340. The answer is b. (Mehta, pp 173-190.) Lower back pain is a very common complaint. The differential diagnosis includes soft tissue problems (muscles and ligaments), disk problems (prolapse), facet problems (degenerative joint disease), spinal canal disease (spinal stenosis), and vertebral body diseases (osteoporosis causing a compression fracture, infection, metastatic disease, spondylolisthesis). Patients with disk herniation at L5-S1 may present with S1 nerve root compression (the herniated disk affects the nerve root below the lesion). The patient is unable to stand on his or her toes and has an absent Achilles reflex (S1). The straight-leg raising test is positive. Spondylolysis is a defect of a lumbar vertebra (lack of ossification of the articular processes) and rarely causes symptoms. Spondylolisthesis occurs when the vertebra slips forward from its position and is generally a consequence of spondylolysis or degenerative joint disease (DJD) without spondylolysis. It, too, is usually asymptomatic. A back strain is an injury to a ligament or muscle; it may mimic disk disease, but the neurologic exam and straight-leg raising test generally remain normal. Although radiologic studies are needed in this patient to make a definitive diagnosis, the leading diagnosis with her history of breast cancer and weight loss is metastatic disease to the lum-bosacral area. Pain made worse by lying down or at night may be a sign of malignancy or infection.
341. The answer is a. (Mehta, pp 38, 111, 180-182.) Lumbar disk her-niation may occur rapidly after lifting heavy objects awkwardly or with poor technique but usually resolves with a short period of rest ("unloading the spine") and nonsteroidal anti-inflammatory agents. Surgery is rarely needed. If a patient develops significant neurologic deficit after the initial pain has resolved, the diagnosis is most likely nerve impingement due to a herniation of the disk. Tibial stress fractures (shin splints) may occur due to weight-bearing exercises or training errors. These injuries cause anterior tibial pain after exercise but not weakness. Anterior compartment syndrome occurring after weight-bearing exercise may cause a neu-ropraxia of the peroneal nerve, leading to footdrop. A gastrocnemius muscle tear usually occurs suddenly after rapid dorsiflexion of the ankle and causes severe midcalf pain. In a few days, the calf characteristically develops a bluish discoloration. A popliteal cyst (Baker's cyst) causes calf pain, swelling, and knee effusion. It is often a complication of rheumatoid arthritis and represents a diverticulum of the synovial sac that protrudes through the posterior joint capsule of the knee.
342. The answer is e. (Mehta, pp 191-214.) Passive range of motion (ROM) tests are performed by the examiner, while active ROM tests are performed by the patient. Passive ROM tests need not be done if active ROM tests are performed adequately. The loss of passive range of motion indicates a stiffening shoulder ("frozen shoulder" or adhesive capsulitis). The most likely etiology in this patient would be impingement of the rotator cuff causing inflammation, degeneration, and possibly a tear. The rotator cuff, which is formed by the SITS tendons of the Supraspinatus, Infraspinatus, Teres minor, and Subscapularis muscles, stabilizes the glenohumeral joint and prevents upward movement of the head of the humerus. Injuries may occur from overhead activities including freestyle and butterfly-style swimming. The "drop arm sign" may be positive in rotator cuff tear (abduct the arm to 180° and ask patient to bring it down slowly; at 90° the arm will drop quickly due to weakness). An injection of lidocaine often relieves the inflammation in the subacromial space in patients with rotator cuff tendinitis and alleviates the symptoms. Fracture of the surgical head of the humerus is usually seen in the elderly after a fall. Swelling and ecchymosis are visible. Cervical radiculopathy typically results in decreased sensation, strength, and reflexes all matching one root level of the upper extremity. Bicipital tendinitis may be seen with overuse and trauma, but pain is typically felt over the anterior aspect of the shoulder and palpation of the biceps tendon in the bicipital groove elicits tenderness. A pain produced on supination of the forearm against resistance (Yergason sign) confirms bicipital tendinitis. Lidocaine injection into the synovial sheath of the long head of the biceps relieves pain. Calcific tendinitis is due to calcium deposits in the subacromial region and is especially common in the supraspinatus tendon near its insertion.
