Orthopedics packrat Flashcards
Which of the following would demonstrate rotational misalignment in a patient with a fracture of the fourth metacarpal?
A. base of the ring fingernail and index fingernail line up in the partially closed hand
B. fingernails of the open hand form an asymmetric arc
C. ring finger of the closed hand overlaps the little finger
D. ring finger of the open hand is shortened
(c) C. All fingernails should point to the same spot when the hand is closed. Overlapping of one finger over the other indicates rotational misalignment.
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.
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.
An 18 year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis? A. avascular necrosis B. myositis ossificans C. compartment syndrome D. reflex sympathetic dystrophy
(c) C. Compartment syndrome is characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture.
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle? A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis
(c) A. Abduction against resistance tests the supraspinatus.
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.
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.
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 55 year-old secretary presents and she must shake her hand to regain feeling in it. Which of the following physical examination signs will be present?
A. Hypothenar atrophy
B. Weakness of finger abduction
C. Inability to maintain wrist extension against resistance
D. Weakness of thumb abduction
(c) D. Median nerve injury causes weakness of thumb abduction (measured by thumb opposition strength) along with thenar atrophy. Tinel’s and Phalen’s signs will also be positive with carpal tunnel syndrome.
A 60 year-old female injured her right wrist when she slipped and fell onto her outstretched hand. Radiographs show a fracture through the metaphysis of the distal radius with dorsal displacement and angulation. Which of the following splints is the best method of temporary immobilization? A. Dorsal forearm B. Ulnar gutter C. Volar forearm D. Volar with thumb spica
(c) C. The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures and is the splint of choice for Colles’ fracture.
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 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 most consistent with which of the following? A. spondylolysis B. spondylolisthesis 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.
A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical examination 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? A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis
(c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.
An 18 year-old male presents with pain in his wrist after he fell off of a moving motor cycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of the wrist. Which of the following is the recommended treatment for this patient?
A. Ace wrap of the wrist
B. Closed reduction of the fracture site
C. Thumb spica cast application
D. Open reduction of the fracture site
(c) C. Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical
snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for
all presumed nondisplaced scaphoid fractures.
A 41 year-old female complains of 3 weeks of gradually worsening pain at the base of the thumb and radial aspect of the wrist. She and her husband have been renovating their home for the past 2 months and it has become increasingly difficult for her to hold a hammer. She denies numbness or tingling. She denies any history of previous trauma to the wrist. On examination, there is tenderness over the distal radial styloid and pain reproduced with ulnar deviation of a fist clenched over the abducted thumb. Which of the following is the most likely diagnosis? A. Carpal tunnel syndrome B. deQuervain's tenosynovitis C. Ganglion cyst D. Volar flexor tenosynovitis
(c) B. deQuervain’s tenosynovitis typically results from repetitive activity involving pinching the thumb while moving the wrist. There is often pain and tenderness over the radial styloid and Finkelstein’s is positive in this patient.
A 60 year-old patient who has a 20 year history of diabetes mellitus arrives at the clinic with a complaint of mild to moderate ankle pain. There is no history of trauma. You note on exam that the joint is unstable but not erythematous or warm. On x-ray you would expect to see
A. osteopenia.
B. loss of articular cartilage.
C. disintegration of the joint with osteophytes.
D. subchondral cysts.
(c) C. Various degrees of joint destruction and disintegration with osteophyte formation are usually present with Charcot’s joint.
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.
A 13 year-old girl reports two weeks of worsening right knee pain with no history of antecendent injury or recent trauma. She reports frequent episodes of nighttime awakening with knee pain in the past two weeks. Examination of the knee reveals edema and a tender mass over the anterior proximal right tibia. Her knee exam is otherwise within normal limits. Radiographs of the right knee show a lytic mass with a multi-laminated periosteal reaction involving the proximal anterior tibia. What is the most likely diagnosis? A. Ewing sarcoma B. Osteochondroma C. Multiple myeloma D. Osteoid osteoma
(c) A. The distinctive feature of Ewing sarcoma is the radiographic appearance of a periosteal “onion skin” reaction.
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.
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 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis? A. Rheumatoid arthritis B. Septic arthritis C. Gouty arthritis D. Osteoarthritis
(c) B. Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels.
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 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.
A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?
