Pestana Chap 2 - Orthopedics

Question 1

Does developmental dysplasia of the hip run in families? When should it ideally be diagnosed?

Answer 1

1) Yes

2) Ideally, right after birth

Question 2

What does physical exam of a child with developmental dysplasia show?

Answer 2

Children have uneven gluteal folds, and physical examination of the hips shows that they can be easily dislocated posteriorly with a jerk and a “click,” and returned to normal with a “snapping”

Question 3

If signs of developmental dysplasia are equivocal, what test can be done next to help determine your diagnosis?

Answer 3

Sonogram is diagnostic (do not order x-rays; the hip is not calcified in the newborn)

Question 4

What is the treatment for developmental dysplasia of the hip and for how long?

Answer 4

Abduction splinting with Pavlik harness for about 6 months

Question 5

What two areas of the pelvis and lower extremity will develop pain in the presence of hip pathology in children?

Answer 5

1) Hip pain

2) Knee pain

Question 6

What is Legg-Calve-Perthes disease? When does it present? How does it present?

Answer 6

1) Avascular necrosis of the capital femoral epiphysis
2) It occurs around age 6
3) Insidious development of limping, decreased hip motion, and hip (or knee) pain. Kids walk with an antalgic gait, and passive motion of the hip is guarded

Question 7

How is diagnosis of Legg-Calve-Perthes reached?

Answer 7

AP and lateral hip x-rays

Question 8

What is treatment of Legg-Calve-Perthes?

Answer 8

Treatment is controversial, usually containing the femoral head within the acetabulum by casting and crutches

Question 9

Is slipped capital femoral epiphysis an orthopedic emergency?

Answer 9

Yes

Question 10

What does the typical patient with slipped capital femoral epiphysis look like? What does he complain of and what is he noted to be doing while ambulating? What is noticeable about the affected side foot when the patient sits with the legs dangling?

Answer 10

1) The typical patient is a chubby (or lanky) boy, around age 13
2) They complain of groin (or knee) pain and are noted to be limping
3) When they sit with the legs dangling, the sole of the foot on the affected side points toward the other foot

Question 11

What is noticed on physical exam of a patient with slipped capital femoral epiphysis?

Answer 11

On physical exam there is limited hip motion, and as the hip is flexed the thigh goes into external rotation and cannot be rotated internally

Question 12

What test is diagnostic for slipped capital femoral epiphysis and what is the treatment?

Answer 12

X-rays are diagnostic, and surgical treatment pins the femoral head back in place

Question 13

Is septic hip an orthopedic emergency?

Answer 13

Yes

Question 14

In what age group is septic hip seen and how do they present?

Answer 14

It is seen in little toddlers who have had a febrile illness and then refuse to move the hip

Question 15

How do patients with septic hip hold their leg?

Answer 15

They hold the leg with the hip flexed, in slight abduction and external rotation, and do not let anybody try to move it passively

Question 16

What lab value is elevated in patients with septic hip?

Answer 16

Sedimentation rate

Question 17

How is diagnosis of septic hip made? What is done if pus is obtained from this diagnostic test?

Answer 17

Aspiration of the hip under general anesthesia, and further open drainage is done if pus is obtained

Question 18

In which patients is acute hematogenous osteomyelitis seen in?

Answer 18

Little kids who have had a febrile illness, but it shows up with severe localized pain in a bone (and no history of trauma to that bone)

Question 19

Why are MRIs preferred over X-rays for diagnosis of acute hematogenous osteomyelitis? How is this condition treated?

Answer 19

1) MRI gives prompt diagnosis, while x-rays will not show anything for a couple of weeks
2) Treat with antibiotics

Question 20

Up to what age is genu varum (bowlegs) normal? Is treatment needed at this time? What is the most common disease associated with persistent varus beyond age 3? What can be done at this time?

Answer 20

1) Up to the age of 3 years
2) No treatment is needed
3) Blount disease (a disturbance of the medial proximal tibial growth plate)
4) Surgery can be done

Question 21

Between what ages is genu valgus (knock-knee) normal? Is treatment needed at this time?

Answer 21

1) Between ages 4 and 8

2) No treatment is needed

Question 22

What is Osgood-Schlatter disease? What age are patients with the disease and how do they present? What does physical exam show?

Answer 22

1) Osteochondrosis of the tibial tubercle
2) It is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps
3) Physical exam shows localized pain right over the tibial tubercle, and there is no knee swelling

Question 23

How do first responders to Osgood-Schlatter disease manage the condition? What if these measures are unsuccessful?