343. The answer is a. (Mehta, pp 282-286.) Legg-Calve-Perthes disease (osteochondrosis) is an uncommon disorder that affects boys more than girls between the ages of 2 and 12. The hallmark is avascular necrosis of the capital femoral epiphysis, which has the potential to regenerate new bone. Consequently, children with Legg-Calve-Perthes disease are of short stature and present with a "painless limp." Osgood-Schlatter's disease occurs in adolescence and is usually self-limiting. It is due to patellar tendon stress, which causes pain in the region of the tibial tuberosity especially when the patient extends the knee against resistance. Rickets is attributed to vitamin D deficiency and is manifested by bowing of the long bones, enlargement of the epiphyses of the long bones, delayed closure of the fontanels, and enlargement of the costochondral junctions of the ribs (rachitic rosary). Juvenile rheumatoid arthritis is an inflammatory disorder that begins in childhood and may produce extraarticular symptoms, including iridocyclitis, fever, rash, anemia, and pericarditis. Muscular dystrophy is characterized by progressive weakness and muscle atrophy.
344. The answer is d. (Mehta, pp 198, 209-210.) Glenohumeral dislocations may be anterior, posterior, or inferior depending on the position of the head of the humerus in relation to the glenoid. The most common dislocation is anterior (>90%) and is due to forceful abduction, external rotation, or extension. There is typically flattening of the deltoid and loss of the greater tuberosity, causing a "squared-off" appearance of the shoulder. The patient is usually in severe pain and holds the arm in slight abduction and external rotation. Posterior dislocations are typically seen following a seizure. Possible complications of shoulder dislocation include damage to the axillary artery, axillary nerve (deltoid paralysis), and brachial plexus. First-time dislocation requires orthopedic management (surgery or therapeutic exercise), since 80% of patients will have a recurrence. Rupture of the long head of the biceps causes a bulge in the lower half of the arm and pain upon elbow flexion.
345. The answer is b. (Mehta, pp 225-230.) Scaphoid fractures occur as a result of a fall on an outstretched hand. These fractures heal poorly due to a poor blood supply in this area. Radiographs done early may be negative, but later radiographs may show evidence of healing (callus fracture). Cervical (C6-C8) radiculopathy causes pain, numbness, and tingling from the neck to the hand. de Quervain's disease or tenosynovitis of the tendon sheath of the extensor pollicis brevis and abductor pollicis longus causes swelling and tenderness of the anatomic snuffbox. This disorder is usually found in middle-aged women who perform repetitive activity. The Finkel-stein test is positive (patient makes a fist around his or her own thumb; pain is produced with adduction toward the ulnar side) in de Quervain's disease. Compartment syndrome is a surgical emergency and is due to a tight cast or swelling causing compression of the blood vessels and nerves in the forearm. A boxer's fracture causes flattening or loss of the fifth knuckle prominence due to displacement of the metacarpal toward the palm. It is usually the result of striking an object with a clenched fist.
346. The answer is a. (Mehta, pp 330-335.) Ligament injuries of the ankle are common and may occur in sports requiring jumping and running. These injuries occur when the foot twists as it lands on the ground and can even be a consequence of walking on uneven ground. The medial ligament is typically injured with eversion and the lateral ligament (the ligament most commonly affected by injuries) with inversion. The lateral ligament is composed of three parts: the anterior talofibular ligament, the cal-caneofibular ligament, and the posterior talofibular ligament. The injured ligament is tender to palpation, ecchymotic, and swollen. Metatarsal stress fractures ("march" fractures) occur after long periods of running or walking; pain is typically in the middle of the forefoot. Rupture of the Achilles tendon may occur with running and jumping. It causes a palpable defect, swelling, and tenderness over the tendon. The Thompson test is positive (patient lies with knee flexed to 90° and the examiner squeezes the calf muscle; if the Achilles tendon is ruptured, the foot will not move, but if the tendon is intact, the foot will plantarflex). Plantar fasciitis causes pain over the medial aspect of the plantar fascia. It usually starts slowly and is of long duration. The windlass test is positive (pain increases with ankle and great toe dorsiflexion). Tarsal tunnel syndrome occurs with entrapment of the posterior tibial nerve. The patient complains of burning and numbness that extends from the sole of the foot and toes to the medial malleolus.
