Chapter 12: Orthopedics and Sports Medicine

General note: If you have a choice between acetaminophen and an NSAID for an acute injury, acetaminophen will always be the right choice. Most acute injuries are not inflammatory and acetaminophen is a lot safer without gastropathy or platelet inhibition. If you do use an NSAID, naproxen is the safest from a cardiovascular standpoint but carries the same gastrointestinal risks as other NSAIDs.

A 5-year-old boy presents with acute onset of left anterior thigh and hip pain that began 2 days ago with no known prior trauma. He reports that it initially "loosened-up" after he had been out of bed for a few hours but has become worse again by afternoon. His pain is exacerbated by weight bearing and active or passive range of motion (ROM). His mother notes that he had a cold 7 to 10 days ago, but has been asymptomatic until he complained of thigh pain two nights ago. She also notes that he has had a low-grade fever. He has no other significant constitutional symptoms and appears to be in some pain, but otherwise he appears well.

Question 12.1.1 Based on the information obtained thus far, which of the following is the most likely diagnosis?

A) Osteomyelitis.

B) Rheumatic fever.

C) Slipped capital femoral epiphysis (SCFE).

D) Legg–Calve–Perthes disease (LCPD).

E) Transient (toxic) synovitis.

Answer 12.1.1 The correct answer is "E." This presentation is classic for transient (toxic) synovitis. This is the most common cause of hip pain in children aged 3 to 10 years, with peak occurrence in ages 5 to 6 years. It is more commonly seen in boys (male:female ratio of 2–3:1) and is often preceded by a viral respiratory infection, although numerous studies have failed to demonstrate a specific viral or bacterial agent. Physical examination reveals a limp or refusal to walk and complaint of pain over the groin and/or proximal thigh. There is pain with ROM testing, especially during abduction. Most children will be afebrile with a temperature of ≤38°C.

Question 12.1.2 Appropriate diagnostic work-up might include which of the following?

A) Joint aspiration.

B) Plain film radiographs.

C) Inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

D) CBC with differential.

E) All of the above.

Answer 12.1.2 The correct answer is "E." All of the above may be appropriate as transient synovitis is a diagnosis of exclusion. Patients with mild symptoms may be observed without further investigation. However, if the pain is significant, ROM is significantly impaired, or the temperature is >37.5°C, further diagnostic work-up is indicated. Laboratory findings consistent with transient synovitis include: clear joint fluid aspirate, normal CBC, and a mildly increased ESR. Blood cultures, antistreptolysin O (ASO) titer, bone scan, and MRI may also be of benefit to rule out other possibilities (e.g., septic arthritis, rheumatic fever, and SCFE). It is of extreme importance to differentiate transient synovitis from septic arthritis. Unfortunately, there is no combination of physical findings and laboratory tests short of joint fluid that will definitively rule out septic arthritis. There are published clinical decision tools, but these are generally based on observational data and often have conflicting results. It requires clinical judgment; decide which patients you are worried enough about that you want to commit them to hip joint aspiration.

Question 12.1.3 What is the most appropriate treatment for this patient with transient synovitis?

A) Open fixation.

B) Immobilization.

C) Antibiotics.

D) Surgical decompression.

E) Ibuprofen and rest.

Answer 12.1.3 The correct answer is "E." Conservative treatment is warranted: the appropriate initial treatment is rest, weight bearing as tolerated, and observation. Transient synovitis generally responds well to oral NSAIDs. Home care is acceptable; however, admission is indicated if the diagnosis is equivocal or if significant pain management is required. For septic arthritis, prompt administration of an intravenous (IV) antibiotic—directed at the most likely infecting pathogen and altered as necessary based on culture results—is indicated. Surgical irrigation of the joint is often necessary and early orthopedic consultation is needed.

Objectives: Did you learn to…

• Recognize the clinical presentation of transient synovitis?

• Differentiate transient synovitis from septic arthritis?

• Treat a patient with transient synovitis?

A 6-year-old white male is brought into clinic by his parents because he is complaining of pain in his hip and anterior thigh. He is walking much less than usual since the pain began about 4 weeks ago. You order a plain radiograph, which shows mild sclerosis with some increased density of the femoral head. An MRI is ordered, which the radiologist interprets as "demonstrating osteonecrosis of the femoral head."

Question 12.2.1 What is the most likely diagnosis in this patient?

A) Osteomyelitis.

B) Septic arthritis.

C) SCFE (Slipped Capital Femoral Epiphysis).