Answer 23

1) They use conservative managmenet, as suggested by the mnemonic RICE: rest, ice, compression, and elevation
2) These patients are referred to an orthopedic surgeon, who at most would use an extension or cylinder cast for 4 to 6 weeks

Question 24

At what age is club foot (talipes equinovarus) seen? What do the feet look like?

Answer 24

1) At birth
2) Both feet are turned inward, and there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia

Question 25

What is the sequential correction using serial plaster casts to treat club foot? What else is often added? If someone does not respond to casting, what must be done and when it it typically done?

Answer 25

1) Serial plaster casts started in the neonatal period provide sequential correction starting with the adducted forefoot, then the hindfoot varus, and last the equinus
2) Often Achilles tenotomy and part-time, long-term use of braces are added
3) Surgery, typically done between the ages of 9 and 12 months

Question 26

In which patients do you primarily see scoliosis? What is the most sensitive screening test to identify scoliosis?

Answer 26

1) Primarily in adolescent girls, whose thoracic spines are curved toward the right
2) Look at the girl from behind while she bends forward and a hump will be noted over her right thorax

Question 27

Until what point does the deformity of scoliosis progress until? In severe cases, what can develop in addition to the cosmetic deformity?

Answer 27

1) Until skeletal maturity is reached (at the onset of menses skeletal maturity is about 80%)
2) Decreased pulmonary function

Question 28

What is used to arrest the progression of scoliosis? What may be needed in severe cases?

Answer 28

1) Bracing

2) Surgery

Question 29

How does the degree of angulation in an adult and child fracture differ and why? How does the speed of the healing process differ in the adult and the child for a fracture?

Answer 29

1) The degrees of angulation that would be unacceptable in the adult may be okay when fractures are reduced and immobilized in children because remodeling occurs to an astonishing degree in children’s fractures
2) The healing process is much faster in children than in the adult

Question 30

What are the only areas where children have special problems with fracture remodeling?

Answer 30

1) Supracondylar fractures of the humerus

2) Fractures of any bone that involve the growth plate

Question 31

How do supracondylar fractures of the humerus occur? What secondary injuries are you concerned about and why?

Answer 31

1) Hyperextension of the elbow in a child who falls on the hand, with the arm extended
2) Vascular or nerve injuries can easily occur, and they could lead to Volkmann contracture (permanent shortening [contracture] of forearm muscles, usually resulting from injury, that gives rise to a clawlike deformity of the hand, fingers, and wrist)

Question 32

How can supracondylar fractures of the humerus be treated? What else do they require monitoring of?

Answer 32

1) Appropriate casting or traction (seldom need surgery)

2) Vascular and nerve integrity, and vigilance regarding development of a compartment syndrome

Question 33

Do primary malignant bone tumors occur in young or old people? What do these patients complain of? What is seen on X-ray?

Answer 33

1) Young people
2) Persistent low-grade pain, present for several months
3) X-ray appearance includes invasion of the adjacent soft tissue, a “sunburst” pattern, and periosteal “onion skinning”

Question 34

What is the most common primary malignant bone tumor? In what age patients is it seen? In what part of the body is it seen in? What is described as the classical appearance on X-rays?

Answer 34

1) Osteogenic sarcoma
2) Ages 10-25 years old
3) Usually around the knee (lower femur or upper tibia)
4) “Sunburst” pattern on X-rays

Question 35

What is the second most common primary malignant bone tumor? In what age patients is it seen? In what part of the body is it seen? What is described as the classical appearance on X-rays?

Answer 35

1) Ewing sarcoma
2) Younger children, ages 5 to 15
3) It grows in the diaphyses of long bones
4) “Onion skinning”-type pattern is often seen on x-rays

Question 36

Where do most malignant bone tumors in adults originate from?

Answer 36

Metastases from breast in women (lytic lesions) and prostate in men (blastic lesions)

Question 37

What is an early finding with malignant bone tumors of adults? Which test is diagnostic and which can give more information? What do lytic lesions sometimes present with in patients?

Answer 37

1) Localized pain
2) X-rays can be diagnostic, CT scans give more information, and MRI is even better
3) Pathologic fracture (i.e., fracture precipitated by events that would not justify it, such as lifting a bag of groceries

Question 38

In which patients is multiple myeloma seen in? What test is diagnostic and what does it show? What other findings are found in these patients (urine and blood)? What is it treated with and what is used in the event that this treatment fails?

