MSK

Question 1

Pt 55yom p/w diffuse bone pain, increasing head size, frontal bossing, tibial bowing labs, dx, rx?

Answer 1

Paget’s dz (Osteitis Deformans); Elevated alkaline phosphatase with normal Ca, phosphate; rx bisphosphonates, calcitonin 2nd line

Question 2

45yof p/w fatigue, myalgia, proximal muscle weakness, sluggish ankle reflex, normal ESR, elevated CK, dx?

Answer 2

Hypothyroid myalgia, check TSH

Question 3

25yo p/w back pain, improves with use, afebrile, normal neuro exam, dx/wokup?

Answer 3

Ankylosing spondylitis involving apophyseal joints, check for uveitis, enthesitis, elevated ESR, CRP, HLAB27, spine xray

Question 4

Acute back pain and point tenderness after strenous activity; dx/etilogy?

Answer 4

Vertebral compression fracture; Osteoperosis (most common), osteomalacia, malignancy, infection, hyperparathyroidism, trauma

Question 5

65yo w/ b/l leg pain when standing (extension), better w/ sitting (flexion), lower back pain, ABI>1.1; dx?

Answer 5

Spinal canal narrowing/spinal stenosis (degenerative disks/spondylosis, hypertrophy of ligamentum flavum) causing Neurogenic claudications, get MRI for dx

Question 6

Cauda equina syndrome

Answer 6

Urine retention/incontinence, saddle anesthesia, weakness; look for malignency

Question 7

35yom on chronic steroids for sarcoid p/w hip pain, normal ESR, dx?

Answer 7

Osteonecrosis (avascular bone necrosis); MRI to confirm

Question 8

13yo w/ pain over tibia at knee, tissue swelling, tibial tubercle irregularity or fracture (dissociation) from the shaft; dx?

Answer 8

Osgood-Schlatter traction apophysitis of the tibial tubercle

Question 9

Twisting knee injury w/ pop, late joint effusion, pain with extension and knee locking, tibial torsion w/ fixed flexed knee produces pop; dx?

Answer 9

Medial meniscus tear w/ positive McMurray’s test

Question 10

Abduction injury to knee, positive Valgus test?

Answer 10

Medial Collateral Ligament tear

Question 11

Adduction injury to knee, positive Varus test?

Answer 11

Lateral Collateral Ligament tear

Question 12

Hyperextension knee injury w/ immediate effusion and positive ant drawer test, Lachman test, pivot shift test?

Answer 12

Anterior Cruciate ligament tear

Question 13

Forceful posterior hit to tibia w/ flexed knee, positive post drawer, reverse pivot shift and post sag tests?

Answer 13

Posterior Cruciate ligament tear

Question 14

Tender mass in popliteal fossa, hx of RA, (or osteoarthritis, cartilage tear)

Answer 14

Bakers Cyst from excess fluid production from an inflamed synovium

Question 15

Midshaft humerus fx, wrist drop?

Answer 15

Radial n injury

Question 16

Tendons of rotator cuff?

Answer 16

SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis

Question 17

Arm passively abducted, upon lowerin rapidly falls once at 90 degrees, dx?

Answer 17

Rotator cuff tear, Supraspinatus

Question 18

Hypothyroidism w/ median n compression signs of carpal tunnel sx; path?

Answer 18

Accumulation of matrix protein, mucupolysacharides, in the perineurium and endoneurium of the median nerve

Question 19

Winged scapula, axillary lymphadenectomy, dx?

Answer 19

Long thoracic, serratus anterior

Question 20

Sexually active young adult w/ polyarthritis, tender swollen purulent joint w/ 50k synovial WBC, may p/w polyarthalgia w/ tensynovitis or dermatitis; dx?

Answer 20

Septic joint via Neisseira Gonorrhea; rx IV Ceftriaxone then PO Cefexime, empiric chlamydia rx Azithromycin or Doxycycline

Question 21

Diabetic p/w deformed feet on xray there’s joint effusion, osteophytes and extra-auricular joint fragments; dx?

Answer 21

Charcot joint (neurogenic arthropathy); a/w diabetes, B12 deficiency, Tabes dorsalis, spinal cord injuries

Question 22

Periarticular osteopenia and joint margin erosions, with tendon damage and subluxation of cervical vertebrae?

Answer 22

Rheumatoid Arthritic joint

Question 23

Calcification of cartilagenous joint structures / cynovial calcium deposits?

Answer 23

Pseudogout Calcium PyroPhosphate Dihydroate (CPPD) positive birefringent rhomboid

Question 24

Punched out erosions w a rim of cortical bone?

Answer 24

Gouty arthritis

Question 25

Narrowing of joint spaces, cartilage destruction and osteophyte formation?

Answer 25

Osteoarthritis, also w subchondral sclerosis/cysts

Question 26

Distal phalangeal bone resorption, xray “pencil in cup”?

Answer 26

Arthritis mutilans variant of psoriatic arthritis

Question 27

25yoF w/ weakness, mild fever, ESR, facial rash, joint pain?

Answer 27

SLE w/ Migratory lupus arthritis, non deforming

Question 28

Passive arm raise above head causes shoulder pain, improves with lidocaine injection; dx?

Answer 28

Rotator cuff impingement from tendonitis, seen commonly in painters

Question 29

Adolescent p/w several months of back pain, recent urinary incontinence and “step off” lesion at the lumbar sacral junction; dx?

Answer 29

Spondilolysthesis, slipped vertebrae usually L5 over S1

Question 30

Suprachondylar fx of humerus (fall on outstretched hand); complications?

