Board Review Ortho

8/10/2019 Board Review Ortho

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SPORTS MEDICINE/ORTHOPEDICS

Board Review



5. An 18-year-old female basketball player comes to

your office the day after sustaining an inversion injury

to her ankle. She says she treated the injury overnightwith rest, ice, compression, and elevation. You examine

her and diagnose a moderate to severe lateral ankle

sprain. In addition to rehabilitative exercises, you

advise

A) a short-term cast

B) a posterior splint that allows no flexion or extension

C) a semi-rigid stirrup brace (Air-Stirrup)

D) an elastic bandageE) no external brace or support



ANSWER: C

In acute ankle sprains, functional treatment with

a semi-rigid brace (Aircast) or a soft lace-up

brace is recommended over immobilization.

Casting or posterior splinting is no longerrecommended. Elastic bandaging does not offer

the same lateral and medial support. External

ankle support has been shown to improve

proprioception.



37. A 20-year-old female long-distance runner

presents with a 3-month history of

amenorrhea. A pregnancy test is negative, and

other blood work is normal. She has no other

medical problems and takes no medications.

With respect to her amenorrhea, you adviseher

A) to increase her caloric intake

B) that this is a normal response to trainingC) to begin an estrogen-containing oral

contraceptive

D) to stop running



ANSWER: A

Amenorrhea is an indicator of inadequate calorie intake,

which may be related to either reduced food

consumption or increased energy use. This is not a

normal response to training, and may be the first

indication of a potential developing problem. Young

athletes may develop a combination of conditions,including eating disorders, amenorrhea, and

osteoporosis (the female athlete triad). Amenorrhea

usually responds to increased calorie intake or a

decrease in exercise intensity. It is not necessary forpatients such as this one to stop running entirely,

however



45. A 56-year-old African-American male has pain and

tingling in the medial aspect of his ankle and the

plantar aspect of his foot. He jogs 3 miles daily and

has no history of any injury. The symptoms are

aggravated by activity, and sometimes keep him

awake at night. The only findings on examination are

paresthesias when a reflex hammer is used to tap just

inferior to the medial malleolus.

This patient probably has

A) a stress fractureB) a herniated nucleus pulposus at L5 or S1

C) plantar fasciitis

D) diabetic neuropathy

E) tarsal tunnel syndrome



ANSWER: E

Entrapment of the posterior tibial nerve or its branches as the nerve

courses behind the medial malleolus results in a neuritis known astarsal tunnel syndrome. Causes of compression within the tarsal

tunnel include

varices of the posterior tibial vein, tenosynovitis of the flexor tendon,

structural alteration of the tunnel secondary to trauma, and direct

compression of the nerve. Pronation of the foot causes pain and

paresthesias in the medial aspect of the ankle and heel, and

sometimes the plantar surface of the foot.

The usual site for a stress fracture is the shaft of the second, third, or

fourth metatarsals.

A herniated nucleuspulposus would produce reflex and sensorychanges. Plantar fasciitis is the most common cause of heel pain in

runners and often presents with pain at the beginning of the workout.

The pain decreases during running only to recur afterward.

Diabetic neuropathy is usually bilateral and often produces

paresthesias and burning at night, with absent or decreased deeptendon reflexes.



81. A 32-year-old female who is an avid runner

presents with knee pain. You suspect

patellofemoral pain syndrome. Which one ofthe following signs or symptoms would

prompt an evaluation for an alternative

diagnosis?

A) Peripatellar pain while running

B) Knee stiffness with sitting

C) A “popping” sensation in the knee D) “Locking” of the joint

E) A positive “J” sign (lateral tracking of the

patella when moved from flexion to full extension)



ANSWER: D

Patellofemoral pain syndrome is a clinical diagnosis and

is the most common cause of knee pain in the

outpatient setting. It is characterized by anterior knee

pain, particularly with activities that overload the joint,

such as stair climbing, running, and squatting. Patients

complain of “popping,” “catching,” “stiffness,” and“giving way.” On examination there will be a positive “J”

sign, with the patella moving from a medial to a lateral

location when the knee is fully extended from the 90°

position. This is caused by an imbalance in the medialand lateral forces acting on the patella. “Locking” is not

characteristic of patellofemoral pain syndrome, so loose

bodies or a meniscal tear should be considered if this is

found.



84. A 22-year-old male with no previous history

of shoulder problems is injured in a fall. He

has immediate pain and is unable to abducthis arm. He goes to the emergency department

and an MRI reveals an acute tear of the rotator

cuff. Which one of the following is the best

initial treatment for this injury?