Answer 38

1) Old men with fatigue, anemia, and localized pain at specific places on several bones
2) X-rays are diagnostic, showing multiple punched-out lytic lesions
3) Bence-Jones protein in the urine and abnormal immunoglobulins in the blood, best shown by serum immunoelectrophoresis
4) Chemotherapy; thalidomide

Question 39

How quickly do soft tissue sarcomas grow and where can they grow in the body? Are they firm or soft and what are they fixed to?

Answer 39

1) They have relentless growth (several months) and are found as a soft tissue mass anywhere in the body
2) They are firm and fixed to surrounding structures

Question 40

Where do soft tissue sarcomas metastasize to? What helps to diagnose malignancy?

Answer 40

1) They metastasize to lungs but not to lymph nodes

2) MRIs may help diagnose malignancy (but not specific type)

Question 41

What test can be done to sample a soft tissue sarcoma? What does treatment consist of?

Answer 41

1) Incisional biopsy

2) Very wide local excision, radiation, and chemotherapy

Question 42

What views should X-rays for suspected fractures always include and what joints should be included? If the mechanism of injury suggests it, what other x-rays should be taken for a bone fracture?

Answer 42

1) Always include two views at 90 degrees to one another and always include the joints above and below the broken bone
2) Bones that are “in the line of force,” which might also be broken (for instance, the lumbar spine when somebody falls from a height and lands on-and breaks-his feet)

Question 43

As a general rule, which broken bones can be immobilized in a cast (“closed reduction”) for repair? Which broken bones require surgical intervention to reduce and fix the fracture (“open reduction and internal fixation”)?

Answer 43

1) Those that are not badly displaced or angulated or that can be satisfactorily aligned by external manipulation
2) Those that are severely displaced or angulated or that cannot be aligned easily

Question 44

At what part of the clavicle do clavicular fractures typically occur? What is the traditional treatment? What is a more comfortable treatment that also works well? If very precise outcome is desired for cosmetic reasons, what can be done?

Answer 44

1) At the junction of middle and distal thirds
2) A figure-of-eight device that, by pulling back on both shoulders, aligns the bone
3) Wearing a sling is more comfortable and also works well
4) Open reduction and internal fixation

Question 45

What is the most common type of shoulder dislocation? How do patients hold their arm with this type of shoulder dislocation? What symptoms might they feel in the deltoid and why?

Answer 45

1) Anterior dislocation of the shoulder
2) Patients hold the arm close to their body but rotated outward as if they were going to shake hands
3) There may be numbness in a small area over the deltoid, from stretching of the axillary nerve

Question 46

What is diagnostic of an anterior dislocation of the shoulder? What may some patients develop in the future after an anterior dislocation of the shoulder?

Answer 46

1) AP and lateral x-rays are diagnostic

2) Some patients develop recurrent dislocations with minimal trauma

Question 47

How does a posterior shoulder dislocation occur? How do these patients hold their affected arm? What X-ray view is needed for diagnosis and why?

Answer 47

1) It is rare and occurs after massive uncoordinated muscle contractions, such as epileptic seizure or electrical burn
2) The arm is held in the usual protective position (close to the body, internally rotated)
3) Regular x-rays can easily miss it; axillary views or scapular lateral views are needed

Question 48

How does a Colles fracture occur and in which patients does it occur? What does the deformed and painful wrist look like? In which direction is the main lesion displaced and angulated and what bone is affected? How is it treated?

Answer 48

1) Results from a fall on an outstretched hand, often in old osteoporotic women
2) “Dinner fork”
3) The main lesion is a dorsally displaced, dorsally angulated fracture of the distal radius
4) Treat with closed reduction and long arm cast

Question 49

How does a Monteggia fracture occur? What is fractured and what is dislocated?

Answer 49

1) A direct blow to the ulna (such as a raised protective arm hit by a nightstick)
2) There is a diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head

Question 50

What bone gets the direct blow in a Galeazzi fracture and where is there dorsal dislocation?

Answer 50

The distal third of the radius gets the direct blow and has the fracture, and there is dorsal dislocation of the distal radioulnar joint

Question 51

In both a Monteggia and Galeazzi fracture, what does the broken bone require for treatment and what does the dislocated one require?

Answer 51

The broken bone often requires open reduction and internal fixation, whereas the dislocated one is typically handled with closed reduction

Question 52

Who does fracture of the scaphoid (carpal navicular) affect? What do patients complain of? What does physical exam show?

Answer 52

1) A young adult who falls on an outstretched hand
2) Wrist pain
3) Localized tenderness to palpation over the anatomic snuffbox

Question 53

In undisplaced scaphoid fractures, are x-rays usually positive or negative? If x-rays are negative, when is casting for a scaphoid fracture still indicated? When will X-rays show the fracture?