Answer 30

Injury to brachial artery and median nerve, cubitus varus malformation, compartment sx/Volkman’s ischemic contracture

Question 31

25yo p/w pain in heel, iliac crests, tibial tuberosities, shoulder, limited spine movement; dx?

Answer 31

Enthesitis (pain at insertion of tendons), seen in HLAB27+ Ankylosing Spondylithis, psoriattic arthritis, reactive arthritis

Question 32

Newborn w/ shoulder dystocia p/w “claw hand” extended wrist, no grasp reflex, ptosis, myosis, intact Moro and biceps reflex; dx?

Answer 32

Klumpke’s palsy w/ damage to C8 and T1 (p/w horner’s)

Question 33

Newborn w/ shoulder dystocia p/w internally extended elbow, pronated forarm, flexed wrist and fingers, decreased moro and biceps reflex on affected side, entact grasp reflex; dx?

Answer 33

Erb-Duchenne’s palsy w/ waiter’s tip sign, damage to 5th and 6th cervical nerves

Question 34

Benign tumor of osteoblasts at cortex of long bones, pain resolves with aspirin, xray shows mass

Answer 34

Osteoid osteoma

Question 35

Metaphysis of long bones, often around knee. Codman triangle (from elevation of periosteum) or sunburst pattern on x-ray.

Answer 35

Osteosarcoma; Aggressive. Treat with surgical en bloc resection (with limb salvage) and chemotherapy

Question 36

Boys

Answer 36

Ewings Sarcoma; Extremely aggressive with early metastases, but responsive to chemotherapy.

Question 37

Men 30–60 years old. Malignant cartilaginous tumor. May be of 1° origin or from osteochondroma. Expansile glistening mass within the medullary cavity. Usually located in pelvis, spine, scapula, humerus, tibia, or femur.

Answer 37

Chondrosarcoma

Question 38

Expansile eccentric lytic lesion (soup bubble appearance on xray) usually at distal epyphesis of long bones (femur tibia near knee), multinucleated giant cells

Answer 38

Giant Cell tumor, requires surgery

Question 39

Mature bone with cartilaginous cap. Rarely transforms to chondrosarcoma. Most common benign tumor. Males

Answer 39

Osteochondroma (exostosis)

Question 40

Tingling in pinky finger, discomfort on medial forarm and weak grip; dx/ nerve compression location?

Answer 40

Ulner nerve compression at elbow at epicondyle groove or cubital tunnel

Question 41

Mid humerus fx, wrist drop; dx?

Answer 41

Radial N damage; traverses spiral goove of dorsal humerus; loss sensation dorsal hand, strength of finger and wrist extensors

Question 42

Supracondylar humerus fx; nerve involved?

Answer 42

Median N

Question 43

Urinary Hydroxyproline, hydroxypyridinoline, C or T -telopeptide

Answer 43

Urinary markers of bone degredation (ie. Pagets)

Question 44

Chondrocalcinosis (usually at the knee); dx/ associations?

Answer 44

CPPD (Pseudogout); idiopathic or a/w hyperPTH, Hemochromatosis (look for diabetes, skin pigmentation, hepatomegaly, dilated cardiomyopathy), Hypomagnesia

Question 45

Inability to anchor scapula to thoracic cage, cannot abduct arm above horizontal position, winged scapula?

Answer 45

Lesion of long thoracic nerve (Serratus anterior), Axillary node dissection after mastectomy

Question 46

Supracondylar fracture of humerus (proximal lesion); carpal tunnel syndrome and wrist laceration (distal lesion)

Answer 46

Median (C5-T1) “Ape hand” and “Pope’s blessing”; Loss of wrist and lateral finger flexion, thumb opposition, lumbricals of 2nd and 3rd digits Loss of sensation over thenar eminence and dorsal and palmar aspects of lateral 3 1⁄2 fingers with proximal lesio; Tinel sign (tingling on percussion) in carpal tunnel syndrome

Question 47

Fracture of medial epicondyle of humerus “funny bone” (proximal lesion); fractured hook of hamate (distal lesion)

Answer 47

Ulnar (C8-T1) “Ulnar claw” on digit extension; Radial deviation of wrist upon flexion (proximal lesion)Loss of flexion of wrist and medial fingers,abduction and adduction of fingers (interossei),actions of medial 2 lumbrical muscles Loss of sensation over medial 11/2 fingersincluding hypothenar eminence

Question 48

Midshaft fracture of humerus; compression of axilla (e.g., due to crutches or sleeping with arm over chair (“Saturday night palsy”)

Answer 48

Radial (C5-T1) Wrist drop: loss of elbow, wrist, and finger extension grip strength (wrist extension necessary for maximal action of flexors) Loss of sensation over posterior arm/forearm and dorsal hand

Question 49

Inability to curl toes and loss of sensation on sole of foot. In proximal lesions, foot everted at rest with loss of inversion and plantarflexion.

Answer 49

Tibial (L4–S3) via Knee trauma, Baker cyst (proximal lesion); tarsal tunnel syndrome (distal lesion)

Question 50

Trendelenburg sign/gait—pelvis tilts because weight-bearing leg cannot maintain alignment of pelvis through hip abduction (superior nerve􏰄medius and minimus). Lesion is contralateral to the side of the hip that drops, ipsilateral to extremity on which the patient stands.

Answer 50

Superior gluteal (L4–S1) via Posterior hip dislocation, polio

Question 51

Foot drop—inverted and plantarflexed at rest, loss of eversion and dorsiflexion. “Steppage gait.” Loss of sensation on dorsum of foot.

Answer 51

Common peroneal (L4–S2) via Trauma or compression of lateral aspect of leg, fibular neck fracture