A) Observation without treatment for 1 month

B) Immobilization for 1 month

C) Physical therapy for 1 month

D) Corticosteroid injection

E) Surgical repair



ANSWER: E

An acute rupture of any major tendon should

be repaired as soon as possible. Acute tears of

the rotator cuff should be repaired within 6

weeks of the injury if possible (SOR C).Nonsurgical management is not recommended

for active persons. Observing for an extended

period will likely lead to retraction of the

detached tendon, possible resorption of tissue,and muscle atrophy.



131. You see a 5-year-old white female with

in-toeing due to excessive femoral

anteversion. She is otherwise normal andhealthy, and her mobility is unimpaired. Her

parents are greatly concerned with the

cosmetic appearance and possible future

disability, and request that she be treated.

You recommend which one of the following?

A) ObservationB) Medial shoe wedges

C) Torque heels

D) Sleeping in a Denis Browne splint for 6

months



ANSWER: A

There is little evidence that femoral anteversion causeslong-term functional problems. Studies have shown

that shoe wedges, torque heels, and twister cable splints

are not effective. Surgery should be reserved for

children 8 –10 years of age who still have cosmeticallyunacceptable, dysfunctional gaits. Major complications of

surgery occur in approximately 15% of cases, and can

include residual in-toeing, out-toeing, avascular necrosis

of the femoral head, osteomyelitis, fracture, valgus

deformity, and loss of position. Thus, observation alone is

appropriate treatment for a 5-year-old with

uncomplicated anteversion.





169. In a preadolescent athlete, sudden death

from a blunt injury to the chest (commotio

cordis) is most likely to occur in which one of

the following situations?

A) A pitcher is struck by a line driveB) A basketball player is struck by the ball

C) A chest-to-chest collision occurs during a

soccer game

D) Hockey players skate into each otherE) A football player is struck by the shoulder pad

of a lineman



ANSWER: A

Commotio cordis usually results from impact with

a projectile in sports. Children and adolescents

may have increased risk due to a compliant chest

wall. Ventricular fibrillation is thought to resultfrom the impact. Softer “safety” baseballs are one

consideration in primary prevention.

Older competitors are at less risk. Large bluntobjects or body-to-body contact also carries less

risk.



216. An overweight 13-year-old male presents with a 3-

week history of right lower thigh pain. He first noticed

the pain when jumping while playing basketball, but

now it is present even when he is just walking. Onexamination he can bear his full weight without an

obvious limp. There is no localized tenderness, and the

patella tracks normally without subluxation. Internal

rotation of the hip is limited on the right side comparedto the left. Based on the examination alone, which one

of the following is the most likely diagnosis?

A) Avascular necrosis of the femoral head (Legg-Calvé-

Perthes disease)

B) Osteosarcoma

C) Meralgia paresthetica

D) Pauciarticular juvenile rheumatoid arthritis

E) Slipped capital femoral epiphysis



ANSWER: E

This is a classic presentation for slipped capital femoral epiphysis

(SCFE) in an adolescent male who has probably had a recent growth

spurt. Pain with activity is the most common presenting symptom, asopposed to the nighttime pain that is typical of malignancy. Obese

males are affected more often. The pain is typically in the anterior thigh,

but in a high percentage of patients the pain may be referred to the

knee, lower leg, or foot. Limited internal rotation of the hip, especially

with the hip in 90° flexion, is a reliable and specific finding for SCFEand should be looked for in all adolescents with hip, thigh, or knee pain.

Meralgia paresthetica is pain in the thigh related to entrapment of the

lateral femoral cutaneous nerve, often attributed to excessively tight

clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis ofthe femoral head) is more likely to occur between the ages of 4 and 8

years. Juvenile rheumatoid arthritis typically is associated with other

constitutional symptoms including stiffness, fever, and pain in at least

one other joint, with the pain not necessarily associated with activity.



237. A 7-year-old male is brought to your office

after hurting his hand when he fell on a wet kitchen

floor. He is unable to describe the mechanism of

injury. On examination the maximal point of

tenderness is at the third metacarpal-phalangeal

joint, which also has some generalized swelling but

no ecchymosis. Range of motion is limited in this

joint due to pain. A radiograph of the hand is

shown in Figure 7. Which one of the following isthe most likely diagnosis?

A) Boxer’s fracture

B) Greenstick fracture

C) Salter type II fractureD) Spiral fracture

E) No abnormality



ANSWER: C

Recognizing common fracture types is an important part

of determining how to proceed when caring for an

injured patient. Fractures in children can be different

from those in adults for several reasons, including the

elasticity of immature bone, the possibility of child

abuse, and the presence of growth plates. Theradiograph shown with this question is an example of a

fracture through the growth plate. Approximately 6% –

7% of such fractures will cause a restriction of growth.