D) LCPD (Legg-Calve-Perthes Disease).

E) Sickle cell anemia.

Answer 12.2.1 The correct answer is "D." LCPD is idiopathic osteonecrosis of the femoral head. It is unilateral in 90% of cases, and the typical age range is 4 to 8 years, but patients may be as young as 2 years and as old as 12 years. "A" is a possibility, although there should be evidence of osteomyelitis on MRI. "B" is discussed in the previous case. "C," SCFE, classically occurs in obese children (male predominance) who are 10 to 16 years old. "E," sickle cell anemia, can cause osteonecrosis of the femoral head also, but the disease is rare in white populations. LCPD is less common in black populations.

Question 12.2.2 Which of the following factors best predicts a poor outcome for patients with LCPD?

A) Later age at onset of illness.

B) Findings of subchondral fractures or fragmentation.

C) Early appropriate treatment.

D) Severity of pain and ability to bear weight.

E) Bilateral involvement.

Answer 12.2.2 The correct answer is "A." Compared to older children, younger children generally have a longer time for remodeling to occur via molding of the femoral head within the acetabulum; and therefore, younger children have less flattening of the femoral head.

Question 12.2.3 Which of the following is the best initial treatment for this patient with LCPD?

A) Joint replacement.

B) Osteotomy.

C) Rest and physical therapy.

D) Opioids.

E) Corticosteroid injection of the hip joint.

Answer 12.2.3 The correct answer is "C." The initial treatment for a patient with LCPD typically includes rest, activity restriction, and physical therapy. The objectives are to increase ROM in the hip and to reduce the risk of significant deformity. In general, patients should be seen by an orthopedic specialist. The likelihood of a good outcome with nonoperative treatment is significantly higher in younger patients, less than 8 years of age. "A" is incorrect because joint replacement is not an option. "B" is incorrect. While osteotomy may be used, it is typically reserved for older children and patients who are not progressing well with conservative therapy. "D" and "E" are not appropriate interventions in this patient with mild pain and no joint inflammation.

LCPD is difficult to treat largely because of the long duration of treatment and activity restrictions required. Periods of rest with activity restriction, physical therapy, and surgical intervention may be indicated over 1 to 2 years of treatment and observation. Even with the best of care, prognosis is fair with need for total hip replacement reaching approximately 50% by middle age due to severe degenerative arthritis.

Objectives: Did you learn to…

• Recognize the clinical presentation of LCPD?

• Manage a patient with LCPD?

A 15-year-old female cross-country runner presents to your clinic with the chief complaint of bilateral knee pain. She describes a gradual increase in her symptoms during the first 3 weeks of the season. She wants to run varsity this year and has done extra running and hill training after practice each day. She describes anterior knee pain in the patellar region with little or no swelling, but complains of crepitus and pain exacerbated by running, squatting, stair climbing, and prolonged sitting with the knee bent.

Question 12.3.1 The most likely diagnosis for the condition described is:

A) Osgood–Schlatter disease.

B) Chondromalacia patellae.

C) Patellofemoral pain syndrome (PFPS).

D) Femoral stress fracture.

E) Jogger's joints.

Answer 12.3.1 The correct answer is "C." PFPS is a common overuse syndrome seen more frequently in runners and female athletes (thus the moniker "runner's knee"). This condition is due to forces across the knee that lead to biomechanical overload of the patellofemoral joint and other anterior knee structures. Maltracking and malalignment of the patellofemoral joint can contribute to this overload, as can training errors, core weakness, and muscle imbalance. "A," Osgood–Schlatter disease, is also related to overuse but is 2 to 3 times more common in males, particularly in athletes engaging in repetitive jumping. The pain of Osgood–Schlatter is generally well localized to the tibial tubercle. Radiographic evidence of fragmentation of the epiphysis or heterotropic ossification anterior to the tubercle may be seen but is not necessary for diagnosis. "B," chondromalacia patella, is softening of the articular cartilage of the patella as seen on arthroscopy and may be a result of long-term patellofemoral dysfunction. This is a surgical diagnosis and the term should be avoided clinically. Femoral stress fracture ("D") would be unlikely to present bilaterally. "E" is not a real thing but has nice alliteration.

Question 12.3.2 What is the preferred treatment for this female runner?

A) Arthroscopic debridement.

B) Decreased activity level along with and quadriceps and hip strengthening exercises.

C) Evaluation for "Female Athlete Triad."

D) Casting or immobilization.

E) Corticosteroid injection.