A. Open reduction and internal fixation
B. Continuous extension of the DIP with splinting
C. Continuous flexion of the PIP with splinting
D. Application of short arm cast
(c) B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via
splinting for 6 to 8 weeks.
Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase? A. Probenecid (Benemid) B. Allopurinol (Zyloprim) C. Colchicine D. Indomethacin (Indocin)
(c) B. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid.
A 43 year-old male with a history of a right medial meniscectomy and a strong family history of osteoarthritis presents to the clinic for a routine physical exam. He states he is very active and runs 20-25 miles a week and competes routinely in 5 km races. He is 5’ 10” and 160 lbs, BP is 128/76 and P 72. His physical examination is unremarkable. Which of the following would you recommend to this patient to delay the onset of osteoarthritis?
A. weight loss
B. corticosteroid injections
C. 1500 mg of calcium daily
D. consider swimming or biking instead of running
(c) D. Swimming and biking would promote excellent joint motion and muscle strength and void the high-impact of competitive short-distance running.
Which of the following is the most sensitive to determine whether there is a small effusion in the knee?
A. Compress the patella and move it against the femur, noting any crepitus
B. Flex the knee to about 90 degrees and palpate for tenderness over the joint line
C. Milk the medial aspect of the knee, press lateral margin of the patella, and note a bulge of returning fluid medial to the patella
D. Force fluid into space between the patella and the femur, tap the patella over the femur to detect a click
(c) C. A small bulge of returning fluid after milking fluid upward from the knee is useful for detecting small effusions.
A 45 year-old patient presents with pain in the left wrist after a FOOSH (fall on outstretched hand) injury. On examination he has snuff box tenderness with limited range of motion. Which of the following immobilization devices is the most appropriate intervention? A. Sugar tong splint B. Wrist “cock up” splint C. Thumb spica splint D. Short arm ulnar gutter splint
(c) C. Thumb spica splint is most appropriate as it immobilizes the thumb and wrist. It is utilized for scaphoid fractures or fractures of the thumb.
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 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the emergency department. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory? A. Anterior plain film of knee B. Sunrise view of the knee C. Measurement of compartment pressures D. Angiography
(c) D. The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and
should be evaluated with an arteriogram despite the presence of pedal pulses.
A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?
A. Open reduction and internal fixation
B. Continuous extension of the DIP with splinting
C. Continuous flexion of the PIP with splinting
D. Application of short arm cast
(c) B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via
splinting for 6 to 8 weeks.
A 60 year-old female presents for pre-op evaluation for surgical treatment of a tri-malleolar fracture of the left ankle. Which of the following puts her at an increased risk for infection post surgery? A. Recent URI B. Diabetes mellitus C. Heart murmur D. Swelling of the ankle
(c) B. Diabetes mellitus puts her at risk for infection post surgery.
A 22 year-old female complains of worsening pain, swelling, and tenderness in her left heel for 1 week. She sustained a penetrating injury to the heel two weeks ago when she stepped on a nail while running in tennis shoes. Examination reveals a draining puncture wound with surrounding erythema and exquisite tenderness. X-ray of the left foot demonstrates periosteal reaction associated with the wound. Which organism is classically responsible for this infection? A. Escherichia coli B. Streptococcus pyogenes C. Pseudomonas aeruginosa D. Staphylococcus aureus
(c) C. Pseudomonas aeruginosa is frequently associated with osteomyelitis involving puncture wounds of the foot. This is believed to result from direct inoculation with P. aeruginosa via the foam padding found in tennis shoes.
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.
Which of the following is an established risk factor for osteoporosis? A. Parity status B. Carbohydrate intake C. Lactation history D. Low body weight
(c) D. Established risk factors for osteoporosis include low body weight, female sex, advanced age, Caucasian race, and bilateral oophorectomy before menopause without estrogen replacement.
The most reliable site from which to identify the causative organism in cases of osteomyelitis is the A. base of ulcer. B. blood. C. sinus tract. D. bone.
(c) D. Samples from needle aspiration of pus in the bone, or from a bone biopsy, are essential to determine the exact causative agent.
A patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of the following portions of the spinal column are most likely affected? A. Lateral spinothalamic tract B. Ventral spinothalamic tract C. Posterior column D. Transection of the cord
(c) C. The posterior column affects proprioception (position sense) and vibration sense.
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.