The Salter classification system was developed toclassify fractures into the growth plate and can be used

to estimate the risk of growth restriction. The higher the

classification, the greater the risk of complications.





5. A 15-year-old white male complains of

bilateral foot pain. He does not recall any

injury, and the pain improves with rest.Examination reveals tenderness over the

lateral and anterior ankle, along with a rigid

flatfoot, peroneal tightness, and pain on foot

inversion. The most likely diagnosis is

A) tarsal coalition

B) stress fractureC) plantar fasciitis

D) turf toe

E) foot sprain



ANSWER: A

Tarsal coalition is the fusion of two or more of the tarsal bones. It is congenital, and

50% of the time is bilateral. It is asymptomatic until early adolescence. On clinical

examination there is tenderness over the subtalar joint (lateral and anterior ankle),rigid flatfoot, limited subtalar motion, peroneal tightness, and pain on foot inversion.

Treatment is conservative.

A stress fracture would present with pain in the forefoot, warmth, mild swelling, and

point tenderness over the affected metatarsals, most commonly the second or third.

Radiographs are often negative initially, but a callus is usually evident by the thirdweek of symptoms.

Plantar fasciitis presents with pain in the heel or sole of the foot and is most painful

with the first step after arising from bed or prolonged sitting. It may be associated

with pes planus (flat foot), but in plantar fasciitis the flat foot is flexible, not rigid.

Turf toe is inflammation of the first metatarsophalangeal joint due to acute and/or

repetitive hyperextension injury resulting from sudden toe-off against an unyielding

surface, such as artificial turf. The patient may present acutely with a tender, red,

swollen first metatarsophalangeal joint, with pain on passive extension. Others may

develop a chronic condition and present with hallux rigidus. Foot sprain is a

nonspecific term for an acute ligamentous injury.



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8. Which one of the following is characteristic

of osteoarthritis of the knee?

A) Greater frequency in men than in women

B) Increased pain with rest

C) A direct correlation between radiographic

changes and pain severity

D) Reduction of pain with repair of associated

meniscal tears

E) Reduction of pain with muscle strengthening





30. A 62-year-old white female presents to your office

with moderately severe knee pain. She has a history of

osteoarthritis and is not aware of any recent injury. The

pain bothers her both during the day and at night.

Examination reveals a moderately obese female with a

normal knee examination except for tenderness in the

medial tibial plateau region, approximately 3 cm (1½ in)

below the medial joint line of the knee. The area of

tenderness is about the size of a quarter. All ligaments of

the knee are intact on examination. There is no knee

effusion. A radiograph is negative except for minimal

degenerative changes. Which one of the following should

you suspect?

A) De Quervain’s tendinitis

B) Prepatellar bursitis

C) Bursitis of the medial collateral ligament

D) Anserine bursitis



ANSWER: D

Anserine bursitis is characterized by pain, particularly at night, that

occurs in the medial knee region over the upper tibia. It is locatedabout 2 –3 cm below the medial joint line. It can be bilateral. A

diagnosis of anserine bursitis requires local tenderness confined to a

quarter-sized area of the medial tibial plateau, approximately 3 cm

below the medial joint line; a negative valgus stress maneuver, which

indicates an intact medial collateral ligament; and a normalradiograph of the tibia indicating no underlying pathology. De

Quervain’s tendinitis is located in the wrist region, not the knee.

Prepatellar bursitis is characterized by knee swelling and pain over

the front of the knee. Bursitis that occurs adjacent to the medial

collateral ligament typically presents with tenderness over the medial

aspect of the knee. Medial joint line pain is

characteristic of osteoarthritis, second and third degree medial

collateral ligament injuries, medial meniscal tears, and fractures of

the tibial plateau.





49. A 14-year-old male who is active in sports most of

the year presents with bilateral anterior knee pain

that is worse in the right knee. An examinationreveals tenderness and some swelling at the tibial

tubercles. Which one of the following is true

regarding this patient’s condition?

A) It is almost never seen in adultsB) Treatment with a straight leg cylinder cast for 6 weeks

is often needed

C) Corticosteroid injection of the tibial tubercle is a safe

and effective treatmentD) Radiographs should always be ordered to rule out

other conditions

E) Bilateral symptoms are unusual



ANSWER: A

Osgood-Schlatter disease is encountered in patients

between 10 and 15 years of age. These patients are

often active in sports that involve a lot of jumping. It is

thought to be secondary to repetitive microtrauma and

traction apophysitis of the tibial tuberosity. Bilateral

symptoms are present in 20% –30% of patients.Radiographs may reveal abnormalities, but are rarely

indicated in straightforward cases. This condition is

usually self-limited, and most patients are able to return

to full activity within 2 –3 weeks. Treatment includesrest, ice, anti-inflammatory medications, a rehabilitation

program, and an infrapatellar strap during activities.