Answer 12.3.2 The correct answer is "B." The most effective treatment modality is a combined physical therapy regimen consisting of strength training of the hip abductors and quadriceps, as well as quadriceps stretching. Quadriceps strengthening is usually initiated by resisted straight leg raises (SLRs) to minimize patellofemoral compressive forces. NSAIDs, cross-training, and core strengthening may also be of benefit. Adjunctive trials of therapeutic modalities such as orthotics may be considered, but should not be used in isolation. Recalcitrant cases and patients with recurrent dislocation/subluxation should be referred to your friendly neighborhood orthopedic surgeon for consideration of surgical intervention.

Three months later, the same patient presents complaining of unilateral right knee pain over the medial knee joint. Again, this pain is exacerbated by knee flexion and she notes popping and snapping when she stands from sitting. She notes that the pain is worse after prolonged sitting or going up or downstairs. Your examination shows tenderness about 1 cm medial to the patella with palpable fullness in the area.

Question 12.3.3 The most likely diagnosis is:

A) Osteosarcoma

B) Medial collateral ligament (MCL) strain

C) Plica syndrome

D) Recalcitrant PFPS

E) Meniscal tear

Answer 12.3.3 The correct answer is "C." This is the typical presentation of plica syndrome. Plicae are synovial remnants that did not resorb properly during development. They can be irritated, usually chronically or subacutely, especially in sports that require repeated flexion of the knee (e.g., rowing, cycling, running etc.). Typical symptoms include popping or snapping sensation with knee flexion; there may also be knee locking and catching as well as having the knee "give." Treatment includes rest, ice, quadriceps strengthening, and NSAIDs. If conservative management fails, steroid injection or arthroscopy may alleviate the symptoms.

Objectives: Did you learn to…

• Identify and manage PFPS?

• Recognize plica syndrome?

A mother brings her 18-month-old son in for well child check. Her only new concern today is that he seems to walk "bow-legged." He has been somewhat pigeon-toed since he could pull himself up and cruise along walls and furniture at home. On examination, you find the child's feet to be pointing inward. The foot is flexible and looks normal. The patellae are in a neutral position facing directly forward.

Question 12.4.1 What is the most likely diagnosis in this patient?

A) Cerebral palsy.

B) Excessive femoral retroversion.

C) Forefoot varus.

D) Internal tibial torsion.

E) Bilateral developmental dysplasia of the hip (DDH).

Answer 12.4.1 The correct answer is "D." This represents a case of intoeing (pigeon-toeing), which is often caused by internal tibial torsion. Internal tibial torsion is characterized by a flexible, normal foot, with the patellae in a neutral position. The condition can be diagnosed by examining the child on his knees. Normally, there should be approximately 30 degrees of external rotation of the feet in this position. With internal tibial torsion, the toes will be pointing inward. In addition, when the child is sitting with legs dangling over a table, the lateral malleolus will be anterior to the medial malleolus, which is the opposite of what is normally observed. Finally, the hips must be normal in order to confirm this diagnosis. "A" is incorrect because you would expect other findings in a patient with cerebral palsy. "B" is incorrect. In fact, femoral retroversion is synonymous with "outtoeing," which is the opposite of intoeing (of course!). Excessive femoral anteversion can be a cause of intoeing. "C" is incorrect because the foot examination does not show varus deformity. Finally, "E" is incorrect, although bilateral DDH can be quite difficult to diagnose if not caught early in the newborn period. With DDH one would expect external rotation of the leg rather than intoeing.

Question 12.4.2 What is the treatment of choice for this child?

A) Referral for bilateral osteotomy.

B) Shoe modification and bracing.

C) Physical therapy referral.

D) Serial casting.

E) Reassurance and watchful waiting.

Answer 12.4.2 The correct answer is "E." Spontaneous resolution is the norm for most intoeing and outtoeing deformities. Most will spontaneously correct by age 6. Children continuing to have difficulty with persistent trips and falls or grossly unsightly gait beyond this time may benefit from a rotational osteotomy. Children with neuromotor disorders and cerebral palsy are more likely to require surgical intervention.

Objective: Did you learn to…

• Evaluate and manage intoeing and outtoeing in children?

A 13-year-old male presents to the clinic with his mother for difficulty walking. He is unsure of when the problem first began, but has noticed it getting worse over the last week. It has forced him to stop playing sports. He reports a dull pain in the left hip but denies trauma. On examination, you find an obese male in no distress. There is loss of internal rotation, abduction, and flexion at the left hip joint. When his hip is flexed to 90 degrees, this loss of ROM is more pronounced.

