History & Physical/Orthopedics/Rheumatology
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
Explanations
(c) A. Abduction against resistance tests the supraspinatus.
(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.
(u) C. See B for explanation.
(u) D. Medial rotation against resistance tests the subscapularis.
History & Physical/Orthopedics/Rheumatology
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 flexi
Explanations
(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.
(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, h
History & Physical/Orthopedics/Rheumatology
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 t
Explanations
(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.
(u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.
(c) C. Asymmetry of the posterior chest wall on forward bendi
Diagnostic Studies/Orthopedics/Rheumatology
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 horm
Explanations
(u) A. Paget's disease of bone presents with bone pain, kyphosis, bowed tibias, large head, and deafness. The initial lesions are destructive and radiolucent. Paget's disease has a normal serum calcium and phosphate, but the serum alkaline ph
Diagnostic Studies/Orthopedics/Rheumatology
In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is
Answers
A. lateral.
B. oblique.
C. anteroposterior.
D. odontoid.
Explanations
(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.
(u) B. The oblique view is usually not included in the ini
Diagnostic Studies/Orthopedics/Rheumatology
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, th
Explanations
(u) A. X-rays of the lower leg and ankle will only determine bone placement.
(u) B. Doppler studies will confirm the presence of a decreased pulse.
(u) C. A bone scan is not indicated in the evaluation of compartment syndrome.
(c) D. Compartm
Diagnosis/Orthopedics/Rheumatology
A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibia
Explanations
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
(u) B. See A for explanation.
(u) C. Osgood-Schlatter disease is an injury occurring at the insertion of
Diagnosis/Orthopedics/Rheumatology
A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has
Answers
A. carpal tunnel syndrome.
B. radial tunnel syndrome.
C
Explanations
(u) A. Carpal tunnel is diagnosed by a positive Tinel's or Phalen's maneuver.
(u) B. Radial syndrome is demonstrated by simultaneously extending the patient's wrists and fingers while the examiner passively flexes the patient's long finger, w
Clinical Intervention/Orthopedics/Rheumatology
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen's test is positive; however, there is no atrophy of the thena
Explanations
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
(
Clinical Intervention/Orthopedics/Rheumatology
Which of the following is the correct treatment for a Grade II ankle sprain resulting from an inversion injury?
Answers
A. Corticosteroid injection
B. Rest, ice, compression, elevation
C. Moist heat and a wal
Explanations
(u) A. See B for explanation.
(c) B. The majority of ankle sprains are treated with RICE (rest, ice, compression and elevation). Corticosteroid injections, moist heat, and a walking cast provide no benefit. Surgical intervention for repair of
Clinical Intervention/Orthopedics/Rheumatology
A 4 year-old boy presents to the ED after sustaining a crush injury to his distal third phalanx. Physical exam reveals an associated nail bed injury. Which of the following is the appropriate management?
Answ
Explanations
(u) A. Rest, ice, and elevation are only palliative measures and not appropriate management (c) B. Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered "open" and the patient sh
History & Physical/Orthopedics/Rheumatology
Which of the following clinical characteristics is associated with bicipital tendonitis?
A. Aggravated by resisted supination of the forearm
B. Bulging appearance to the proximal arm
C. Weakness of the arm with
Explanations
(c) A. Supraspinatus tendonitis will be aggravated by resisted supination of the forearm.
(u) B. Biceps rupture may present with a bulging appearance of the proximal arm.
(u) C. Weakness of the arm with internal rotation and adduction is char
Health Maintenance/Orthopedics/Rheumatology
Which of the following risk factors is the most predictive for the development of osteoarthritis?
A. Age
B. Major joint trauma
C. Prior inflammatory joint disease
D. Repetitive stress
Explanations
(c) A. Age is the most significant risk factor for osteoarthritis. Prevalence and severity increase with age. Ninety percent of people greater than the age of 40 have degenerative changes of the weight bearing joints. Major joint trauma, prio
Diagnostic Studies/Orthopedics/Rheumatology
The most accurate way to determine the exact degree of spinal curvature in a child with scoliosis is by which of the following?
A. Calculation of the Cobb angle
B. Measurement of waist asymmetry
C. Measurement o
Explanations
(c) A. The scoliotic curve is measured by the Cobb method using AP and lateral x-ray films of the entire length of the spine.
