Sports medicine/Orthopedics

1
Sports medicine/Orthopedics

• Board Review

2
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 overnight with 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 bandage E) no external brace or support
3
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 longer recommended. Elastic bandaging does not
offer the same lateral and medial support.
External ankle support has been shown to improve
proprioception.
4
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 advise her A) to increase her
caloric intake B) that this is a normal response
to training C) to begin an estrogen-containing
oral contraceptive D) to stop running
5
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 for patients such as this one to stop
running entirely, however
6
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 fracture B) a herniated nucleus pulposus
at L5 or S1 C) plantar fasciitis D) diabetic
neuropathy E) tarsal tunnel syndrome
7
ANSWER E Entrapment of the posterior tibial
nerve or its branches as the nerve courses behind
the medial malleolus results in a neuritis known
as tarsal 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 sensory
changes. 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 deep
tendon reflexes.
8
81. A 32-year-old female who is an avid runner
presents with knee pain. You suspect
patellofemoral pain syndrome. Which one of the
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)
9
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 medial and 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.
10
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 abduct his 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
11
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.
12
131. You see a 5-year-old white female with
in-toeing due to excessive femoral anteversion.
She is otherwise normal and healthy, 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) Observation B) Medial shoe
wedges C) Torque heels D) Sleeping in a Denis
Browne splint for 6 months E) Derotational
osteotomy of the femur
13
ANSWER A There is little evidence that femoral
anteversion causes long-term functional problems.
Studies have shown that shoe wedges, torque
heels, and twister cable splints are not
effective. Surgery should be reserved
for children 810 years of age who still have
cosmetically unacceptable, 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.
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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 drive B) 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 other E) A football player is struck by the
shoulder pad of a lineman
16
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 result from the impact. Softer
safety baseballs are one consideration in
primary prevention. Older competitors are at
less risk. Large blunt objects or body-to-body
contact also carries less risk.
17
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. On examination 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 compared
to 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
18
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, as opposed 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 SCFE and 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 of the 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.
19
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 is the most likely
diagnosis? A) Boxers fracture B) Greenstick
fracture C) Salter type II fracture D) Spiral
fracture E) No abnormality
20
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. The radiograph
shown with this question is an example of a
fracture through the growth plate. Approximately
67 of such fractures will cause a restriction
of growth. The Salter classification system was
developed to classify 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.
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22
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 fracture C) plantar
fasciitis D) turf toe E) foot sprain
23
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 third week 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
26
ANSWER E Osteoarthritis of the knee is more
common in women than in men. Rest improves the
pain of osteoarthritis, and increasing muscle
strength improves joint stability and reduces
pain. Meniscal tears are extremely common in
advanced osteoarthritis, but repairing them fails
to improve the course of the disease.
Radiographic changes correlate poorly with pain
severity in osteoarthritis.
27
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 Quervains tendinitis B)
Prepatellar bursitis C) Bursitis of the medial
collateral ligament D) Anserine bursitis E)
Medial meniscus tear
28
ANSWER D Anserine bursitis is characterized by
pain, particularly at night, that occurs in the
medial knee region over the upper tibia. It is
located about 23 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
normal radiograph of the tibia indicating no
underlying pathology. De Quervains 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.
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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
examination reveals tenderness and some swelling
at the tibial tubercles. Which one of the
following is true regarding this patients
condition? A) It is almost never seen in
adults B) 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 treatment D) Radiographs
should always be ordered to rule out other
conditions E) Bilateral symptoms are unusual
31
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 2030 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 23 weeks. Treatment includes
rest, ice, anti-inflammatory medications, a
rehabilitation program, and an infrapatellar