Question 12.5.1 What is the most likely diagnosis in this case?

A) Osteoarthritis.

B) Septic arthritis.

C) SCFE.

D) LCPD.

E) Juvenile rheumatoid arthritis.

Answer 12.5.1 The correct answer is "C." SCFE occurs most commonly in active, overweight, adolescent males. Shear forces across the relatively weak physis causes displacement. Slippage is generally gradual, but may occur acutely. Mean age at presentation is 12 for females (range 10–14) and 13 for males (range 11–16). Endocrinopathies, such as hypothyroidism and osteodystrophy, should be considered in those presenting atypically or outside the typical age range. Watch for development of a similar process in the contralateral hip over time, which has been reported anywhere from 20% to 80% of the time.

Question 12.5.2 Which of the following is the first study you order to confirm the diagnosis?

A) AP and frog-leg lateral radiographs of the hip.

B) CT scan of the hip/pelvis.

C) MRI of the hip/pelvis.

D) ESR.

E) None; physical examination is sufficient.

Answer 12.5.2 The correct answer is "A." Radiographs of the hip should demonstrate displacement of the femoral head, which can then be classified as mild, moderate, or severe. "B" and "C" are incorrect because the radiograph is diagnostic in most cases. "D" is incorrect since SCFE is not an inflammatory condition. "E" is incorrect. Imaging should be obtained in order to confirm the diagnosis and rate the severity. MRI may be able to diagnose an early SCFE when radiographs are negative.

Question 12.5.3 The treatment of choice for this patient is:

A) Antibiotics.

B) Immobilization.

C) Physical therapy.

D) Surgical decompression.

E) Surgical fixation.

Answer 12.5.3 The correct answer is "E." The goals of treatment of SCFE are to prevent further slippage, promote closure of the physis, and to minimize the risk of osteonecrosis or chondrolysis. These aims are best accomplished through referral to an orthopedic surgeon and, ultimately, surgical fixation. "B" and "C" are incorrect because they delay definitive therapy and will not produce the desired result. "A" and "D" are incorrect because SCFE is not an infectious process.

Objectives: Did you learn to…

• Recognize the clinical presentation of a child with SCFE?

• Treat a patient with SCFE?

A worried mother presents with her 4-year-old son for evaluation of lower extremity pain. She reports the boy has complained of some vague bilateral leg pains over the past several weeks after vigorous physical activities. She became alarmed after he had awakened the past two nights crying in pain. The boy reports the pain is hardly noticeable during the day. Recently, the pain has been in the bilateral distal thighs; however, his mother notes times of unilateral pain. The boy and his mother both deny constitutional symptoms now or over the past several weeks. Examination reveals an afebrile, well-developed male in no distress. The musculoskeletal examination is normal.

Question 12.6.1 The most likely diagnosis for the condition described above is?

A) Ewing sarcoma.

B) Growing pain.

C) Kohler disease.

D) Leukemia.

E) Osteochondritis dissecans.

Answer 12.6.1 The correct answer is "B." Growing pain is a diagnosis of exclusion, although history and physical examination usually suffice for excluding more serious diagnoses. It is a condition of unknown etiology, but is thought by some to be a result of overuse/over activity on an immature musculoskeletal system. It is most frequently seen in otherwise healthy, active children aged 2 to 5, with some older children affected as well. Pain is commonly bilateral or/and localized to the calf, but may be felt at the ankle, knee, or thigh. Pain may be felt during the day after vigorous activities but is more common in the evening or causing awakening at night. Presentation with constitutional symptoms should lead to radiographic and/or metabolic evaluation.

Question 12.6.2 Which of the following should you entertain when a patient presents with typical growing pain?

A) Osteomyelitis.

B) Malignancy.

C) Juvenile rheumatoid arthritis.

D) All of the above.

E) None of the above.

Answer 12.6.2 The correct answer is "D." It is important to consider other potential causes of what would otherwise appear to be growing pain. Although you may not find it necessary to perform any laboratory or radiologic studies, you should at least keep these and other diagnoses in mind when taking your history and performing your examination. Remember, growing pain is a diagnosis of exclusion.

Question 12.6.3 Treatment for growing pain includes:

A) Reassurance, rest, and short-term use of NSAIDs.

B) Amputation.

C) Chemotherapy and radiation.

D) Casting and bracing followed by physical therapy.

