Orthopedics packrat Flashcards
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle? Answers A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis
(c) A. Abduction against resistance tests the supraspinatus.
A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexion and external rotation at the hip. Which of the following knee maneuvers does this represent? Answers A. Abduction stress test B. Anterior drawer sign C. Lachman test D. McMurray test
(c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 15 degrees of flexion and external rotation of the hip.
A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is the most striking and consistent abnormality of which of the following? Answers A. Spondylolysis B. Spondolisthesis C. Scoliosis D. Herniated disc
(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.
Physical exam findings in a 4 year-old child that include blue sclerae and recurrent fractures indicates which of the following? Answers A. Ehlers-Danlos syndrome B. Marfan syndrome C. Achondroplasia D. Osteogenesis imperfecta
(c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.
A 65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine? Answers A. Radiolucent lesions B. Demineralization C. Chondrocalcinosis D. Subperiosteal resorption
(c) B. Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X- ray findings demonstrate demineralization in the spine and pelvis.
In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is Answers A. lateral. B. oblique. C. anteroposterior. D. odontoid.
(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done? Answers A. X-ray of the lower leg and ankle. B. Doppler studies. C. Bone scan. D. Compartment pressure
(c) D. Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.
A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical exam the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis? Answers A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis
(c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.
A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh that he noticed about 3 days ago. Physical exam reveals a large annular lesion with a bright red outer border and partial central clearing. Which of the following is the most likely diagnosis? Answers A. Rheumatoid arthritis B. Kawasaki disease C. Lyme disease D. Nongonococcal arthritis
(c) C. After an incubation period of 3 to 32 days, erythema migrans develops at the site of the tick bite. Within days or weeks after the onset of erythema migrans the patients develop a severe headache, mild stiffness of the neck, migratory musculoskeletal pain, arthralgias and profound malaise and fatigue.
A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis? A. Shin splint B. Stress fracture C. Osgood-Schlatter disease D. Patellofemoral pain syndrome
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has Answers A. carpal tunnel syndrome. B. radial tunnel syndrome. C. tenosynovitis. D. gamekeeper's thumb.
(c) C. Tenosynovitis is diagnosed using Finkelstein maneuver. The patient’s thumb is placed in the palm of the hand and the wrist is abruptly deviated to the ulnar aspect of the wrist, causing pain on the radial aspect.
A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has
Answers
A. carpal tunnel syndrome. B. radial tunnel syndrome.
C. tenosynovitis.
D. gamekeeper’s thumb.
(c) C. Tenosynovitis is diagnosed using Finkelstein maneuver. The patient’s thumb is placed in the palm of the hand and the wrist is abruptly deviated to the ulnar aspect of the wrist, causing pain on the radial aspect.
The most important preventive medicine recommendation for patients with osteoarthritis is which of the following? Answers A. Start an exercise program B. Brace the affected joint C. Rest the joint D. Inject steroids monthly
(c) A. Patients with osteoarthritis who exercise are able to maintain range of motion, strengthen periarticular muscles, and improve physical fitness.
Bone mass measurement should be considered in all women by what age? Answers A. 30 – 35 B. 40 – 45 C. 50 – 55 D. 60 – 65
(c) D. According to the National Osteoporosis Foundation, all women should have a bone mass measurement by age 60 – 65.
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen’s test is positive; however, there is no atrophy of the thenar eminence. Which of the following is the initial step in management of this patient? Answers A. Wrist splint for 2-6 weeks B. Corticosteroid injection C. Surgical referral D. Darvocet
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
Which of the following is the correct treatment for a Grade II ankle sprain resulting from an inversion injury? Answers A. Corticosteroid injection B. Rest, ice, compression, elevation C. Moist heat and a walking cast D. Surgical intervention
(c) B. The majority of ankle sprains are treated with RICE (rest, ice, compression and elevation). Corticosteroid injections, moist heat, and a walking cast provide no benefit. Surgical intervention for repair of a ruptured ligament is only necessary in chronically unstable joints.
A 4 year-old boy presents to the ED after sustaining a crush injury to his distal third phalanx. Physical exam reveals an associated nail bed injury. Which of the following is the appropriate management?
A. Rest, ice, elevation
B. Immobilize, antibiotics, orthopedics referral
C. Splint for 48 hours, aspirin, ice
D. Surgical referral for amputation of digit
(c) B. Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered “open” and the patient should be given antibiotics and follow-up with ortho in one week.
Which of the following is the antibiotic of choice when treating a patient with osteomyelitis whose culture demonstrates penicillin-resistant, methicillin sensitive Staphylococcus aureus? Answers A. Cefuroxime B. Levofloxacin C. Nafcillin D. Tobramycin
(c) C. Treatment for osteomyelitis is as follows: Penicillin G is the drug of choice for the treatment of infections due to penicillin-sensitive staphylococci and streptococci; nafcillin or oxacillin is preferred for penicillin-resistant, methicillin-sensitive staphylococci. Regimens for infections due to susceptible gram-negative rods includes cefuroxime and fluoroquinolones. Tobramycin is effective against Pseudomonas aeruginosa.