347. The answer is a. (Mehta, pp 73, 176.) The sciatic nerve is located between the ischial tuberosity and the greater trochanter; tenderness over the nerve indicates irritation of the nerve roots forming the nerve. The most common cause of sciatica is a herniated disk usually occurring at the L4-L5 or L5-S1 levels. The straight-leg raising test is usually positive in sciatic nerve irritation (pain is produced with elevation of <70° and worsened with dorsiflexion of foot or Lasegue's sign). A pulling or tight sensation in the hamstring is not a positive straight-leg raising test. Cross-leg raising test (elevation of unaffected leg causes pain in affected leg) may also be positive. Osteomyelitis and epidural abscesses are usually accompanied by systemic symptoms (i.e., fever) and are found in patients who are immunocompromised. The typical presentation for cauda equina syndrome is progressive weakness and numbness of the lower extremities bilaterally with urinary retention. There is perineal and perianal sensory loss ("saddle anesthesia") and a lax anal sphincter. The cauda equina syndrome is a true surgical emergency. Kyphosis ("hunchback") is a smooth and rounded backward convexity of the thoracic region.
348. The answer is c. (Mehta, pp 225-233.) The radial nerve lies next to the shaft of the humerus in the spiral groove. It may be injured as a result of humeral fractures, especially those involving the distal third of the humerus. The radial nerve (C6-C8) supplies the extensor muscles of the wrist; damage to it results in wristdrop, a condition in which the patient is unable to extend the wrist. Clawhand is due to paralyzed interosseous and lumbrical muscles from an ulnar nerve (C8-T1) injury. The median nerve (C6-T1) supplies most of the flexors in the forearm (motor branches) and supplies sensory branches to the radial part of the hand; an injury will cause thenar atrophy.
349. The answer is e. (Mehta, p 47.) The signs and symptoms of fat embolism syndrome are those of adult respiratory distress syndrome (ARDS) in association with musculoskeletal trauma. It usually occurs 2-4 days after the injury. The predominant feature is respiratory failure. Petechiae are found in 50-60% of patients, generally on the anterior chest and neck, axillae, and conjunctivae. Although fractures of the pelvis may cause life-threatening blood loss and subsequent hypovolemic shock, the patient will probably have had other symptoms, such as oliguria, hypotension, pale conjunctiva, clouded sensorium, and cool extremities.
350. The answer is a. (Mehta, pp 289-306.) The anterior and posterior cruciate ligaments are intraarticular ligaments and contribute to the stability of the knee. The most likely diagnosis in this gymnast is tear of the ante-
rior cruciate ligament (ACL). Both the Lachman test (the patient is placed in the supine position with the knee flexed at 15° while the examiner stabilizes the distal thigh with one hand and grasps the patient's leg distal to the tibiofemoral joint with the other hand; the test is positive if the examiner is able to move the tibia anteriorly) and the anterior drawer test (the foot is immobilized while the hip and knee are flexed, then the tibia is moved anterior relative to the femur; a positive test occurs with forward displacement of the tibia of more than 0.5 cm) are positive in this kind of injury. The Lachman test is more sensitive than the drawer test. Aspirated joint fluid is usually bloody in ACL injuries. An MRI is helpful in diagnosing this injury. A posterior cruciate ligament (PCL) tear would have a positive posterior drawer test whereby posterior displacement of the tibia is elicited on physical examination. A torn medial meniscus often causes the patient to complain of knee catching, locking, and clicking. The McMurray test (with the patient supine, flex the knee and hold the foot in one hand; rotate the leg and slowly extend the knee while palpating the posteromedial margins of the joint for a palpable click as the femur passes over the torn meniscus) is positive for a torn medial meniscus. A torn lateral meniscus is tested by palpating the posterolateral margin of the knee joint with the leg in full internal rotation as the knee is extended. Medial meniscus tears are more common than lateral meniscus tears and are usually due to twisting injuries. Unlike the immediate swelling seen with tears of vascular structures such as the ACL, the relatively avascular meniscus (cartilage) causes more gradual swelling.