E) Staging of the disease is required prior to initiation of therapy.

Answer 12.6.3 The correct answer is "A." OK, so this was just a fun one. Do not do anything drastic for a benign condition! Those of you who chose "B," amputation, will find themselves in one of Dante's circles (or in court—which is worse?) … and clearly need a coffee break.

The same boy returns with his mother years later. He is now 12 years old and requires a physical examination for junior high school sports. You plan to evaluate him for scoliosis.

Question 12.6.4 Which of the following screening methods is the most sensitive for detecting scoliosis?

A) Observe the patient from the front with a loose-fitting shirt on. Measure the difference in shoulder height.

B) Observe the patient from behind, with shirt off, while he bends forward at the waist. Look for elevation of the ribs or paravertebral muscle mass on one side.

C) Observe the patient from the front, with shirt off, while he bends forward at the waist. Look for elevation of the ribs or paravertebral muscle mass on one side.

D) Observe the patient from the side, with shirt off, while he bends forward at the waist. Look for elevation of the ribs or paravertebral muscle mass on one side.

Answer 12.6.4 The correct answer is "B," which is known as the "forward bending test." This test is more sensitive than the other methods described. The forward bending test is accomplished by having the patient bend at the waist with feet together and hands hanging free. Observe the patient from behind and note any elevation of the ribs or paravertebral muscle mass on one side. The elevation should be measured in degrees (inclinometers are available), and an inclination of 5 degrees or more should be evaluated further. Options "A," "C," and "D" are not accepted methods of screening for scoliosis.

On forward bending test, you find slight elevation of the left paravertebral muscles mass, which you estimate to be 7 degrees. The remainder of the examination is normal. You decide to obtain radiographs that show 12 degrees of angulation (Cobb angle).

Question 12.6.5 This patient's scoliosis is most likely:

A) Congenital.

B) Idiopathic.

C) Related to a tumor.

D) Secondary to infection.

Answer 12.6.5 The correct answer is "B." Most scoliosis that develops during adolescence is idiopathic. When there is no pain, fever, weight loss, or other warning signs (e.g., neurologic symptoms), the curvature is unlikely to be due to tumor or infection. "A," congenital scoliosis, typically presents earlier in life.

Question 12.6.6 The most appropriate initial management plan for this patient includes:

A) Bracing.

B) Observation.

C) Physical therapy.

D) Surgery.

Answer 12.6.6 The correct answer is "B." In an otherwise healthy patient with a curvature measured at <25 degrees, observation is appropriate. "C" is incorrect because physical therapy and exercise regimens do not seem to limit the progression of scoliosis. "A" and "D" are incorrect because bracing and surgery are typically not warranted for this degree of scoliosis. Repeat examination and possibly repeat radiographs are warranted, but if the scoliosis remains stable and mild, the patient is not likely to experience any significant progression of disease with aging.

The mother returns now with her 2-year-old daughter who is refusing to move her right arm. Earlier today she threw a tantrum at the store when her father refused to buy her the new "princess toy" (advertising hits them young). Dad was holding on to her arm when she flopped to the floor. She immediately began crying and refusing to move her right arm. In the office, she is well but holds her right arm adducted, flexed, and pronated. (The princess toy is in the other hand. Guilt is a powerful weapon.) Despite every trick you know, you can't get her to move that arm. You inspect and palpate the entire extremity and clavicle and find no crepitus, swelling, or tenderness.

Question 12.6.7 What is your next diagnostic step?

A) Obtain an x-ray of the elbow.

B) Actively supinate the forearm and flex the elbow while applying pressure over the radial head.

C) Actively twist the forearm at the elbow 360 degrees.

D) Consult orthopedics.

E) Perform a skeletal survey, mostly to bide time.

Answer 12.6.7 The correct answer is "B." This child has a "nursemaid's elbow" that is due to subluxation of the annular ligament rather than subluxation or dislocation of the radial head. It occurs in toddlers due to traction via pulling on a pronated and extended arm. Symptoms are immediate and care is sought due to child's refusal to move the arm. The diagnosis is clinical. Manual reduction may be done via supination/flexion or hyperpronation. Sedation is not needed. A palpable click may be felt. The child usually regains immediate movement of the arm and relief of discomfort. Immobilization is not needed but parents should be told that recurrent subluxations may occur and therefore pulling on the arm should be avoided. "A" would be correct if there was concern for a fracture based on findings of swelling, history of trauma, or focal tenderness. "C" is impossible: Can you really rotate a joint 360 degrees? "D" is incorrect as any primary-care provider may manage this. "E" is unnecessary as a nursemaid elbow is not a marker of abuse, although traumatic injuries in children should always make one consider abuse.