(u) B. While waist asymmetry and rib hump deformity may be observed on physical examination of the patient with scol
Clinical Intervention/Orthopedics/Rheumatology
A 53 year-old female massage therapist presents with new onset of sudden swelling involving the right elbow. She denies previous episodes similar to this. On physical examination, the patient is afebrile. The
Explanations
(c) A. Rest and NSAID is the most appropriate initial intervention in a patient with olecranon bursitis.
(u) B. Surgical excision is reserved for chronic bursitis and is not indicated in this acute initial presentation.
(u) C. Incision and dr
Diagnosis/Orthopedics/Rheumatology
A 30 year-old male sustains a blow to his right lateral leg during a soccer game. He complains of pain with weight bearing. Examination reveals tenderness along the lateral aspect of the right lower leg, but no point ten
Explanations
(u) A. Anterior cruciate ligament injury would have a positive drawer test and mechanism of injury can be due to a direct blow to the knee or as a result of sudden deceleration and rotation of the knee.
(c) B. Isolated fibular fractures can o
Scientific Concepts/Orthopedics/Rheumatology
During the stages of fracture healing which of the following is responsible for producing collagen?
A. Osteoclasts
B. Chondrocytes
C. Glycosaminoglycans
D. Fibroblasts
Explanations
(u) A. Osteoclasts are responsible for removing necrotic bone.
(u) B. Chondrocytes make up the articular cartilage.
(u) C. Glycosaminoglycans help form the osteon or vascular canal.
(c) D. Fibroblasts produce collagen during the inflammation
History & Physical/Orthopedics/Rheumatology
Which of the following mechanisms of action is most commonly associated with meniscal tears?
A. Hyperextension
B. Axial loading and rotation
C. Hyperflexion
D. Valgus force to the lateral knee
Explanations
(u) A. Hyperextension injuries usually result in ACL and PCL injuries.
(c) B. Axial loading and rotation most likely result in meniscal injuries.
(u) C. Hyperflexion injuries result in PCL injuries.
(u) D. Valgus force to the lateral knee mor
Diagnosis/Orthopedics/Rheumatology
A 14 year-old patient, who fell on his outstretched hand, complains of pain along his entire arm. There is point tenderness and swelling over the midshaft of the radius. There is significant pain with limited flexion of
Explanations
(c) A. Galeazzi's fracture/dislocation involves a fracture of the mid or distal radial shaft with distal radioulnar joint dislocation.
(u) B. A scaphoid fracture is a fracture of the scaphoid bone and would not cause pain in the elbow joint.
Diagnostic Studies/Orthopedics/Rheumatology
Which of the following x-ray views will show the presence of a "Scotty dog" deformity seen with spondylolysis?
A. Lateral
B. Oblique
C. Anteroposterior
D. Open-mouth odontoid
Explanations
(u) A. The lateral view is the most appropriate for evaluation of the possible presence of spondylolisthesis, not spondylolysis.
(c) B. Spondylolysis results from a defect through the pars interarticularis, which is seen as a defect in the ne
Clinical Intervention/Orthopedics/Rheumatology
An x-ray taken on a patient complaining of wrist pain after being hit by a baseball reveals a non-displaced mid-shaft ulnar fracture. Which of the following splints is most appropriate for treatment?
A. Thumb
Explanations
(u) A. Thumb spica splints are used for scaphoid fractures.
(c) B. Sugar tong splints are best used to immobilize the elbow, wrist and forearm.
(u) C. Cock-up wrist splints may be useful in some situations unrelated to fractures, such as to i
Diagnosis/Orthopedics/Rheumatology
A 12 year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a sligh
Explanations
(u) A. Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy.
(u) B. Legg-Calve-Perthes disease is avascular necrosis of the hip affecting boys ages 4-1
Clinical Intervention/Orthopedics/Rheumatology
Which of the following interventions is initially indicated for helping to relieve the symptoms of plantar fasciitis?
A. Steroid injections
B. Short leg walking cast
C. Arch supports
D. Surgical release
Explanations
(u) A. Steroid injections can be used to relieve symptoms but may be harmful by causing rupture if given in the plantar tendon greater than 3 or 4 times.
(u) B. Short leg walking cast may be used for severe cases refractory to initial treatme
History & Physical/Orthopedics/Rheumatology
In the neonate, unequal thigh folds may indicate which of the following?