Answer 53

1) X-rays are usually negative
2) Thumb spica cast is indicated just with the history and physical findings
3) 3 weeks later

Question 54

If original x-rays show diaplced and angulated fracture of the scaphoid, what treatment is needed? What are scaphoid fractures notorious for?

Answer 54

1) Open reduction and internal fixation

2) Scaphoid fractures are notorious for a very high rate of nonunion

Question 55

How do metacarpal neck fractures (typically the fourth or fifth, or both) happen? What does the hand look like and what test is diagnostic? What does treatment depend on and what are treatment options for mild and bad fractures?

Answer 55

1) When a closed fist hits a hard surface (like a wall)
2) The hand is swollen and tender, and x-rays are diagnostic
3) The degree of angulation, displacement, or rotary malalignment: closed reduction and ulnar gutter splint for the mild ones; Kirschner wire or plate fixation for the bad ones

Question 56

In which patients do hip fractures typically occur? How does it present classically? What does specific treatment depend on?

Answer 56

1) The old who sustain a fall
2) The hip hurts, and the patient’s position in the stretcher is classic: the affected leg is shortened and externally rotated
3) Specific treatment depends on specific location (as shown by x-rays)

Question 57

What do femoral neck fractures compromise, particularly if displaced? How can faster healing and earlier mobilization be achieved?

Answer 57

1) The very tenuous blood supply of the femoral head

2) Faster healing and earlier mobilization can be achieved by replacing the femoral head with a prosthesis

Question 58

What are intertrochanteric fractures less likely to lead to when compared to femoral neck fractures? What are they treated with? What does the unavoidable immobilization that ensues from treatment pose a very high risk for and how can this be avoided?

Answer 58

1) Less likely to lead to avascular necrosis
2) Open reduction and internal fixation
3) Deep venous thrombosis and pulmonary emboli; post-op anticoagulation is recommended

Question 59

What are femoral shaft fractures often treated with? If bilateral and comminuted, what consequence may they produce and what may help with this while the patient is stabilized? If the fracture is open, what is required? What may happen in the event of multiple fractures?

Answer 59

1) Intramedullary rod fixation
2) Internal blood loss to lead to shock (external fixation may help while the patient is stabilized)
3) If they are open, they are an orthopedic emergency requiring OR cleaning and closure within 6 hours
4) If multiple, they may lead to the fat embolism syndrome

Question 60

What do knee injuries typically produce? What is the best test to look look inside the knee?

Answer 60

1) Swelling of the knee (knee pain without swelling is unlikely to be a serious knee injury)
2) Swelling of the knee has been described as “the poor man’s MRI,” a reference to its clinical reliability, and to the fact that MRI is the best highly technological way to look inside the knee

Question 61

How are collateral ligament injuries usually sustained? What ligaments do medial blows disrupt and what ligaments do lateral blows disrupt? How will the knee present?

Answer 61

1) In a sideways blow to the knee (a common sports injury)
2) Medial blows disrupt the lateral ligaments, and vice versa
3) The knee will be swollen and show localized pain by direct palpation on the affected side

Question 62

What will produce pain on torn collateral ligaments and allow further displacement than the normal leg? What does abduction demonstrate? What does adduction diagnose?

Answer 62

1) With the knee flexed 30 degrees, abduction or adduction
2) Abduction demonstrates the medial injuries (valgus stress test)
3) Adduction diagnoses the lateral injuries (varus stress test)

Question 63

What are isolated collateral ligament injuries treated with? What is preferred when several ligaments are torn?

Answer 63

1) A hinged cast

2) Surgical repair

Question 64

What is more common: anterior cruciate ligament or posterior cruciate ligament injuries? How does an ACL injury present? What is the anterior drawer test? What is the Lachman test? How does a posterior cruciate ligament injury present in relation to an ACL injury?

Answer 64

1) Anterior cruciate ligament injuries
2) There is severe knee swelling and pain
3) With the knee flexed 90 degrees, the leg can be pulled anteriorly, like a drawer being opened
4) A similar finding can be elicited with the knee flexed at 20 degrees by grasping the thigh with one hand, and pulling the leg with the other
5) It produces the opposite findings

Question 65

What is diagnostic of a cruciate ligament injury? How may sedentary patients be treated? How may athletes be treated? Almost all cruciate injuries are related to what and require what?