Casting and corticosteroid injections are not indicated.



56. Which one of the following is a

contraindication to participation in

contact sports?

A) A single testicle

B) FeverC) Documented scoliosis of 20º

D) Sickle cell trait



ANSWER: B

Having a single testicle is not a contraindication to contact sports,

but it does necessitate a discussion regarding the potential risk, as

well as the use of a protective cup. A single ovary is not a

contraindication because it is well protected.

Fever is a contraindication to participation since it increases

cardiovascular effort, as well as the potential for heatstroke and

orthostatic hypotension and dehydration. The rare possibility of anassociated myocarditis also should be taken into account. Carditis

may result in sudden death with exertion.

Scoliosis should be looked into prior to allowing a child to participate

in contact sports, but once the diagnosis is made it is rarely acontraindication unless the curvature is greater than 40º.

Sickle cell trait is not a contraindication to contact sports, although

sickle cell disease can be a contraindication to

strenuous activities or sports associated with significant contact.



64. The most effective means of preventing

sudden death in high-risk patients with

asymptomatic hypertrophic cardiomyopathyis

A) amiodarone (Cordarone)

B) metoprolol (Lopressor)C) verapamil (Calan, Isoptin)

D) chronic dual-chamber pacing

E) an implantable cardioverter-defibrillator (ICD)



ANSWER: E

Many patients with hypertrophic cardiomyopathy (HCM) never have

any clinical signs or symptoms. The major cause of mortality is sudden

death, which can occur in both asymptomatic and symptomaticpatients, often after physical exertion. Patients with HCM should be

counseled about the risk of competitive sports and dehydration.

Medications such as verapamil, ß-blockers, and diltiazem are used for

symptom management, but do not decrease the risk of sudden death.

Because of its effects on decreasing dysrhythmias, amiodarone maydecrease the risk of sudden death, which is supported by anecdotal

data.

For most patients with HCM, the annual risk of dying is similar to that

of the normal adult population, or 1% per year. Patients most at risk for

sudden death include those with ventricular tachycardia on anambulatory monitor, marked left ventricular hypertrophy, abnormal

blood pressure response to exercise, syncope, and a family history of

sudden death. At present, the implantable cardioverter-defibrillator

(ICD) is the most effective modality for preventing sudden death in

high-risk patients with asymptomatic HCM. Pacing does not reduce

risk significantly.





75. A 43-year-old house painter presents with

chronic pain in the radial aspect of the wrist,

radiating down the thumb. Her symptoms are

worsened with pinching and with wrist movement.

She has had to quit her job due to the severity of

symptoms. On examination she has pain in the

thumb with opening and closing her hand, and a

Finkelstein’s test is positive. The most effectivetreatment for this patient would be

A) rest

B) NSAIDsC) splinting

D) local corticosteroid injection



ANSWER: D

The history and physical findings are mostconsistent with de Quervain’s tenosynovitis,

which affects the abductor pollicis longus and the

extensor pollicis longus and brevis tendons.

Local corticosteroid injection is the most effectivetreatment. NSAIDs and splinting may be

somewhat effective for mild cases, but are less

effective than corticosteroids. Rest alone has not

been shown to be very helpful.



86. A 6-year-old female is brought to your office for

recurring limb pain. For the past 2 weeks she has

complained of cramping pain in her thighs and calves,

which has caused her to awaken at times. Massage

and occasional acetaminophen help. In the morning

the symptoms are gone and daily activity is

unimpaired. Her physical examination is normal. On

examination she has no inflammatory signs and no joint or muscle tenderness. Which one of the

following would be most appropriate at this point?

A) Radiographs of the hips and knees

B) An erythrocyte sedimentation rate

C) A CBC

D) Antinuclear antibody (ANA) testing

E) No further testing



ANSWER: E

This patient is experiencing benign nocturnal pains of

childhood, formerly called “growing pains.” These arecramping pains of the thigh, shin, and calf, and affect

approximately 35% of children 4 –6 years of age. The pain

typically occurs in the evening or at night, may awaken the

child from sleep, and disappears by morning. This classic

presentation in the absence of other inflammatory or chronicsigns and symptoms should reinforce the benign nature of this

condition. Physical findings are normal, so in the absence of

worrisome complaints or anatomic abnormalities no further

diagnostic testing is required. Parents should be reassured

that there are no long-term sequelae. If activity is impaired,the physical examination is abnormal, or any constitutional or

systemic complaints are present, then further evaluation with

additional testing is indicated, and may include an erythrocyte

sedimentation rate, CBC, antinuclear antibody, or radiographs

of affected bones or joints.