A. Coxa vara
B. Legg-Calve-Perthes disease
C. Developmental hip dysplasia
D. Slipped capital femoral epiphysis
Explanations
(u) A. Coxa vara is a hip deformity that would present with a decrease in the hip angle and a shift of the femoral shaft medially.
(u) B. Legg-Calve-Perthes disease presents with a painless limp in children ages 4-10 due to avascular necrosis
Diagnosis/Orthopedics/Rheumatology
A mother brings her 14 month-old son to your clinic. Earlier today she lifted her son by grabbing him by the wrists and pulling him up off the floor. The child is sitting in his mother's lap with his left forearm is exte
Explanations
(c) A. This clinical history is classic for radial head dislocation or nursemaid's elbow.
(u) B. There is no edema, deformity or erythema to suggest a fractured wrist.
(u) C. Osteochondritis dissecans is avascular necrosis of subchondral bone
Scientific Concepts/Orthopedics/Rheumatology T
In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis?
A. Femur
B. Humerus
C. Vertebral spine
D. Tibia
Explanations
(u) A. Long bones are most commonly affected with osteomyelitis in children.
(u) B. See A for explanation.
(c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach
the well-perfused v
Clinical Therapeutics/Orthopedics/Rheumatology
Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions?
A. Rheumatoid arthritis of the knee
B. Osteoarthritis of the knee
C. Olecranon b
Explanations
(u) A. See B for explanation.
(c) B. Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis
of the knee that have failed other therapies. Although the onset of action of this medic
Diagnosis/Orthopedics/Rheumatology
A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the
proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the pr
Explanations
(u)A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint. (c) B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.
(u) C. A Colles' f
Diagnosis/Orthopedics/Rheumatology
A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibi
Explanations
(c) A. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults.
(u) B. Prepatellar burs
Clinical Intervention/Orthopedics/Rheumatology
Which of the following is the treatment of choice for a torus (buckle) fracture involving the distal radius?
A. Open reduction and internal fixation
B. Ace wrap or anterior splinting
C. Closed reduction and c
Explanations
(u) A. See B for explanation.
(c) B. A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as
painful as unstable fractures. They heal uneventfully in 3-4 weeks.
(u) C. See B for explana
Diagnostic Studies/Orthopedics/Rheumatology
Which of the following views on plain films is preferred to identify spondylolysis?
A. Anterior
B. Posterior
C. Oblique
D. Lateral
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
(u) D. See C for explanation.
Clinical Intervention/Orthopedics/Rheumatology
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 jo
Explanations
(u) A. See B for explanation.
(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.
(u) C. See B for explanation.
(u) D. Short arm casting is indicate
History & Physical/Orthopedics/Rheumatology
A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be
Explanations
(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.
(u) B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is mor
Clinical Intervention/Orthopedics/Rheumatology
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 th
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(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 th
Diagnostic Studies/Orthopedics/Rheumatology
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
Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery.
(c) D. The popliteal artery is at risk fo
History & Physical/Orthopedics/Rheumatology
A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foo
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soles muscles, a
History & Physical/Orthopedics/Rheumatology
A 55 year-old secretary presents with ongoing pain and numbness in her hand. These symptoms are worse at night and she must shake her hand to regain feeling in it. Which of the following physical examination sig
Explanations
(u) A. Hypothenar atrophy may occur with aging and disuse but it is not part of the median nerve involvement that occurs with carpal tunnel syndrome.
(u) B. Finger abduction weakness is associated with ulnar nerve injury, which does not occur
Scientific Concepts/Orthopedics/Rheumatology
Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the
Explanations
(c) A. A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is m
Scientific Concepts/Orthopedics/Rheumatology
Which of the following leads to retropatellar pain?
A. increased Q angle
B. increased quadriceps tone and strength
C. Osgood-Schlatter Disease
D. hamstring stretching
Explanations
(c) A. Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome.
(u) B. Quadriceps strengthening aids in restoring patellofemoral tracking.
(u) C. Osgood
Diagnosis/Orthopedics/Rheumatology
A 14 year-old male who is overweight presents with complaints of left knee and anteromedial thigh pain for the past month. He states the pain gets better with rest and denies any known trauma. On examination of the gait,
Explanations
(u) A. Genu valgum is a knock-knee deformity of the knees and would be detected on physical examination.
(u) B. Legg-Calve-Perthes presents in a younger population.
(u) C. Osgood-Schlatter disease is characterized by local pain, swelling, and
Scientific Concepts/Orthopedics/Rheumatology
Which of the following fractures is associated with the greatest risk of avascular necrosis of the femoral head?