strap during activities. Casting and
corticosteroid injections are not indicated.
32
56. Which one of the following is a
contraindication to participation in contact
sports? A) A single testicle B) Fever C)
Documented scoliosis of 20º D) Sickle cell trait
33
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 an
associated 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 a contraindication 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.
34
64. The most effective means of preventing sudden
death in high-risk patients with asymptomatic
hypertrophic cardiomyopathy is A) amiodarone
(Cordarone) B) metoprolol (Lopressor) C)
verapamil (Calan, Isoptin) D) chronic
dual-chamber pacing E) an implantable
cardioverter-defibrillator (ICD)
35
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 symptomatic patients, 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 may decrease
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 an ambulatory 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.
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37
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
Finkelsteins test is positive. The most
effective treatment for this patient would be A)
rest B) NSAIDs C) splinting D) local
corticosteroid injection
38
ANSWER D The history and physical findings are
most consistent with de Quervains tenosynovitis,
which affects the abductor pollicis longus and
the extensor pollicis longus and brevis tendons.
Local corticosteroid injection is the most
effective treatment. 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.
39
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
40
ANSWER E This patient is experiencing benign
nocturnal pains of childhood, formerly called
growing pains. These are cramping pains of the
thigh, shin, and calf, and affect approximately
35 of children 46 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 chronic signs 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.
41
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 of the distal
radius and ulna. Which one of the following
treatments has the best functional outcome at 34
weeks? A) An ACE wrap B) A removable splint C) A
long arm cast D) A thumb spica cast E) Surgical
reduction and internal fixation
42
ANSWER B Although casting for 34 weeks with a
short arm cast 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.
43
96. A healthy 25-year-old female runner presents
with a complaint of right heel pain for 2 months.
The pain is most pronounced with 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
acute treatment? A) Extracorporeal shock wave
therapy B) Prefabricated insoles (heel pad) C)
Night splints D) Corticosteroid iontophoresis E)
NSAIDs
44
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 is
recommended only after 12 months of symptoms.
45
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 physical examination is notable
for point tenderness and swelling at the proximal
tibia. A radiograph shows a displaced fracture of
the proximal tibia through the physis and
epiphysis. The most appropriate management is A)
a long leg cast B) a rigid knee immobilizer C) a
functional (hinged) knee immobilizer D)
orthopedic referral
46
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 fracture through 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.
47
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 handdominant 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 leg B) 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
time as the right leg E) Switch the cane between
hands at intervals of several hours to distribute
the load equally
48
ANSWER C The standard walking cane generally is
designed as 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 this choice 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 the hand opposite the most severely
affected leg, and the movement of the cane tracks
the movement of the affected leg, consistent with
normal gait.
49
122. Little League elbow refers to a problem
located over the A) medial epicondyle B) lateral
epicondyle C) olecranon D) capitellum E) ulnar
groove
50
ANSWER A Little League elbow is an apophysitis
of the medial 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 may
cause 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.
51
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 lt6
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
etiology E) New-onset bilateral lower-extremity
paresis
52
ANSWER A Vertebroplasty is a reasonable
therapeutic consideration for vertebral
compression fractures if pain is not adequately
controlled 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, including bladder
dysfunction, paralysis, and sensory deficits, is
a relative contraindication to vertebroplasty.
Spinal cord compression requires other treatment,
and high degrees of compression (gt67) 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.
53
138. A high-school gymnast presents to your
office with a history of back pain for the past
34 weeks. She reports that symptoms are worse
with any hyperextension activity. Examination
demonstrates a hyperlordotic 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 this diagnosis is
true? A) Most athletes can resume full activity
in 46 weeks B) Spondylolisthesis gt25 requires
referral to a spine surgeon C) 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
54
ANSWER C Complete fracture and
spondylolisthesis with prolonged disability 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) is similar 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 (gt50) may need to be
comanaged by an orthopedic or spine surgeon to
guide treatment and assist in return-to-play
decisions.
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56
Spondylolysis
57
Spondylolisthesis