Answer 65

1) MRI
2) Immobilization and rehabilitation
3) Surgical reconstruction
4) Sports-related and require surgery

Question 66

Meniscal tears are difficult to diagnose clinically and on x-rays, but are beautifully shown how? How do patients present? What is the treatment? What does complete meniscectomy lead to?

Answer 66

1) On MRI
2) Patients often have protracted pain and swelling after a knee injury, and they may describe catching and locking that limit knee motion, and a “click” when the knee is forcefully extended
3) Repair is done, trying to save as much meniscus as possible
4) Late development of degenerative arthritis

Question 67

What three injuries often occur simultaneously in the knee?

Answer 67

Injuries to the medial meniscus, the medial collateral, and the anterior cruciate

Question 68

In which patients are tibial stress fractures seen? What is found on physical exam and x-rays? What are two treatment options?

Answer 68

1) Young men subjected to forced marches
2) There is tenderness to palpation over a very specific point on the bone, but x-rays are initially normal
3) Treat with a cast and repeat the x-rays in 2 weeks. Non-weight bearing (crutches) is another option

Question 69

When are leg fractures involving the tibia and fibula seen? What does physical exam show? Are x-rays diagnostic? How are fractures that are easily reduced treated? What about those that cannot be aligned?

Answer 69

1) Often when a pedestrian is hit by a car
2) Angulation
3) Yes
4) Casting
5) Intramedullary nailing

Question 70

What are two of the most common locations for the development of compartment syndrome? What does increasing pain after a long leg cast has been applied require?

Answer 70

1) The lower leg and the forearm

2) Immediate removal of the cast and appropriate assessment

Question 71

In which patients is rupture of the Achilles tendon seen? What happens as they plant the foot and change direction? Is plantarflexion possible? What brings them to the doctors? What does palpation of the tendon reveal? What allows healing in several months and what treatment approach achieves quicker cure?

Answer 71

1) Out-of-shape middle-aged men who subject themselves to severe strain (tennis, for instance)
2) A loud popping noise is heard (like a rifle shot), and they fall clutching the ankle
3) Limited plantarflexion
4) Pain, swelling, and limping bring them to the doctor
5) Casting in equinus position allows healing in several months; surgery achieves quicker cure

Question 72

How do fractures of the ankle occur? What bone in the feet break? What x-ray views are diagnostic? What is the treatment needed if fragments are displaced?

Answer 72

1) They occur when falling on an inverted or everted foot
2) In either case, both malleoli break
3) AP, lateral, and mortise x-rays are diagnostic
4) Open reduction and internal fixation is needed if the fragments are displaced

Question 73

What are precipitating events for compartment syndrome? What is the most common cause of compartment syndrome in the lower leg by far? How does it present? What does physical exam show and what is the most reliable physical exam finding? What is required for treatment?

Answer 73

1) Prolonged ischemia followed by reperfusion, crushing injuries, or other types of trauma
2) A fracture with closed reduction
3) The patient has pain and limited use of the extremity
4) The compartment feels very tight and tender to palpation. The most reliable physical exam finding is excruciating pain with passive extension. Pulses may be normal
5) Emergency fasciotomy

Question 74

How is pain under a cast always handled?

Answer 74

Remove the cast and examine the limb

Question 75

What do open fractures (the broken bone sticking out through a wound) require?

Answer 75

Cleaning in the OR and suitable reduction within 6 hours from the time of injury

Question 76

When does posterior dislocation of the hip occur? How does the patient present? Why is emergency reduction required for a posterior dislocation of the hip?

Answer 76

1) When the femur is driven backward, such as in a head-on car collision where the knees hit the dashboard
2) The patient has hip pain and lies in the stretcher with the leg shortened, adducted, and internally rotated (in a broken hip the leg is also shortened, but it is externally rotated)
3) Because of the tenuous blood supply of the femoral head, emergency reduction is needed to avoid avascular necrosis

Question 77

How does gas gangrene occur? What happens to the patient over the next 3 days? How does the affected site present on physical exam? What is required for treatment?

Answer 77

1) It occurs with deep, penetrating, dirty wounds (stepping on a rusty nail, with lots of mud or manure)
2) In about 3 days the patient is extremely sick, looking toxic and moribund
3) The affected site is tender, swollen, discolored, and has gas crepitation
4) Copious IV penicillin, extensive emergency surgical debridement, and hyperbaric oxygen

Question 78

In which patients are other galloping soft tissue infections primarily seen in? Patients debilitated by extensive burns or widespread trauma may suffer from what? What is the most feared of these infections in extensive burns or widespread trauma and how is diagnosis confirmed? What do all of these conditions require?