A. intertrochanteric
B. femoral neck
C. subtrochanteric
D. pelvic rim
Explanations
(u) A. See B for explanation.
(c) B. Femoral neck fractures lead to the greatest disruption of arterial blood supply to the femoral head.
(u) C. See B for explanation.
(u) D. See B for explanation.
History & Physical/Orthopedics/Rheumatology
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 20 degrees of flexi
Explanations
(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.
(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, h
History & Physical/Orthopedics/Rheumatology
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.
Explanations
(u) A. Failure of the planes of the fingernails in the partially closed hand to line up indicates rotational misalignment.
(u) B. Fingernails of the open hand normally form an asymmetric arc.
(c) C. All fingernails should point to the same sp
Clinical Intervention/Orthopedics/Rheumatology
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen's test is positive; however, there is no atrophy of the thena
Explanations
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
(
Diagnostic Studies/Orthopedics/Rheumatology
An x-ray reveals a break in the cortex of one side of the ulna shaft without a separation or break of the opposite cortex describes what type of fracture?
A. greenstick
B. transverse
C. torus (buckle)
D. epiphys
Explanations
(c) A. A greenstick fracture is a break in the cortex of one side of bone shaft without a break in the opposite cortex. (u) B. A transverse fracture is a complete fracture of both cortices.
(u) C. A torus fracture is a bowing, bending, or buc
Clinical Therapeutics/Orthopedics/Rheumatology
A 67 year-old female presents with progressive pain in her left knee that is worse with activity and relieved with rest. She notes stiffness of the knee that last about 20 minutes after activity is resumed. S
Explanations
(u) A. Naprosyn is contraindicated in patients with abnormal renal function.
(u) B. Oral prednisone is not appropriate for the long-term management of osteoarthritis.
(c) C. Acetaminophen is recommended as first-line pharmacotherapy in patien
Diagnosis/Orthopedics/Rheumatology
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
Explanations
(u) A. Avascular necrosis is a late complication of fracture resulting from disruption of the blood supply to the bone.
(u) B. Myositis ossificans occurs primarily in muscles post-traumatically and may not arise for several months after an in
Diagnosis/Orthopedics/Rheumatology
A 58 year-old male presents complaining of anterior right shoulder pain the day after performing extensive yard work. The pain is localized over the anterior proximal humerus with distinct point tenderness. There are no
Explanations
(u) A. Supraspinatus tendonitis, subacromial bursitis and rotator cuff tear usually present with pain in the area of the deltoid muscle, limited abduction and are reproduced through impingement tests that narrow the space between the acromium
History & Physical/Orthopedics/Rheumatology
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. spondyloly
Explanations
(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.
(u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.
(c) C. Asymmetry of the posterior chest wall on forward bendi
DiagnosticStudies/Orthopedics/Rheumatology
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.
Explanations
(u) A. See C for explanation.
(u) B. While blood cultures are indicated in acute cases of osteomyelitis, they are only positive in 25-50% of pediatric hematogenous osteomyelitis and 10% of other forms of bone infection.
(u) C. Taking specimen
Health Maintenance/Orthopedics/Rheumatology
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
Explanations
(u) A. The patient's BMI is 23. Obesity is not a contributing factor for this patient.
(u) B. Corticosteroid injections may be used for symptomatic treatment but are not used for prevention.
(u) C. Calcium supplementation is indicated for ost
Diagnosis/Orthopedics/Rheumatology
A 20 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on during practice. Physical exam reveals pain to palpation over the
Explanations
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
(u) B. See A for explanation.
(u) C. Osgood-Schlatter disease is an injury occurring at the insertion of
Clinical Intervention/Orthopedics/Rheumatology
A 36 year-old male has a history of recurrent low back pain. When lifting a stack of books yesterday, he experienced sudden, severe pain in the lumbar area. He denies radicular pain. His lower extremity exami
Explanations
(u) A. The patient can be managed conservatively by a primary care provider since there are no neurological deficits.
(c) B. Continuation of activities as tolerated is recommended during the acute phase. After symptoms resolve, an exercise pr
Clinical Therapeutics/Orthopedics/Rheumatology
A 42 year-old female experiences pain on the plantar surface of her left foot in the area of the third metatarsal head. The pain is associated with wearing tight shoes and is relieved by removing shoes. Exami
Explanations
(u) A. Casting the foot in a patient with Morton's neuroma is not effective therapy.