• Graded according to its degree of severity. The
  Myerding grading system measures the percentage
  of vertebral slip forward over the body beneath.
  The grades are as follows
• Grade 1 25Grade 2 25 to 49Grade 3 50 to
  74Grade 4 75 to 99Grade 5 100

58
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 a new
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 the contralateral joint D) an acutely
infected joint
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ANSWER A The major indication for joint
replacement is severe joint pain, usually pain at
rest. Loss of joint function and radiographic
evidence of severe destruction of the joint may
also be considered in the decision. The
appearance of the joint and the status of the
contralateral joint may be minor considerations.
Surgical insertion of a foreign body into an
infected joint is contraindicated.
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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 is
greater 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
62
ANSWER B Marfans syndrome is an autosomal
dominant disease manifested by skeletal,
ophthalmologic, and cardiovascular abnormalities.
Men taller than 72 in and women taller than 70 in
who have two or more manifestations of Marfans
disease should be screened by echocardiography
for associated cardiac abnormalities. Any of
these athletes who have a family history of
Marfans syndrome should be screened, whether
they have manifestations themselves or not. If
there is no family history, echocardiography
should be performed if two or more of the
following are present cardiac murmurs or clicks,
kyphoscoliosis, anterior thoracic deformity, arm
span greater than height, upper to lower body
ratio more than 1 standard deviation below the
mean, myopia, or an ectopic lens. Patients with
Marfans syndrome who have echocardiographic
evidence of aortic abnormalities should be placed
on beta-blockers and monitored with
echocardiography every 6 months.
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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. Stabilizing the
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 E) Long-term semirigid support
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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 is often 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.
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179. A 35-year-old male complains of 2 months of
right shoulder pain. He does not recall an
injury, but says it is painful to lie on his
right side or to work with his right hand above
his head. On examination, the shoulder appears
normal and there is no pain with external
rotation of the shoulder, bringing the arm across
the body (scarf test), or attempted external and
internal rotation of the shoulder against
resistance. Lowering the arm from full abduction
(painful arc), attempted abduction above 45º
against resistance, and elevating the internally
rotated arm above 90º against resistance are all
painful. The most likely diagnosis is A)
subdeltoid bursitis B) adhesive capsulitis C)
impingement syndrome D) glenohumeral
osteoarthritis E) acromioclavicular osteoarthritis
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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
arthritis produces a positive scarf sign, and
often a visible bump over the joint, since it
lies so close to the skin surface.
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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. She says 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
68
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 not been
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.
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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
71
ANSWER D The Lachman test is performed with the
knee flexed to 25º- 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, but it 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.
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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,
ring splint) would be adequate D) Splinting
should be continued for 2 weeks E) A boutonniere
deformity may result
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ANSWER E An injury to the central extensor slip
can occur when the proximal interphalangeal (PIP)
joint is forcibly flexed while the digit is
actively extended. The injury is evaluated by
holding the joint in a position of 15º30º 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. The stack splint
should only be used to treat injuries of the
distal interphalangeal joint.
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Mallet finger Tx - Stack splint for 6 weeks
Boutonnière deformity Tx PIP joint splint for 6
weeks
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229. A 25-year-old runner complains of non-focal
knee pain. She does not remember any specific
injury. You suspect patellofemoral pain
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
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ANSWER A Patellofemoral pain syndrome causes
nonfocal or 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 there
swelling, locking, or giving way these symptoms
are more likely to be associated with more
profound problems such as a ligament or cartilage
tear.
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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 are normal. Which one of the
following, if present, would be most suggestive
of a rotator cuff tear? A) Inability to flex at
the elbow against resistance B) Signs of
decreased arterial perfusion of the hand C)
Swelling of the acromioclavicular joint D)
Weakness in external rotation of the shoulder
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ANSWER D Shoulder pain after a fall may result
from a strained muscle or ligament, an
exacerbation of a smoldering subacromial 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.
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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, but extension 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 fracture D) A scapholunate
dislocation
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Metacarpal Anatomy
82
ANSWER B A dorsiflexion injury will typically
cause a scaphoid fracture in a young adult,
resulting in tenderness to palpation over the
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.
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Scapholunate dislocation
Normal
84
Ottawa Ankle and Foot Rule
85
Ottawa knee rule

• A knee xray series is indicated for any of these
• Age 55 years or older
• Tenderness at head of fibula
• Isolated tenderness of patella
• Inability to flex knee to 90 degrees
• Inability to walk four weight-bearing steps
  immediately after the injury and in the emergency
  department