After successful reduction, you see the same 2-year-old child a month later presenting to your clinic with the parents who state that the child has been crying and has refused to walk since tripping over a toy a couple of hours ago. You look at the child and find no signs of abuse. The injured area is represented by the lower leg image in Figure 12-1.

FIGURE 12-1.

Question 12.6.8 Your approach at this point is to:

A) Consult Child Welfare since this is almost always abuse

B) Consult orthopedics for casting and further treatment.

C) No treatment necessary for this particular fracture in a 2-year-old.

D) Obtain an MRI.

Answer 12.6.8 The correct answer is "B." This is a typical "toddler's fracture" that consists of a spiral fracture of the tibia usually from insignificant rotational trauma (e.g., running and falling with a twisting motion). There should not be an associated fibular fracture. "A" is incorrect because this type of fracture is not usually from abuse. A mid-shaft fracture would more likely be from abuse. "C" is incorrect because this fracture needs to be treated.

Objectives: Did you learn to…

• Consider a broader differential diagnosis in a patient presenting with typical "growing pain?"

• Initiate conservative treatment for a patient with growing pain?

• Screen a patient for scoliosis?

• Develop an approach to the adolescent with scoliosis?

• Recognize the clinical presentation and treatment of a "nursemaid's elbow" (radial head subluxation)?

• Recognize a toddler's fracture?" (tibial spiral fracture).

A mother presents to your clinic with her 10-month-old son. She is concerned that he has been very irritable since she arrived home from work, particularly when his legs are touched. She states that he has been crying "nonstop" since she arrived home. He was well when she left for work this morning, leaving the patient under the care of her boyfriend, Tony "the Hustler" Jones. The patient's mother denies any fevers, vomiting, diarrhea, or cough. On examination, he is generally fussy, worsening with palpation of his left leg, particularly around his knee. You also note five bruises on his anterior and posterior chest. The remainder of the examination is unremarkable. You obtain the following radiograph of his left knee (Fig. 12-2).

FIGURE 12-2.

Question 12.7.1 Which of the following mechanisms is most likely responsible for the fracture seen on x-ray (marked with the helpful arrow sign)?

A) A low-energy fall (fall off a low couch).

B) A high-energy fall (fall out of a second story window).

C) A low-energy rotational force (tripping causing the foot to twist inward).

D) A high-energy tension or shearing force (a violent twisting of the leg).

E) Any of the above could result in the injury.

Answer 12.7.1 The correct answer is "D," a high-energy tension or shearing force. The above radiograph depicts a metaphyseal corner fracture that is highly specific for nonaccidental trauma (that's the nice way to say "child abuse"). These fractures are typically caused by shaking of the child with flailing of the extremities or with forceful yanking or twisting or the arm or leg. The incidence of these fractures decreases substantially as children grow beyond 1 year of age.

Question 12.7.2 In which of the following patients is a skeletal survey indicated for concern of nonaccidental trauma?

A) A 2-month-old male with multiple bruises but no other localizing injuries.

B) A 2-year-old female with an intracranial injury on brain CT.

C) A 6-month-old male with a known metaphyseal corner fracture.

D) An 18-month-old female with burns consistent with nonaccidental trauma.

E) A skeletal survey is indicted for all the above patients.

Answer 12.7.2 The answer is "E," all of the above. The American Academy of Pediatrics consensus guidelines on the radiographic evaluation of child abuse state that a skeletal survey should be obtained for all children younger than 2 years of age who may have experienced maltreatment. Skeletal surveys should also be considered for children between the ages of 2 and 5 depending on the clinical scenario. The following images are generally included in a skeletal survey: humeri, forearms, lower legs, hands, feet, skull, cervical spine, thorax (including oblique views), lumbar spine, and pelvis.

Question 12.7.3 Which of the following fractures is considered highly specific for nonaccidental trauma?

A) Posterior rib fractures.

B) Clavicle fractures.

C) Distal radius fractures.

D) Spiral fractures of the tibia.

E) Supracondylar fractures.

Answer 12.7.3 The correct answer is "A," posterior rib fractures. In addition, the following fractures have moderate to high specificity for nonaccidental trauma: metaphyseal fractures, multiple fractures (especially if bilateral), fractures of different ages, epiphyseal separations, vertebral body fractures, digital fractures, scapular fractures, sternal fractures, and complex skull fractures.