(u) B. Physical therapy has not been shown to be of benefit in treating Morton's neuroma.
(c) C. Steroid injection is the treatment of choice for Morton's ne
History & Physical/Orthopedics/Rheumatology
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
Explanations
(c) A. Abduction against resistance tests the supraspinatus.
(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.
(u) C. See B for explanation.
(u) D. Medial rotation against resistance tests the subscapularis.
Diagnostic Studies/Orthopedics/Rheumatology
A 26 year-old male who is an avid swimmer has been experiencing right shoulder pain for the past month. On examination, pain is elicited with palpation below the anterior acromion. Anterior shoulder pain is also
Explanations
(u) A. This patient is experiencing mild impingement syndrome and, although plain films may demonstrate bone spurs on the undersurface of the acromion, his age and relatively recent onset of symptoms suggest that this study would likely be no
Clinical Intervention/Orthopedics/Rheumatology
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 angulati
Explanations
(u) A. The dorsal forearm splint is best used as an alternative to the ulnar or radial gutter splint for protection of fractures of metacarpals two through five.
(u) B. Ulnar gutter splints are best for treatment of stable fractures and dislo
Diagnostic Studies/Orthopedics/Rheumatology
An obese 15 year-old male presents with complaint of a limp and right knee pain for two weeks. He denies recent trauma or history of previous injury. Physical examination of the right knee is unremarkable. Exami
Explanations
(c) A. This patient has slipped capital femoral epiphysis (SCFE) and the classic x-ray findings will demonstrate displacement of the femoral head rotation of the femoral neck anteriorly.
(u) B. Irregularity and fragmentation of the joint spac
Clinical Intervention/Orthopedics/Rheumatology
A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory
Explanations
(h) A. While epidural steroids can be effective in treating lumbar disc herniation, in the case of cauda equina syndrome, immediate surgical decompression is mandatory.
(h) B. NSAIDs may be beneficial in some cases of lumbar muscle strain and
History & Physical/Orthopedics/Rheumatology
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 de
Explanations
(u) A. Crepitus without pain is not significant and does not indicate an effusion.
(u) B. Tenderness over the joint line indicates a meniscal injury, but does not demonstrate an effusion.
(c) C. A small bulge of returning fluid after milking
Diagnosis/Orthopedics/Rheumatology
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 i
Explanations
(u) A. Carpal tunnel syndrome typically presents with pain and paresthesias in the median nerve distribution.
(c) B. deQuervain's tenosynovitis typically results from repetitive activity involving pinching the thumb while moving the wrist. Th
Scientific Concepts/Orthopedics/Rheumatology
A football player complains of burning pain, numbness, and tingling extending from the left shoulder down into the hand after he tackled a player. These symptoms resolved spontaneously in minutes. Following res
Explanations
(u) A. Acute cervical muscle strain might result from the mechanism of injury described but symptoms would not quickly resolve.
(u) B. Concussion involves generalized symptoms such as loss of consciousness but would not affect one limb exclus
Clinical Intervention/Orthopedics/Rheumatology
A 22 year-old male presents several hours after sustaining a hand injury when he punched a wall. X-rays of the hand demonstrate fracture of the fifth metacarpal neck with 65 degrees dorsal angulation and a cl
Explanations
(u) A. Antibiotic treatment would be appropriate if the skin was broken and the injury was sustained in a fist fight with the potential for introduced oral flora.
(u) B. Reduction followed by splinting is recommended for fifth metatarsal frac
Diagnostic Studies/Orthopedics/Rheumatology
A 74 year-old male presents with one month history of right shoulder pain without any known precipitant. His pain involves an area from the right paraspinous musculature to the right deltoid with occasional radi
Explanations
(u) A. Although electromyography and nerve conduction studies would be helpful in localizing the nerves involved, this is not an appropriate first-line diagnostic test.
(u) B. Although there is pain in the shoulder, this patient presents with
History & Physical/Orthopedics/Rheumatology
A 30 year-old diabetic female complains of persistent numbness in her right thumb and forefinger that has been awakening her from sleep for the past week. She is right hand dominant and denies any history of act
Explanations
(u) A. EMG may be performed in a patient who is being considered for surgery.
(u) B. Nerve conduction test may be performed if operative intervention is being planned.
