
Slipped capital femoral epiphysis is the slipping of the epiphysis off the metaphysis, causing a limp and impaired hip flexion and internal rotation. It most commonly occurs in boys, early adolescents, children with obesity, and those with endocrine dysfunction. Get an AP and frog-leg view. This requires surgery! Remember to examine a joint above and a joint below the area of pain. In this case, knee pain should make you think of the hip.

Question 43

Name 2 types of bone cysts.

Answer 43

Unicameral and aneurysmal
Explanation
Bone cysts are either fluid filled (unicameral) or blood filled (aneurysmal) within a bone. Both are noncancerous, typically solitary, and occur in children and young adults. They are either asymptomatic and found incidentally on imaging studies, or symptomatic with pain, limping, or fracture due to weakened bone.

Question 44

What is the initial management of an acute shoulder dislocation?

Answer 44

Answer
Closed reduction and immobilization
Explanation
Because the shoulder moves in many directions, it can dislocate anteriorly, posteriorly, or inferiorly, with anteriorly being the most common. Extreme rotation or a forceful blow that occurs during sports or from a fall is a common cause. Symptoms include severe pain, inability to move the joint, and a visible deformity to the shoulder. Closed reduction is the treatment. If possible, obtain plain radiographs prior to reduction. Postreduction radiographs are necessary to confirm successful reduction and rule out fractures. Immobilization of the arm after reduction is usually needed. After immobilization, physical therapy is the next course of treatment. If the condition becomes chronic, surgery is often required.

Question 45

What are the clinical findings associated with patellar dislocation?

Answer 45

Knee pain
Buckling of the knee
Popping sound
Deformed appearance of the knee
Explanation
Patellar dislocation can result from a contact or noncontact injury. Risk factors include quadriceps or hip weakness, a shallow femoral groove, or ligament laxity. Physical examination shows an effusion and a positive apprehension test (fear with lateral displacement of the patella). Initial treatment is closed reduction. Postreduction radiographs can show fractures. Further treatment includes ice, NSAIDs, brief immobilization, a patellar stability brace, and physical therapy. Sometimes surgery is required if the knee remains unstable after rehabilitation