Objectives: Did you learn to…

• Recognize a metaphyseal corner fracture and what implications this fracture has?

• Know the indications to perform a skeletal survey when suspecting nonaccidental trauma and what images are included?

• Understand which fractures are specific for nonaccidental trauma?

A 35-year-old obese female with a large pannus presents with a burning pain in anterior–lateral thigh. It started when she bought a new wide belt (ornate with skulls and Harley–Davidson logos) and started wearing hip hugger pants in order to display her tasteful sacral tattoo (yikes!). The pain seems worse on days when she wears the belt and seems better on days when she hangs out au naturel at home.

The most likely diagnosis is:

A) Meralgia paresthetica.

B) Supratrochanteric bursitis.

C) Tropical pyomyositis.

D) Ruptured plantaris muscle.

E) Trucker's thigh.

The correct answer is "A." Meralgia paresthetica is described as a burning pain in the anterior–lateral thigh and is caused by compression of the lateral femoral cutaneous nerve. It is most common in those who wear tight jeans and wide belts and who are obese. Treatment is to relieve the inciting cause. Tricyclic antidepressants or other medication for neuropathy may also be helpful. "B," supratrochanteric bursitis, occurs when there is inflammation of the bursa over the greater trochanter of the femur. Patients complain of pain in the lateral hip and outer thigh. There is point tenderness over the greater trochanter. Treatment is physical therapy for core strengthening and a steroid injection of the bursa. "C," tropical pyomyositis, is a deep infection of the muscle that is often caused by Staphylococcus aureus. It is increasingly recognized in the United States. "D," a ruptured plantaris muscle, occurs in the calf and is not related to the thigh. It is often caused by planting of the foot forcefully (such as in tennis or basketball) and patients may report a "pop" followed by calf/gastrocnemius pain. "E" is not a real thing, we are sorry to say.

A concerned father presents to your clinic with a 1-month-old daughter. He is worried that his daughter appears to be pigeon-toed, and his mother-in-law is sure (as most mothers-in-law are) that the child will need immediate surgery for correction. Your examination reveals a pleasant, well-developed 1-month-old female with moderate medial deviation of the forefoot bilaterally. A line bisecting the heel passes through the fourth toe on each foot. The lateral borders of the feet are convex; the heels are in a normal neutral position. The feet are flexible and the deformity can be passively corrected to the midline.

Question 12.8.1 The above description is best characterized as?

A) Clubfoot.

B) Internal tibial torsion.

C) Flexible flatfoot.

D) Excessive femoral anteversion.

E) Metatarsus adductus.

Answer 12.8.1 The correct answer is "E." The above is a classic description of the foot shape of metatarsus adductus. In the normal foot, a line bisecting the heel would pass through the second and the third toe webspace. In those with metatarsus adductus, it passes more laterally depending on the severity. In those with the most severe deformity, a line bisecting the heel would pass through the fourth and the fifth toe webspace. In addition to the heels remaining in a neutral position—indicating that the problem is isolated to the shape of the foot and not to an internal rotation of the tibia—the forefoot is flexible and easily straightened into normal position. This is as opposed to metatarsus varus in which the forefoot is rigid.

Question 12.8.2 The most appropriate treatment for the above case would be?

A) Surgical re-construction.

B) Serial casting.

C) Physical therapy referral for stretching and exercise.

D) Watchful waiting and reassurance.

E) Orthopedic outflare shoes.

Answer 12.8.2 The correct answer is "D." Spontaneous correction occurs in most children. Parents can begin a regimen of gentle foot stretching. It gives them something to do but does not change the outcome. Care should be taken to avoid keeping the child in the prone position with the feet in an inward position. If the deformity is severe and inflexible, serial casting and/or surgical intervention may be indicated. A rigid metatarsus adductus in a child >3 months or a residual problem in a child with a flexible metatarsus adductus >6 months is an indication for pediatric orthopedic referral.

Objectives: Did you learn to…

• Identify a patient with metatarsus adductus?

• Discuss treatment approaches to metatarsus adductus?

A 5-year-old girl who has recently recovered from chicken pox ("Thank you, anti-vaccine parents!") presents with her mother for evaluation of left leg pain and refusal to walk. The mother reports that she has complained of worsening pain over the last 4 to 5 days. She started to limp noticeably yesterday and refused to walk this morning. Also, the mother reports general malaise and subjective fever. The patient complains of pain over the distal thigh and knee. The mother has not seen any swelling of the knee, and the patient denies trauma.