Which of the following is the most common side effect of methotrexate? Answers A. Hemolysis B. Cardiomyopathy C. Stomatitis D. Diarrhea
(c) C. The most common side effects of Methotrexate are stomatitis and gastritis. Other side effects include hepatotoxicity, cytopenia, and interstitial pneumonitis.
A 45 year-old male presents with an acute onset of asymmetric arthritis of the lower extremities. Further history reveals an episode of urethritis two weeks ago. Physical exam reveals a swollen tender right knee and left ankle and vesicles on his palms and soles. Which of the following is the initial treatment of choice in this patient? Answers A. Indomethacin B. Interferon C. Sulfasalazine D. Methotrexate
(c) A. This patient has reactive arthritis (formerly known as Reiter’s syndrome). In recent years, the term has been used to refer to spondyloarthropathies following and enteric or urogenital infection. Indomethacin is the treatment of choice. Interferon is not indicated in reactive arthritis. Sulfasalazine and methotrexate are used in patients with persistent reactive arthritis.
A 25 year-old female presents with a constellation of symptoms including fatigue, chronic headaches, and poor sleep. She also complains of aching pain and stiffness involving her entire body. Minor exertion aggravates the pain and increases her fatigue. Which of the following classes of medications is the most efficacious treatment for this patient's condition? Answers A. Non-steroidal anti-inflammatories B. Opioids C. Corticosteroids D. Antidepressants
(c) D. Antidepressants have shown modest efficacy in treating the symptoms of fibromyalgia.
Which of the following is the most common side effect of methotrexate? Answers A. Hemolysis B. Cardiomyopathy C. Stomatitis D. Diarrhea
(c) C. The most common side effects of Methotrexate are stomatitis and gastritis. Other side effects include hepatotoxicity, cytopenia, and interstitial pneumonitis.
A 45 year-old male presents with an acute onset of asymmetric arthritis of the lower extremities. Further history reveals an episode of urethritis two weeks ago. Physical exam reveals a swollen tender right knee and left ankle and vesicles on his palms and soles. Which of the following is the initial treatment of choice in this patient? Answers A. Indomethacin B. Interferon C. Sulfasalazine D. Methotrexate
(c) A. This patient has reactive arthritis (formerly known as Reiter’s syndrome). In recent years, the term has been used to refer to spondyloarthropathies following and enteric or urogenital infection. Indomethacin is the treatment of choice. Interferon is not indicated in reactive arthritis. Sulfasalazine and methotrexate are used in patients with persistent reactive arthritis.
A 25 year-old female presents with a constellation of symptoms including fatigue, chronic headaches, and poor sleep. She also complains of aching pain and stiffness involving her entire body. Minor exertion aggravates the pain and increases her fatigue. Which of the following classes of medications is the most efficacious treatment for this patient's condition? Answers A. Non-steroidal anti-inflammatories B. Opioids C. Corticosteroids D. Antidepressants
(c) D. Antidepressants have shown modest efficacy in treating the symptoms of fibromyalgia.
Why are fractures of the scaphoid bone prone to aseptic necrosis? Answers A. Disrupted arterial supply B. Lack of weight bearing C. Inadequate immobilization D. Impaired venous drainage
(c) A. Scaphoid bone blood supply is from one single vessel that enters distally and once disrupted causes aseptic necrosis.
An elderly patient presents to the ED complaining of right shoulder pain occurring after falling on his right outstretched hand with the elbow extended. On physical examination the arm is pale and pulseless and there is tenderness of the upper arm. Which of the following structures is most likely injured? Answers A. Axillary artery B. Subclavian vein C. Superior thoracic artery D. Ulnar vein
(c) A. Injury to the axillary artery is the most common vascular injury in proximal fractures of the humerus due to the close approximation of the axillary artery to the coracoid process.
An elderly patient presents to the ED complaining of right shoulder pain occurring after falling on his right outstretched hand with the elbow extended. On physical examination the arm is pale and pulseless and there is tenderness of the upper arm. Which of the following structures is most likely injured? Answers A. Axillary artery B. Subclavian vein C. Superior thoracic artery D. Ulnar vein
(c) A. Injury to the axillary artery is the most common vascular injury in proximal fractures of the humerus due to the close approximation of the axillary artery to the coracoid process.
Which of the following tests would be included in the physical exam to evaluate a high ankle sprain with instability? A. Anterior drawer B. Lachman C. Vibratory sense D. Thompson
(c) A. Anterior drawer, in addition to compressing the ankle mortise, is most reliable to indicate rupture to the anterior talofibular, anterior inferior tibiofibular and calcaneofibular ligaments.