Answer 78

1) Immunocompromised patients (diabetics, AIDS patients), the most common being synergistic bacterial gangrene and necrotizing fasciitis
2) Fulminating fungal infections
3) Mucormycosis, in which the affected areas turn black; diagnosis is confirmed by tissue biopsy
4) Massive surgical excisions of dead tissue in addition to approrpiate antibiotics (broad spectrum for synergistic bacterial gangrene and necrotizing fasciitis, IV amphotericin B for mucormycosis)

Question 79

In what type of fracture can the radial nerve be injured in? When is surgical exploration not needed for these fractures? When is it needed?

Answer 79

1) Oblique fractures of the middle to distal thirds of the humerus
2) If the patient comes in unable to dorsiflex (extend) the wrist and regains function when the fracture is reduced and the arm is placed on a hanging cast or captation sling, no surgical exploration is needed
3) If nerve paralysis develops or remains after reduction, the nerve is entrapped and surgery has to be done

Question 80

In what injury do popliteal artery injuries occur? What are key issues to look out for? What will minimize vascular compromise? What is required if restoration of flow is delayed?

Answer 80

1) In posterior dislocations of the knee
2) Attention to the integrity of pulses, Doppler studies, or CT angio, are key issues
3) Prompt reduction
4) Prophylactic fasciotomy

Question 81

What produces an obvious injury that may produce another one that is less obvious and needs to be sought?

Answer 81

The direction of force

Question 82

While falls from a height landing on the feet may have obvious foot or leg fractures, what may be less obvious and should be looked for?

Answer 82

Fractures of the lumbar or thoracic spine

Question 83

What injuries may be obvious in a head-on automobile collision? What if the knees hit the dashboard?

Answer 83

1) The face, head, and torso

2) Femoral heads may be driven backward into the pelvis or out of the acetabulum

Question 84

What should facial fractures and closed head injuries always prompt?

Answer 84

Evaluation of the cervical spine

Question 85

In which patients does carpal tunnel syndrome occur? What do they complain about? How can the symptoms be reproduced?

Answer 85

1) Mostly in women who do repetitive hand work (such as typing)
2) They complain about numbness and tingling in their hands, particularly at night, and in the distribution of the median nerve (radial 3.5 fingers)
3) The symptoms can be reproduced by hanging the hand limply for a few minutes, or by tapping, percussing or pressing the median nerve over the carpal tunnel

Question 86

How is the diagnosis of carpal tunnel syndrome made and what does the American Academy of Orthopedic Surgery recommend? What is the initial treatment? If surgery is needed, what should precede it?

Answer 86

1) The diagnosis is clinical, but the American Academy of Orthopedic Surgery recommends that wrist x-rays (including carpal tunnel view) be done to rule out other things
2) Splints and anti-inflammatory agents
3) Electromyography (electro-diagnostic studies of nerve conduction)

Question 87

Is trigger finger more common in men or women? How do these patients present? What is the first line of treatment and last resort?

Answer 87

1) Women
2) Patients wake up in the middle of the night with a finger acutely flexed, and they are unable to extend it until they pull it with the other hand. When they do so, there is a painful “snap”
3) Steroid injection is the first line of therapy; surgery is the treatment of last resort

Question 88

In which patients does De Quervain tenosynovitis present? What do they complain of? On physical exam, how can the pain be reproduced? What is treatment?

Answer 88

1) Young mothers who, as they carry their baby, force their hand into wrist flexion and thumb extension to hold the baby’s head
2) They complain of pain along the radial side of the wrist and the first dorsal compartment
3) Ask her to hold her thumb inside her closed fist, then force the wrist into ulnar deviation
4) Splint and antiinflammatory agents can help, but steroid injection is best. Surgery is rarely needed

Question 89

In which patients does Dupuytren contracture occur? How does it present? When may surgery be needed?

Answer 89

1) Older men of Norwegian ancestry
2) There is contracture of the palm of the hand, and palmar fascial nodules can be felt
3) Surgery may be needed when the hand can no longer be placed flat on a table

Question 90

What is a felon? What do patients complain of and what are their classic findings? What will happen if surgical drainage is not urgently done?

Answer 90

1) An abscess in the pulp of a fingertip, caused by a neglected penetrating injury
2) Patients complain of throbbing pain and have all the classic findings of an abscess, including fever
3) Because the pulp is a closed space with multiple fascial trabecula, pressure can build up and lead to tissue necrosis

Question 91

What is a gamekeeper thumb? What is found on physical exam? What should be done for treatment?