351. The answer is c. (Fauci, 14/e, pp 611-613.) A history of pain that increases in severity, worsens at night, and is relieved by aspirin suggests the diagnosis of osteoid osteoma. This benign tumor is more common in males than females, and patients present between 20 and 30 years of age. The proximal femur is the most common site for this tumor. Other benign tumors of bone include giant cell tumor (osteoclastoma), osteochondroma, chondroblastoma, and osteoblastoma. The most common malignant tumors of bone include osteosarcoma (45%), chondrosarcoma (25%), Ewing's sarcoma (15%), and malignant fibrous histiocytoma. Osteosarco-mas commonly involve the distal femur. Chondrosarcomas are seen in older patients (40-50 years old). Osteosarcomas may be seen later in life as a complication of Paget's disease.
352. The answer is c. (Mehta, pp 302-311.) The lateral and medial collateral ligaments are on either side of the knee. Forced valgus bending of the knee may rupture the medial collateral ligament (MCL), also called the tibial collateral ligament. This is the most frequently injured ligament of the knee. Patients present with pain over the medial aspect of the knee. Injuries to the MCL may, in turn, tear the medial meniscus since the MCL is attached to the medial meniscus. Patients with medial mensical tears may complain of "locking" of the knee in flexion with activity while walking. Injuries of the lateral (fibular) collateral ligament cause tenderness over the lateral knee with palpation, but these injuries are not common. Dislocation or subluxation of the patella is due to a great force. "Locking" is common and the patella is usually displaced laterally. Subluxation reduces by itself, while dislocation requires reduction.
353. The answer is b. (Mehta, pp 231-235, 245-247.) Carpal tunnel syndrome (CTS) is the most likely diagnosis. It is due to median nerve compression by the transverse carpal ligament. Risk factors for this disorder include diabetes mellitus, pregnancy, hypothyroidism, rheumatoid arthritis, repetitive activity, and acromegaly. The Tinel sign (paresthesias or pain reproduced with percussion of the volar surface of the wrist) and Phalen sign (symptoms are reproduced by holding the wrist in passive flexion for 1 min) may be positive. Patients may complain of pain in the forearm, the thenar eminence, and the first three digits. Thoracic outlet syndrome usually causes medial arm pain and paresthesia when using the arms. The presence of a cervical rib is a risk factor for this disorder. Dupuytren's contracture is a fibrotic process of the palmar fascia that causes fixed flexion of the ring finger. Mallet finger is a flexion deformity of the distal interphalangeal joint and is generally the result of traumatic rupture of the extensor tendon of the distal phalanx. A ganglion is a painless, firm cystic mass arising from any joint or tendon sheath. A trigger finger may be seen in patients with rheumatoid arthritis. It occurs when an enlarged flexor tendon sheath passes through the pulleys of the digits, causing locking or catching.
354. The answer is c. (Mehta, pp 118, 173-180.) Since the patient has no neurologic compromise, the most likely diagnosis is back strain. Strain is common in people in their forties. It is exacerbated by activity and improves with rest. A straight-leg maneuver is positive for nerve root compression from disk herniation when pain is produced at less than 70° of elevation. Crossover pain (straight-leg maneuver of nonpainful leg worsens pain of involved leg) is also a strong indicator of nerve root compression, but only if pain is produced below the knee. Paravertebral abscess usually presents with fever and tenderness with percussion of the affected back area. Risk factors for osteoporosis include female gender, menopause, lack of activity, slim body habitus, older age, inadequate calcium intake, medications such as corticosteroids, and racial-ethnic background (Asian and northern European descent). Paget's disease (osteitis deformans) is a slowly progressing disease of bone that may be asymptomatic or may cause bone pain, deformities (such as a large skull or leg bowing), hearing loss, and fractures. It begins in middle-aged men and is thought to be due to an inborn error of metabolism causing the formation of poorly organized bone.
355. The answer is d. (Mehta, pp 253-288.) Trochanteric bursitis is a common cause of hip pain in the elderly but may be seen in bicyclists and runners. Pain is exacerbated by standing and by external rotation. Lying on the affected side compresses the inflamed bursa. Ischial bursitis ("weaver's bottom," so named because weavers had to sit for long periods of time, which led to ischial bursitis) causes pain in the buttock made worse with sitting and with hip flexion. Today, it is usually a problem for workers who operate heavy equipment on rough roads. Avascular necrosis (AVN) of the hip may be due to trauma or to medications such as corticosteroids. Patients are usually between the ages of 30 and 60 years and often complain of groin pain made worse with weight-bearing. Fracture of the proximal femur usually follows trauma. On inspection, the affected lower extremity lies in external rotation and is shorter than the normal side. Hip osteoarthritis presents with groin pain exacerbated by the Faber maneuver (also called the Patrick test), which is a mnemonic for Flexion, ABduction, and External Rotation.