90. A 5-year-old male is brought to your office

with forearm pain after a fall, and you

diagnose a non-angulated buckle fracture ofthe distal radius and ulna. Which one of the

following treatments has the best functional

outcome at 3 –4 weeks?

A) An ACE wrap

B) A removable splint

C) A long arm castD) A thumb spica cast

E) Surgical reduction and internal fixation



ANSWER: B

Although casting for 3 –4 weeks with a short armcast has been the traditional treatment for

buckle fractures of the wrist, functional outcome

in the short term is better with a simple

removable splint, and management is easier.Long-term outcomes are good with either

treatment. Rigid splinting adds to short-term

functional stiffness, and a wet cast or foreign

bodies placed between the cast and skin

necessitate additional visits. Surgical

approaches are contraindicated and would not

improve healing or position.



96. A healthy 25-year-old female runner

presents with a complaint of right heel pain

for 2 months. The pain is most pronouncedwith the first steps of the day or after periods

of rest, and is located around the medial

calcaneal tuberosity. Which one of the

following is NOT recommended for acutetreatment?

A) Extracorporeal shock wave therapy

B) Prefabricated insoles (heel pad)

C) Night splints

D) Corticosteroid iontophoresis

E) NSAIDs



ANSWER: A

These findings are classic for plantar fasciitis.Treatments in the acute phase include insoles,

night splints, corticosteroid iontophoresis, and

NSAIDs. Based on current evidence,

extracorporeal shock wave therapy isrecommended only after 12 months of symptoms.



99. A 10-year-old male is brought to your

office with pain and swelling of the knee

after falling out of a tree. A physicalexamination is notable for point tenderness

and swelling at the proximal tibia. A

radiograph shows a displaced fracture of the

proximal tibia through the physis andepiphysis. The most appropriate

management is

A) a long leg castB) a rigid knee immobilizer

C) a functional (hinged) knee immobilizer

D) orthopedic referral



ANSWER: D

Physeal injuries are unique to children, and account for approximately one-

fourth of all pediatric fractures. This child has a Salter-Harris fracture that

requires referral to an orthopedist. Salter-Harris type I injury is a fracturethrough the hypertrophic cartilage that causes widening of the physeal space.

These fractures

are difficult to diagnose radiographically, but their clinical hallmark is point

tenderness at the epiphyseal plate. Type II fractures are the most common,

and extend through both the physis and metaphysis. Although these fractures

may result in some shortening, they rarely cause functional deformities. Type III injuries extend through the physis and epiphysis, disrupting the reproductive

layer of the physis. These injuries may cause chronic sequelae because they

disrupt the articular surface of the bone, but they do not produce deformities

and generally have a good prognosis. Type IV injuries cross through the

epiphysis, physis, and metaphysis. These fractures are also intra-articular,

increasing the risk for chronic disability. They can disrupt the proliferative zone,leading to early fusion and growth deformity. Type V fractures are the least

common but most difficult to diagnose, and have the worst prognosis. The

classic mechanism of injury is an axial force that compresses the epiphyseal

plate without an overt fracture of the epiphysis or metaphysis.



105. A 76-year-old male has fallen twice as a result of buckling

of the left knee during ambulation. Neither fall resulted in injury,

and he is advised to use an offset walking cane. The patient is

left hand –dominant and has normal strength in all four

extremities. Crepitus is present in both knees, but is much more

pronounced in the left knee. Which one of the following

describes the best method for use of a cane by this patient?

A) Place the cane in the left hand and advance it at the same time as

the left legB) Place the cane in the left hand and advance it at the same time as

the right leg

C) Place the cane in the right hand and advance it at the same time

as the left leg

D) Place the cane in the right hand and advance it at the same timeas the right leg

E) Switch the cane between hands at intervals of several hours to

distribute the load equally



ANSWER: C

The standard walking cane generally is designedas a tool to aid in balance and, to a lesser degree,

reduce weight bearing on a specific leg. The offset

cane design results in the downward force vector

being placed directly over the shaft, making thischoice ideal where improved balance and

reduction of weight bearing on a particular leg is

desired. Mechanical advantage produces

maximum benefit when the cane is placed in thehand opposite the most severely affected leg, and

the movement of the cane tracks the movement of

the affected leg, consistent with normal gait.