Answer 91

1) Injury of the ulnar collateral ligament sustained by forced hyperextension of the thumb (historically suffered by gamekeepers when they killed rabbits by dislocating their necks with a violent blow with the extended thumb-nowadays seen as a skiing injury when the thumb gets stuck in the snow or the ski strap during a fall)
2) Collateral laxity at the thumb-metacarpophalangeal joint, and if untreated it can be dysfunction and painful, and lead to arthritis
3) Casting is usually done

Question 92

What is a Jersey finger? What happens when the patient makes a fist?

Answer 92

1) Injury to the flexor tendon sustained when the flexed finger is forcefully extended (as in someone unsuccessfully grabbing a running person by the jersey)
2) When making a fist, the distal phalanx of the injured finger does not flex with the others

Question 93

What is a Mallet finger? What happens when the patient extends the hand? What is the first line of treatment for both a jersey and mallet finger?

Answer 93

1) It is the reverse of a Jersey finger. The extended finger is forcefully flexed (a common volleyball injury), and the extensor tendon is ruptured
2) The tip of the affected finger remains flexed when the hand is extended, resembling a mallet
3) Splinting

Question 94

When are traumatically amputated digits surgically reattached? How should the amputated digit be prepped? What should be avoided in storing/transporting an amputated finger? How can entire amputated extremities be reattached?

Answer 94

1) Whenever possible
2) The amputated digit should be cleaned with sterile saline, wrapped in a saline-moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice
3) The digit should not be placed in antiseptic solutions or alcohol, should not be put on dry ice, and should not be allowed to freeze
4) Electric nerve stimulation to preserve muscular function

Question 95

Where do lumbar disk herniations occur? How old are patients in the peak age of incidence? What do patients complain of and what are each of these types of pain due to? What does the neurogenic pain feel like and what is it exacerbated by?

Answer 95

1) Almost exclusively at L4-L5 or L5-S1
2) 45-46 years old
3) Months of vague aching pain (the “discogenic pain” produced by pressure on the anterior spinal ligament) before they have the sudden onset of the “neurogenic pain” precipitated by an event like attempting to lift a heavy object
4) It is extremely severe, “like an electrical shock that shoots down the leg” (exiting on the side of the big toe in L4-L5, or the side of the little toe in L5-S1), and it is exacerbated by coughing, sneezing, or defecating (if the pain is not exacerbated by those activities, the problem is not a herniated disk)

Question 96

Can patients with a lumbar disk herniation ambulate? How do they hold the affected leg? What does the straight leg-raising test show? What confirms the diagnosis?

Answer 96

1) No
2) They hold the affected leg flexed
3) Excruciating pain
4) MRI

Question 97

How is a lumbar disk herniation treated? Why was this treatment option formerly difficult? Why is it easier now? When is surgical intervention needed? When is emergency intervention required?

Answer 97

1) Spontaneous resolution is the rule, as the body reabsorbs the extruded disc
2) This process used to be very inconvenient for the patient, requiring 3 weeks of strict bed rest
3) The advent of pain control specialists, who perform nerve blocks under radiological guidance, has made the recovery period much easier
4) If neurologic deficits are progressing (progressive muscle weakness)
5) If there is a cauda equina syndrome

Question 98

How does a cauda equina syndrome present? What does it require?

Answer 98

1) It is a surgical emergency that presents with distended bladder, flaccid rectal sphincter, and perineal saddle anesthesia
2) It requires immediate decompression

Question 99

In which patients do you see ankylosing spondylitis? When is the pain worse and how does it improve? Are the symptoms stagnant or progressive? What does x-ray eventually show?

Answer 99

1) In young men in their thirties or early forties who complain of chronic back pain and morning stiffness
2) The pain is worse at rest, and improves with activity
3) Symptoms are progressive
4) X-rays eventually show a “bamboo spine”

Question 100

What is the treatment for ankylosing spondylitis? What autoimmune association do these patients have?

Answer 100

1) Anti-inflammatory agents and physical therapy are used

2) These patients have the HLA B-27 antigen, which is also associated with uveitis and inflammatory bowel disease

Question 101

When should metastatic malignancy to bone be suspected? If advanced, what will x-rays show? At a higher cost, what is the best diagnostic tool?

Answer 101

1) In the elderly who have progressive back pain that is worse at night and unrelieved by rest or positional changes. Weight loss if often an additional finding
2) The lesions (in women, lytic breast cancer metastases at the pedicles; in men, blastic metastases are from the prostate)
3) MRI

Question 102

Do diabetic ulcers cause pain and where are they located? Why do they form and why do they fail to heal? How are they managed theoretically and realistically?