(c) C. The Phalen maneuver is used to reproduce the symptoms of carpal tun
Diagnosis/Orthopedics/Rheumatology Topic
A 42 year-old male sustained a closed left tibial fracture in a fall two days ago. He was treated with a cast for immobilization. Acutely, he developed severe pain in his left leg. Examination reveals the anterolat
Explanations
(c) A. One of the earliest signs of compartment syndrome is severe pain that occurs with extension of the involved muscles.
(u) B. DVT below the knee usually occurs in the posterior compartment and, while potentially painful, should not produ
Clinical Therapeutics/Orthopedics/Rheumatology
A 27 year-old male presents with gradually worsening low back pain and stiffness for the past two years. His symptoms are worse upon awakening and gradually improve throughout the day. Lumbosacral flexion is
Explanations
(c) A. NSAIDs, such as indomethacin, are the mainstay of therapy in ankylosing spondylitis (AS).
(u) B. Methotrexate is beneficial in treatment of rheumatoid arthritis, but there is little evidence that it changes the course of disease in ank
Health Maintenance/Orthopedics/Rheumatology
A 23 year-old male presents to the emergency department with severe right shoulder pain. He is holding his shoulder in internal rotation. Which of the following would increase your suspicion that he has a poster
Explanations
(u) A. This is a common mechanism for anterior glenohumeral dislocation.
(c) B. Tonic-clonic seizures can create severe contraction of the internal rotator muscles of the shoulder.
(u) C. This is a classic finding associated with anterior dis
Scientific Concepts/Orthopedics/Rheumatology
A 33 year-old male presents to your office with a complaint of right knee injury associated with pain and swelling. He states he was running after his loose dog and suddenly stopped, hyperextended his knee, hea
Explanations
(u) A. Medial collateral ligament injuries often occur with rotational injuries or direct impact to the lateral knee. Tenderness medially with laxity with valgus (medial) stress is noted.
(u) B. Lateral collateral ligament injury causes pain
Diagnosis/Orthopedics/Rheumatology
A 60 year-old right hand dominant male presents to your office complaining of right shoulder pain and progressively worsening arm weakness. His symptoms are aggravated when working above the shoulder level. On physical e
Explanations
(c) A. Rotator cuff tears are associated with full passive range of motion but have pain and weakness during active abduction.
(u) B. Subacromial bursitis causes pain with raising hand above head and has mild degree of weakness.
(u) C. Adhesi
Diagnostic Studies/Orthopedics/Rheumatology
A 26 year-old male was lifting a heavy object two weeks ago when he felt a sudden onset of low back pain. He describes pain in the low mid back at the belt line aggravated with movement. Radicular symptoms are n
Explanations
(u) A. See B for explanation.
(c) B. MRI is the diagnostic study of choice in a patient with suspected disc herniation.
(u) C. See B for explanation.
(u) D. See B for explanation.
Clinical Intervention/Orthopedics/Rheumatology
A 22 year-old male presents to the emergency department complaining of right hand pain after punching a brick wall. His pain is noted at the ulnar aspect of his hand and worsens with touch and movement. On ex
Explanations
(u) A. Fixation is warranted for displaced fractures, angulated fractures beyond 40 degrees, or extensor lag.
(u) B. A long finger splint would not immobilize the joint above and below and may not offer enough immobilization.
(c) C. An ulnar
Clinical Therapeutics/Orthopedics/Rheumatology
A 44 year-old female hairdresser presents to the clinic with a two-month history of pain and numbness of her left hand that awakens her from sleep. Your exam reveals electric tingling sensations with percussi
Explanations
(u) A. Corticosteroid use is recommended after initial treatment is unsuccessful.
(u) B. Surgical intervention is reserved for patients not responsive to initial/conservative treatment.
(c) C. Splinting the affected wrist is the initial treat
Health Maintenance/Orthopedics/Rheumatology
A 56 year-old white post-menopausal female had a recent surveillance DEXA bone densitometry. The T-score is -2.7 for her right hip. In counseling this patient, in addition to medications, which of the following
Explanations
(c) A. Weight bearing exercises are an appropriate adjunct to medication in a patient with osteoporosis. Water aerobics are non-weight bearing. Sun exposure adn vitamin D supplementation are useful in preventing and treating osteomalacia.
(u)
Diagnostic Studies/Orthopedics/Rheumatology
A 62 year-old female presents to the emergency room with significant back pain without radiation after lifting a box weighing approximately 15 pounds. She denies any previous trauma or injuries. Past history inc
Explanations
(u) A. CT of the spine should be reserved for fractures that remain symptomatic or progress after treatment.