122. Little League elbow refers to a

problem located over the

A) medial epicondyle

B) lateral epicondyle

C) olecranonD) capitellum

E) ulnar groove



ANSWER: A

Little League elbow is an apophysitis of themedial epicondyle of the elbow. It occurs in

throwing athletes between 9 and 12 years of

age, and causes elbow pain during throwing. It

may also affect velocity and control. It maycause pain and swelling in the arm and/or elbow,

but the diagnosis should be considered in

throwing athletes with elbow pain even if

symptoms are minimal.



127. A 72-year-old white female is experiencing pain

due to a vertebral compression fracture. Pain control

with opioid analgesics and calcitonin therapy is not

adequate. Which one of the following would make

vertebroplasty an appropriate option?

A) Fracture duration <6 months

B) Degree of vertebral collapse 80%C) Radiologic evidence of destruction of the posterior

vertebral wall

D) New-onset bladder dysfunction thought to have a

neurologic etiologyE) New-onset bilateral lower-extremity paresis



ANSWER: A

Vertebroplasty is a reasonable therapeutic consideration for

vertebral compression fractures if pain is not adequatelycontrolled with analgesics and conservative therapy. Some

studies indicate a better response with less chronic fractures.

Treatment of fractures less than 6 months old is acceptable.

More prolonged conservative therapy with an inadequate

response is not appropriate. Neurologic dysfunction, includingbladder dysfunction, paralysis, and sensory deficits, is a relative

contraindication to vertebroplasty. Spinal cord compression

requires other treatment, and high degrees of compression

(>67%) are not amenable to this therapy. Destruction of the

posterior wall is a contraindication to this therapy because the

injected polymethyl methacrylate should not directly contact the

spinal cord. Coagulopathies and infectious processes are also

contraindications.



138. A high-school gymnast presents to your office with

a history of back pain for the past 3 –4 weeks. She

reports that symptoms are worse with any

hyperextension activity. Examination demonstrates ahyperlordotic posture with mild tenderness in the lower

lumbar spine. Radiographs demonstrate the classic

“Scotty dog with a collar” appearance of spondylolysis.

Which one of the following statements about thisdiagnosis is true?

A) Most athletes can resume full activity in 4 –6 weeks

B) Spondylolisthesis >25% requires referral to a spine

surgeonC) Inadequate treatment can lead to complete fracture and

spondylolisthesis with prolonged disability

D) Adolescents should be followed with serial CT every 6

months until they reach skeletal maturity



ANSWER: C

Complete fracture and spondylolisthesis with prolongeddisability may occur if spondylolysis is not diagnosed

early and treated appropriately. Most athletes respond to

conservative management and return to full activity

approximately 6 months after diagnosis. Treatment for

low-grade spondylolisthesis (up to 50% slippage) issimilar to treatment for spondylolysis. Patients should be

followed with serial radiographs at 6-month intervals until

they reach skeletal maturity. Patients with a high-grade

slippage (>50%) may need to be comanaged by anorthopedic or spine surgeon to guide treatment and

assist in

return-to-play decisions.





SPONDYLOLYSIS



SPONDYLOLISTHESIS

Graded according to itsdegree of severity. TheMyerding gradingsystem measures thepercentage of vertebral

slip forward over thebody beneath. Thegrades are as follows:

Grade 1: 25%Grade 2: 25% to 49%Grade 3: 50% to 74%Grade 4: 75% to 99%Grade 5: 100%*



143. A 70-year-old retired farmer presents with

an angulated right knee and a painful hip. He

asks you about the possibility of “getting anew knee,” although he is not eager to do so.

You would advise him that the major indication

for knee replacement is

A) severe joint pain at rest

B) marked joint space narrowing seen on

radiologic studies

C) destruction and loss of motion of thecontralateral joint

D) an acutely infected joint







155. You see a 16-year-old white female for a

preparticipation evaluation for volleyball. She

is 183 cm (72 in) tall, and her arm span isgreater than her height. She wears contacts

for myopia. Which one of the following should

be performed at this time?

A) An EKG

B) Echocardiography

C) A stress test

D) A chest radiograph

E) Coronary MRI angiography





174. A 16-year-old male comes to your office after

suffering an eversion injury to his ankle while being

tackled in a football game 3 days ago. He was not

able to bear weight after the injury and now has

tenderness at the distal tibiofibular joint with no

swelling. Compression of the fibula against the tibia

at the mid-calf elicits pain anterior to the lateral

malleolus and proximal to the ankle joint. Stabilizingthe leg and rotating the foot externally elicits pain at

the same location. Radiographs are negative. Which

one of the following would be most appropriate at

this point?