Answer 102

1) They are typically indolent and located at pressure points (heel, metatarsal head, tip of toes)
2) They start because of neuropathy, and they fail to heal because of the microvascular disease
3) Theoretically they can be healed with good control of the diabetes and by keeping them clean with the leg elevated for many weeks or months. In reality they often get worse and lead to amputations

Question 103

Where are ulcers from arterial insufficiency usually found? What do they look like? What other manifestations of arteriosclerotic occlusive disease does the patient have?

Answer 103

1) As far away from the heart as they can be: at the tip of the toes
2) They look dirty, with a pale base devoid of granulation tissue
3) Absent pulses, trophic changes, claudication or rest pain

Question 104

What does workup of an ulcer from arterial insufficiency begin with? What additional testing will be done and what is the treatment?

Answer 104

1) Doppler studies looking for a pressure gradient (if there isn’t one, there is microvascular disease not amenable to surgical therapy)
2) Then CT angio, MRI angio or arteriograms, and surgical revascularization or angioplasty and stents

Question 105

In the evaluation of chronic foot ulcers, a workup if often done for what two diseases?

Answer 105

Both diabetes and arteriosclerotic occlusive disease, inasmuch as both problems often coexist in the same patient

Question 106

What does the skin look like in a venous stasis ulcer and where is it located? What does the ulcer feel and look like? What is true about the patients leg veins and what do they suffer from frequent bouts of?

Answer 106

1) They develop in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus
2) The ulcer is painless, with granulating bed
3) The patient has varicose veins and suffers from frequent bouts of cellulitis

Question 107

What is useful in the workup of venous stasis ulcers? What does treatment revolve around and how is this best done? What other treatment may be required or used?

Answer 107

1) Duplex scan is useful in the workup
2) Treatment revolves around physical support to keep the veins empty, best done with support stockings measured to fit the patient
3) Surgery may be required (vein stripping, grafting of the ulcer); endovascular ablation with laser or radiofrequency may also be used

Question 108

What is a Marjolin ulcer? What is the classic setting of a Marjolin ulcer in terms of time and cause? What does it look like?

Answer 108

1) It is a squamous cell carcinoma of the skin developing in a chronic leg ulcer
2) The classic setting is one of many years of healing and breaking down, such as seen in untreated third-degree burns that underwent spontaneous healing, or in chronic draining sinuses secondary to osteomyelitis
3) A dirty-looking, deeper ulcer develops at the site, with heaped up tissue growth around the edges

Question 109

What is diagnostic of a Marjolin ulcer? What is the treatment?

Answer 109

1) Biopsy is diagnostic

2) Wide local excision and skin grafting are done

Question 110

Who (age, weight) does plantar fasciitis typically affect and what do they complain of? When is the pain worse?

Answer 110

1) It is a very common but poorly understood problem affecting older, overweight patients who complain of disabling, sharp heel pain every time their foot strikes the ground
2) The pain is worse in the mornings

Question 111

What do X-rays show for plantar fasciitis? Is the bony spur the problem? How long will it take for spontaneous resolution and what can be offered as treatment during this time?

Answer 111

1) X-rays show a bony spur matching the location of the pain, and physical exam shows exquisite tenderness to palpation over the spur
2) The bony spur is not the cause of the problem (many asymptomatic people have similar spurs)
3) Spontaneous resolution can be expected in 12 to 18 months, during which time symptomatic treatment is offered, and removal of the bony spur may help

Question 112

What is a Morton neuroma? Is it palpable and is it tender? What is the typical cause? What does conservative management include and what can be done if needed?

Answer 112

1) Inflammation of the common digital nerve at the third interspace, between the third and fourth toes
2) The neuroma is palpable as a very tender spot there
3) Pointed, high-heeled shoes (or pointed cowboy boots) that force the toes to be bunched together
4) Conservative management includes analgesics and more sensible shoes, but, if needed, surgical excision can be done

Question 113

How does gout present, where does it present commonly, and in whom does it present? What are identified in fluid from the joint? What is treatment? What is used for chronic control?

Answer 113

1) It produces the typical swelling, redness, and exquisite pain of sudden onset at the first metatarsal-phalangeal joint, in a middle-age obese man with high serum uric acid
2) Uric acid crystals are identified in fluid from the joint
3) Treatment for the acute attack is done with indomethacin and colchicine
4) Allopurinol and probenicid are used for chronic control