356. The answer is c. (Hay, 14/e, pp 660, 699-701.) A child with Spren-gel's deformity cannot raise one arm completely due to a small and elevated scapula. Torticollis (wry neck due to shortening of the sternocleidomastoid muscle) often accompanies the deformity. Adolescents with slipped capital femoral epiphysis (SCFE) are often obese African American males who present with thigh or knee pain. SCFE is a disorder of unknown etiology that causes posterior and medial displacement of the femoral head. Children with juvenile rheumatoid arthritis (JRA) present with fever, salmon-colored rash, arthritis, hepatosplenomegaly, nodules, pericarditis, and irido-cyclitis (may lead to blindness). There is no diagnostic test for JRA, but the disease resolves by puberty in the majority of children. Arnold-Chiari malformation is an abnormality of neural tube closure. Cerebral palsy (CP) is a nonprogressive disorder resulting from a perinatal insult; it causes either a spastic paresis of the limbs or extrapyramidal symptoms (chorea, athetosis, ataxia). Patients with CP often have an associated seizure disorder, mental retardation, and speech or sensory deficits.
357. The answer is a. (Mehta, pp 113-115.) The patient is describing pseudoclaudication, which is characteristic of lumbar spinal stenosis.
This arises from compression of the exiting nerve roots by a disk, osteo-phyte, or narrow canal. The leg pain is most pronounced when walking downhill or descending stairs and takes several minutes of sitting or flexing forward before resolution. Often patients who continue to walk with pain will stoop over to relieve the symptoms ("stoop sign"). Claudication is seen in peripheral vascular disease, but the pain that occurs with walking resolves immediately upon stopping or standing without sitting. Peripheral pulses may be compromised. Diffuse idiopathic skeletal hyper-ostosis (DISH) causes calcification of the longitudinal ligaments of the spine and is usually found in patients with diabetes mellitus.
358. The answer is e. (Tintinalli, 5/e, pp 1838-1841.) The patient most likely has compartment syndrome from elevated pressure in a confined space compromising nerve, soft tissue, and muscle perfusion. Etiologies include burn injuries, crush injuries, and fractures. Compartment syndrome is often referred to as the disorder of Six P's (Pain, Pallor, Paralysis, Paresthesias, Poikilothermia, and Pulselessness). Immediate fasciotomy and restoration of tissue perfusion is the treatment for compartment syndrome.
359. The answer is a. (Mehta, pp 215-224.) Tennis elbow or lateral epicondylar tendonitis is most commonly characterized by tenderness of the common extensor muscles at their origin (the lateral epicondyle of the humerus). Passive flexion of the fingers and wrist and having the patient extend the wrist against resistance causes pain. Golfer's elbow or medial epicondylar tendonitis is a similar disorder of the common flexor muscle group at its origin, the medial epicondyle of the humerus. Olecranon bur-sitis is an inflammation of the bursa over the olecranon process caused by acute or chronic trauma ("student's elbow") or secondary to gout, rheumatoid arthritis, or infection. Clinically, there is swelling or pain upon palpation of the posterior elbow. Paralysis of the serratus anterior muscle (innervated by the long thoracic nerve) causes the scapula to protrude posteriorly from the posterior thoracic wall when the patient is asked to push against a wall (winged scapula).
360. The answer is d. (Fauci, 14/e, p 80.) The most likely diagnosis in this patient is whiplash or cervical musculoligamental sprain or strain. Whiplash-associated disorders begin after a symptom-free period following a hyperextension or hyperflexion injury, usually in an MVA. It is vital to perform a complete neurologic examination to exclude other causes of neck pain. Ankylosing spondylitis is a chronic and progressive inflammatory disease that most commonly affects spinal, sacroiliac, and hip joints. Osteoarthritis most often affects the weight-bearing joints. Reiter syndrome usually causes an arthritis of the hips, and there is often a history of ure-thritis, conjunctivitis, and foot involvement.