A) Application of an elastic wrap to the ankle for 2 weeks

B) Therapeutic ultrasound

C) Stress radiographs

D) A CT scan



ANSWER: E

Syndesmotic (high ankle) sprains account for as many as 11% of ankle sprains.

The mechanism of injury is dorsiflexion and/or eversion of the ankle, most

commonly in contact sports. The syndesmotic structures include the anterior,

posterior, and transverse tibiofibular ligaments, as well as the interosseous

membrane.

These injuries can cause chronic ankle instability, resulting in recurrent sprains

and hypertrophic ossification. The diagnosis can be made by several tests. The

squeeze test can be performed by compressing the fibula against the tibia at

mid-calf. A positive test occurs when this elicits pain in the region of the anterior

tibiofibular ligament. A positive external rotation stress test causes pain at the

same site. It is performed by stabilizing the leg and externally rotating the foot.

The crossed-leg test can also detect this injury. The patient places the involved

ankle on the opposite knee and pressure is applied to the medial side of the

involved ankle, which causes pain at the syndesmosis. While ankle support isoften useful for less serious sprains, a Cochrane review showed that semirigid

supports are better than elastic bandages. Therapeutic ultrasound has not

been shown to have any value for ankle sprains. The injury can be confirmed

with an MRI. Indications for referral to an orthopedic surgeon include fracture,

dislocation or subluxation, syndesmotic injury, tendon rupture, and uncertain

diagnosis.



ANSWER: C



ANSWER: C

The combination of a painful arc and pain on use of the

supraspinatus muscle indicates impingement syndrome,which is due to irritation of the rotator cuff under the

coracoacromial arch. It is by far the most common cause

of shoulder pain seen by family physicians. Subdeltoid

bursitis is a much more acute problem, and impairs

shoulder mobility in all directions. Adhesive capsulitis

produces loss of external rotation. Glenohumeral arthritis

produces pain with external rotation, and variable

amounts of impaired mobility, depending on progression

of the problem over time. Acromioclavicular joint arthritisproduces a positive scarf sign, and often a visible bump

over the joint, since it lies so close to the skin surface.



195. A 65-year-old female presents with a complaint

of slowly increasing discomfort in her knees of 3

years’ duration. An examination and radiograph are

consistent with noninflammatory osteoarthritis. Shesays that the pain is well-controlled with

acetaminophen, but she wants to know what can be

done to prevent further damage to the joint. You

recommend

A) referral to a rheumatologist for disease-modifying

agents such as methotrexate

B) hyaluranon injections to preserve cartilage

C) corticosteroid injections

D) symptomatic measures only



ANSWER: D

Osteoarthritis is a common finding in older people; some studies show

that 25% of patients over age 65 have osteoarthritic changes.Unfortunately, no pharmacologic treatments have been found to prevent

the progression of joint destruction. Maintaining ideal weight and

avoiding excessive use of the knees, including deep knee bends,

running, and stair climbing, does lessen destructive forces on the joint. A

reasonable walking program can improve both pain and joint function.

Acetaminophen is the first choice for joint pain in someone with

noninflammatory osteoarthritis. NSAIDs provide better pain relief but can

cause renal damage, fluid retention, and GI bleeding, and are therefore

reserved as a second-line treatment. Narcotics usually are reserved for

short-term use during flares of arthritis. Studies show that injections of

corticosteroids or hyaluranons improve symptoms for some, but have notbeen shown to lessen joint destruction. Disease-modifying agents, such

as methotrexate, can help inflammatory arthritic joints, as in psoriatic

arthritis and rheumatoid arthritis, but have not been shown to

be of benefit in osteoarthritis.





202. A positive Lachman test indicates injury

to the

A) medial collateral ligament

B) posterior cruciate ligament

C) medial meniscus

D) anterior cruciate ligament

E) lateral collateral ligament



ANSWER: D

The Lachman test is performed with the knee flexed to25º- 30º while the examiner grasps the distal femur in one

hand and the proximal tibia in the other. While the femur

is held stationary, the tibia is pulled anteriorly, using a

“shucking” action. If a distinct end point is reached, as if a

piece of loose rope suddenly becomes taut, the test is

negative or normal. A soft or indistinct end point, as if

stretching an elastic band, is a positive or abnormal test

that indicates a ruptured anterior cruciate ligament. In this

case, the anterior drawer test would also be positive, butit is not as specific as the Lachman test. Injuries to the

other structures listed are diagnosed using other

maneuvers, and are not associated with a positive

Lachman test.