(u) B. MRI is a good tool in evaluation of union versus non union fractures and should be reserved for fractures that remain symptoma
Scientific Concepts/Orthopedics/Rheumatology
Which of the following types of hip fracture has the highest risk for avascular necrosis and nonunion?
A. Femoral neck
B. Intertrochanetric
C. Subtrochanteric
D. Greater trochanteric
Explanations
(c) A. Fractures involving the femoral neck typically disrupt the blood supply to the femoral head and may cause avascular necrosis and nonunion.
(u) B. Intertrochanteric fractures usually do not cause avascular necrosis and nonunion due to t
History & Physical/Orthopedics/Rheumatology
Which of the following histories best describes spinal stenosis?
A. Gradual onset of back and thigh pain exacerbated by walking and alleviated by sitting
B. Acute onset of low back pain with radiation of pain to
Explanations
(c) A. Spinal stenosis typically presents as back pain and thigh pain aggravated by ambulation and relieved by sitting.
(u) B. Spinal stenosis is gradual in onset and is improved by sitting.
(u) C. Spinal stenosis, unlike polymyalgia rheumati
Diagnosis/Orthopedics/Rheumatology
A 13 year-old female presents to the office with right knee and thigh pain and the inability to bear weight since waking yesterday morning. The mother states the child had a fever of 100.9 degrees F this morning and cont
Explanations
(u) A. Plain x-rays may aid in diagnostic suspicion, usually after a week or two, but do not aid in treatment choice.
(u) B. ASO titer is not indicated in a patient with osteomyelitis.
(u) C. MRI will detect the early inflammation of osteomye
History & Physical/Orthopedics/Rheumatology
A 14-year old male active in sports, has been complaining of intermittent anterior right knee pain for several months. He denies any specific injuries. On examination, there is no erythema, swelling, deformities
Explanations
(u) A. Discoid meniscus causes clicking over the lateral meniscus during flexion. This disorder is mostly painless and occasionally may cause mild aching or effusion.
(c) B. Osgood-Schlatter disease causes pain at the tibial tubercle and it i
Clinical Intervention/Orthopedics/Rheumatology
A patient is 12 hours post-closed reduction of a tibial fracture and is in a long leg cast. Despite pain medication the patient complains of unrelieved pain and cannot move his toes. Which of the following is
Explanations
(u) A. This measure may be used while the necessary equipment is obtained to bivalve the cast, but it will not treat the underlying condition.
(c) B. The cast for this patient is too tight and the pressure needs to be released. Bivalving the
Clinical Intervention/Orthopedics/Rheumatology
A 30 year-old female presents with left wrist pain after slipping on the ice while walking to her car. On examination, pain is noted on palpation over the anatomical snuff box. X-ray of her wrist shows no ide
Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Tenderness in the snuff box should be treated as a suspected scaphoid fracture. The patient should be treated as if it is fractured and placed in a splint with a referral to a
Clinical Therapeutics/Orthopedics/Rheumatology
A 25 year-old female with irritable bowel syndrome presents with complaint of upper and lower extremity discomfort. The patient has pinpoint muscle tenderness over the shoulder girdle, low back and hips. Whic
(u) A. Opioid medication is not effective in the treatment of fibromyalgia.
(c) B. Amitriptyline is the treatment of choice for fibromyalgia and is typically administered at bedtime.
(u) C. Methotrexate is not effective in treating fibromyalgia.
(u) D. NS
A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is
A. methylpredniso
(u) A. A Medrol dose pack will have no affect on carpal tunnel syndrome.
(c) B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel.
(u) C. Observation will not improve symptoms.
(u) D. Surgical
A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the proper name for this condition?
A. Ga
(u)A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint.
(c) B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.
(u) C. A Colles' fracture is a
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 asso
(u) A. See B for explanation.
(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.
(u) C. See B for explanation.
(u) D. Short arm casting is indicated in wrist an
A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered?
A. Inability to extend the wris
(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.
(u) B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is more commonly in
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 recommen
(u) A. See C for explanation.
(u) B. See C for explanation.
(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 cas
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 cur
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery.
(c) D. The popliteal artery is at risk for injury when
A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his later
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abduc
Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament?
A. Sup
(c) A. A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is most commonly