361-363. The answers are 361-e, 362-b, 363-g. (Mehta, pp 323, 338-343.) Improper footwear results in lateral deviations of the great toe, extensor, and flexor hallucis longus tendons (bunion formation). Hammer toe often affects the second toe. The metatarsophalangeal joint is dorsi-flexed and the proximal interphalangeal joint has plantar flexion. A stress fracture of a metatarsal is called a "march" fracture. Stress fractures result in bone resorption followed by insufficient remodeling due to continued activity. Stress fractures occur in the tibia as well as the metatarsal; examination typically reveals point tenderness and swelling. In genu varum (bowleg), the lateral femoral condyles are widely separated when the feet are placed together in the extended position. In genu recurvatum, the knee hyperextends, and in genu impressum, there is flattening and bending of the knee to one side with displacement of the patella. Pes planus is a flattened longitudinal arch of the foot often called flat foot. Morton's neuroma causes pain in the forefoot that radiates to one or two toes with tenderness between the two metatarsals. The pain may be further aggravated by squeezing the metatarsals together.
364-365. The answers are 364-d, 365-b. (Mehta, pp 67-68, 248-251.) Hypertrophic osteoarthropathy is nail clubbing accompanied by a symmetrical polyarthritis involving the large joints and occasionally the metacarpophalangeal joints. Hypertrophic osteoarthropathy may be seen secondary to malignancy, endocarditis, vasculitis, and other pulmonary and cardiac diseases. Ankylosing spondylitis (AS) is a chronic and progressive inflammatory disease, seen mostly in men in their thirties, that most commonly affects the spinal, sacroiliac, and hip joints. It may go undiagnosed for many years and bilateral hip pain due to sacroiliac involvement may be clinically undetectable. It is strongly associated with HLA-B27. Examination of the spine usually reveals a limitation in movement; patients in advanced stages may have a characteristic bent-over posture. Patients with AS may present with an acute nongranulomatous uveitis and limited chest expansion due to involvement of the costovertebral joints. The Schober test is positive in AS (with the patient erect, marks are made 5 cm below and 10 cm above the lumbosacral junction between the posterior superior iliac spines; the patient bends, marks are measured, and if the distance between the two marks increases by less than 4 cm there is spinal immobility). The pathogenesis of reflex sympathetic dystrophy is unknown. The presentation may be seen after peripheral limb injury; early symptoms include pain in the limb and edema. This disorder may lead to contractures. Charcot joint is a complication of peripheral neuropathy seen in diabetic patients. Repetitive minor trauma to the foot causes deformities, which may lead to skin breakdown, erythema, edema, and callus formation. 366-367. The answers are 366-b, 367-c. (Sapira, pp 483-485.) Ninety percent of radiculopathies involve the L5 or S1 nerve roots. L5 motor: Assessed by asking the patient to walk on the heels L5 sensory: Medial forefoot and lateral aspect of the leg S1 motor: Assessed by asking the patient to walk on the toes S1 sensory: Lateral foot S1 refex: Achilles reflex
L4 motor: Assessed by asking the patient to squat and rise (knee flexion and extension) L4 sensory: Medial aspect of the leg L4 reflex: Patellar
L2 motor: Assessed by hip adduction
368-369. The answers are 368-c, 369-b. (Seidel, 4/e, pp 729, 731.) The Apley test is used to detect a torn meniscus. A positive test occurs when there is pain, clicking, or locking of the knee with rotation. Both the ballottement test and the bulge sign detect a knee effusion. The balottement procedure is performed with the knee extended. Downward pressure is applied on the suprapatellar pouch and the patella is pushed backward against the femur. Pressure on the patella is then released and the patella floats out (fluid wave) with an effusion. A positive bulge test occurs when a bulge of fluid returns to the medial aspect of the knee with lateral tapping.
Was this article helpful?
This report may be oh so welcome especially if theres no doctor in the house Take Charge of Your Arthritis Now in less than 5-Minutes the time it takes to make an appointment with your healthcare provider Could you use some help understanding arthritis Maybe a little gentle, bedside manner in your battle for joint pain relief would be great Well, even if you are not sure if arthritis is the issue with you or your friend or loved one.