A 35 year-old male placed in a thumb spica cast for a scaphoid fracture presents complaining of forearm and hand pain that is not relieved with pain medication and elevation. Which of the following is the earliest physical exam sign for his current condition? A. Slow capillary refill B. Loss of two-point discrimination C. Absent peripheral pulses D. Pain with passive stretch.
(c) B. Loss of two-point discrimination can be the earliest sign of compartment syndrome.
Which of the following is the most sensitive screening test for systemic lupus erythematosus?
A. Anti-Ribonuclear protein (U1-RNP)
B. Antinuclear antibody (ANA)
C. Anti-double-stranded DNA (anti-ds-DNA)
D. Anti-Smith anti-body (anti-Sm)
(c) B. Antinuclear antibody (ANA) is sensitive in 99% of patients with SLE.
Chronic oral steroid use can predispose a patient to which of the following?
A. Charcot’s joint
B. Osteoarthritis
C. DeQuervains syndrome
D. Avascular necrosis of the femoral head
(c) D. Chronic steroid use can predispose a patient to avascular necrosis of the femoral head.
A 35 year-old female who was a back seat passenger in a vehicle which was involved in a head-on collision is brought to the ED. She is able to tell you that she is having difficulty moving both of her legs and is experiencing bilateral leg pain as well. She is embarrassed because she has “wet myself.” Physical examination reveals markedly diminished sensory and motor function of both legs and decreased rectal sphincter tone. Which of the following is the most likely diagnosis?
A. Herniated disc at L5-S1 and L4-L5 B. An anterior cord lesion
C. Cauda equina syndrome
D. An L2 lesion
(c) C. Cauda equina syndrome is a massive central disc protrusion that causes variable degrees of paralysis. Bowel and bladder function may be impaired with saddle anesthesia. This condition is a surgical emergency.
25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and vomiting. He admits to “partying with cocaine all night”. He describes his urine as a dark brown color. Serum creatine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which of the following is the initial mainstay of therapy for this condition?
A. IV rehydration
B. Fasciotomy
C. Toradol (Ketorlac) D. Hydrotherapy
(c) A. IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis.
A 34 year-old female presents with complaints of right forefoot pain. She notes the pain as a severe burning accentuated by activity. She notes her dress shoes aggravate the pain and is relieved when she doesn’t have them on. Massage of her foot also helps to lessen the discomfort. No foot deformity is noted on exam. To confirm the diagnosis, applying digital pressure along the forefoot would commonly create pain in what area?
A. Between the first and second metatarsal
B. Over the first MTP joint
C. The base of the 2nd MTP joint
D. Between the third and fourth metatarsal
(c) D. Pain between the third and fourth metatarsal upon digital pressure is due to Morton’s neuroma.
A 25 year-old female presents to the ED with an open fracture of the left fibula sustained from an auto accident. The patient has no neurological findings. In addition to stabilization of the patient which of the following should be immediately initiated? A. Antibiotic therapy B. Apply a bi-valve cast C. Reduce the fracture D. Surgical debridement
(c) A. Antibiotic therapy should be started immediately along with tetanus if needed.
A patient who has chronic Crohn's disease now complains of a nondeforming asymmetric oligoarthritis of his large joints. The patient also notes that he has been having a flare of his Crohn's disease. Which of the following is the best treatment to alleviate both the inflammatory bowel disease and arthritic symptoms? A. Indomethacin B. Methotrexate C. Infliximab (Remicade) D. Cyclophosamide (Cytoxan)
(c) C. Spondyloarthritides respond to both infliximab and etanercept, where infliximab has greater efficacy in Crohn’s disease.
A 42 year-old male presents with localized dysesthesias on the plantar medial aspect of the left foot. Symptoms are aggravated with activity and relieved by rest. Patient also complains of nocturnal symptoms. Four weeks prior the patient sustained an eversion ankle sprain that is non tender to walk on, but he is left with some residual diffuse swelling. Which of the following is most likely diagnosis? A. Plantar fasciitis B. Tarsal tunnel syndrome C. Peroneus longus tendonitis D. Bone spur of the calcaneus
(c) B. Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes behind the medial malleolus. It is aggravated with activity and relieved with rest.
- Clinical Intervention/Orthopedics/Rheumatology
Which of the following is the most significant complication of a dislocation of the knee?
A. Ligament damage
B. Inability to bear weight
C. Instability of the joint
D. Arterial injury
(c) D. Arterial injury is the most important complication and needs surgical repair immediately.
A 42 year-old male presents with localized dysesthesias on the plantar medial aspect of the left foot. Symptoms are aggravated with activity and relieved by rest. Patient also complains of nocturnal symptoms. Four weeks prior the patient sustained an eversion ankle sprain that is non tender to walk on, but he is left with some residual diffuse swelling. Which of the following is most likely diagnosis? A. Plantar fasciitis B. Tarsal tunnel syndrome C. Peroneus longus tendonitis D. Bone spur of the calcaneus
(c) B. Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes behind the medial malleolus. It is aggravated with activity and relieved with rest.