207 A 16 ld hi h h l b k tb ll l i



207. A 16-year-old high-school basketball player is

struck on the end of her long finger by the ball. Her

finger was fully extended and the result was a forced

flexion injury of the proximal interphalangeal (PIP) joint.She is unable to actively extend the PIP joint, although

passive extension is possible. She is tender over the

dorsal aspect of the middle phalanx. Radiographs are

negative. Which one of the following is true regarding

this injury?

A) Immediate referral to an orthopedist is indicated

B) Buddy taping to the adjacent ring finger is the only

treatment necessary

C) Any splint (fashioned aluminum splint, stack splint, ringsplint) would be adequate

D) Splinting should be continued for 2 weeks

E) A boutonniere deformity may result

ANSWER: E



ANSWER: E

An injury to the central extensor slip can occur when the

proximal interphalangeal (PIP) joint is forcibly flexed whilethe digit is actively extended. The injury is evaluated by

holding the joint in a position of 15º –30º of flexion. The

patient will not be able to actively extend the joint, but

passive extension should be possible. There will be

tenderness over the dorsal aspect of the middle phalanx.

Delay or improper treatment may result in a boutonniere

deformity, which usually develops over several weeks but

can occasionally develop acutely. Treatment consists of

splinting the PIP joint in full extension for 6 weeks. Thestack splint should only be used to treat injuries of the

distal interphalangeal joint.





Mallet finger Tx - Stack splint for 6 weeks

Boutonnière deformity Tx: PIP joint splint for 6 weeks



229. A 25-year-old runner complains of non-

focal knee pain. She does not remember any

specific injury. You suspect patellofemoralpain syndrome.

Which one of the following would be most

consistent with this diagnosis?

A) Pain with prolonged sitting

B) Swelling

C) Locking

D) Giving way



ANSWER: A

Patellofemoral pain syndrome causes nonfocalor anterior knee pain, and is often seen in

runners. Common symptoms include stiffness,

pain with prolonged sitting, and pain with

climbing or descending stairs. Rarely is thereswelling, locking, or giving way; these symptoms

are more likely to be associated with more

profound problems such as a ligament or

cartilage tear.



233. A 53-year-old Hispanic male presents with a 3-

day history of right shoulder pain. The pain started

shortly after he caught himself when he fell coming

down his front steps. Radiographs of the shoulder arenormal. Which one of the following, if present, would

be most suggestive of a rotator cuff tear?

A) Inability to flex at the elbow against resistanceB) Signs of decreased arterial perfusion of the hand

C) Swelling of the acromioclavicular joint

D) Weakness in external rotation of the shoulder

ANSWER: D



ANSWER: D

Shoulder pain after a fall may result from a strained

muscle or ligament, an exacerbation of a smolderingsubacromial bursitis or tendinitis, or a tear of the rotator

cuff. Often there is a combination of two or three of these

conditions. If the rotator cuff tear is small, treatment is

similar to that recommended for the other conditions.However, if a significant rupture has occurred,

immobilization and/or surgical consultation is appropriate.

On physical examination, a painful arc of abduction above

90º and weakness in external rotation would be expected

with a torn rotator cuff. Of these two, weakness in

external rotation is much more specific.

238 A 32-year-old male comes to your



238. A 32-year-old male comes to your

office for the second time for wrist pain

following a fall on the ice 10 days ago. At

his first visit, examination of the wrist

showed no deformity or swelling, butextension was decreased and he had

diffuse tenderness over the dorsum of

the wrist, particularly just distal and

dorsal to the radial styloid. A radiograph

is shown.

Which one of the following do the

radiographs reveal?

A) A dislocated lunate

B) A fracture of the scaphoid

C) A hamate fractureD) A scapholunate dislocation



Metacarpal Anatomy

ANSWER: B



ANSWER: B

A dorsiflexion injury will typically cause a scaphoid fracture

in a young adult, resulting in tenderness to palpation overthe anatomic snuffbox. Often the plain posterior-anterior

wrist radiograph is normal. However, a special view with

the wrist prone in ulnar deviation elongates the scaphoid,

often demonstrating subtle navicular fractures. Hook of

the hamate fractures cause tenderness at the proximal

hypothenar area 1 cm distal to the flexion crease of the

wrist. When this fracture is suspected, carpal tunnel and

supinated oblique view radiographs should be obtained. A

scapholunate dislocation can be identified with a“clenched-fist” view and the supinated view in ulnar

deviation.



Scapholunate dislocation Normal

OTTAWA ANKLE AND FOOT RULE





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