Examination reveals a pleasant 5-year-old female who appears uncomfortable, but nontoxic and in no acute distress. Her temperature is 38.5°C. The left distal thigh (not the joint) is painful to palpation, and slightly warm. The knee joint has no effusion and the ROM is full with only mild discomfort on knee motion. There is no hip joint involvement.

Question 12.9.1 What is the most common bacterial pathogen associated with this patient's condition?

A) Group A Streptococcus.

B) Group B Streptococcus.

C) Haemophilus influenzae.

D) S. aureus.

E) None of the above. This is not an infection.

Answer 12.9.1 The correct answer is "D." The acute nature of the symptoms, presence of fever, and minimal involvement of the joint makes osteomyelitis the most likely diagnosis. In addition, osteomyelitis is associated with chicken pox in children. There is clearly an increase in the prevalence of MRSA as a pathogen in osteomyelitis (two-thirds of cases in a recent review). Thus, it is wise to choose an antibiotic with MRSA coverage.

Allow us to digress.

Question 12.9.2 The most common organism causing osteomyelitis in patients with sickle cell disease is:

A) Neisseria gonorrhoeae (Gonococcus).

B) Polymicrobial.

C) Salmonella species.

D) S. aureus.

E) Streptococcus species.

Answer 12.9.2 The correct answer is "C." Staphylococcus is responsible for the majority of bone infections in the general population. Salmonella species are responsible for up to 85% of bone and joint infections in patients with a history of sickle cell disease with E. coli another important player.

Question 12.9.3 Identification of the pathogen in a case of osteomyelitis is typically made by:

A) ASO titer.

B) Blood culture.

C) Joint aspiration, culture, and Gram stain.

D) Pathology report following open biopsy.

E) Witchcraft.

Answer 12.9.3 The correct answer is "B." A blood culture will reveal the offending organism in 40% to 50% of cases. Joint aspiration is not typically indicated unless there is strong evidence of joint involvement. It can take weeks for changes to be seen on plain film radiographs. Therefore, MRI is the imaging modality of choice. CT or bone scan can also be used if MRI is not available or contraindicated. If changes are identified and a neoplastic process is ruled out, aspiration at the site of periosteal elevation and bony destruction should be considered if a pathogen has not yet been identified by blood culture. "A," an ASO titer, would not be helpful here since this test for Streptococcus pyogenes infection. An ASO titer would be helpful if looking for rheumatic fever. "D," surgical biopsy, may be required if blood cultures do not reveal a pathogen and the patient is not responding appropriately to empiric antibiotics.

Objectives: Did you learn to…

• Diagnose osteomyelitis in a child?

• Identify common pathogens involved in osteomyelitis?

A 45-year-old female with a history of rheumatoid arthritis, on chronic low-dose prednisone, presents to your clinic with 2 days of right knee pain. The patient reports that her knee has been swollen and painful to touch, and she now is having difficulty bearing weight due to the pain. She has had previous knee pain, but nothing this severe. She denies any trauma, fevers, chills, knee surgery, illegal drug use, or risky sexual behavior. On examination, she is well appearing, afebrile, and has a moderate right knee effusion with limited ROM. There is no overlying erythema, but the knee feels warm to touch.

Question 12.10.1 Which of the following diagnostics is the most valuable to rule in or rule out the diagnosis with the highest potential morbidity?

A) Plain films of the affected knee.

B) WBC count.

C) ESR.

D) Arthrocentesis.

E) MRI.

Answer 12.10.1 The correct answer is "D." The most concerning diagnosis with the highest potential morbidity in this patient is septic arthritis. Her history of rheumatoid arthritis as well as long-term steroid use put her at high risk. In a patient in whom you are concerned about septic arthritis, the most important piece of diagnostic data that you can obtain comes from synovial fluid analysis. While plain radiographs, a WBC count, an ESR, and CRP may be obtained (your friendly neighborhood orthopedic surgeon will surely want to know them), they are neither sensitive nor specific enough to rule in or rule out septic arthritis in a high-risk patient.

Question 12.10.2 Which of the following signs or symptoms has sufficient sensitivity to rule out septic arthritis if absent?

A) Joint edema or effusion.

B) Fever.

C) Sweats.

D) Significantly restricted ROM.

E) None of the listed signs or symptoms has sufficient sensitivity to rule out septic arthritis, if absent.

Answer 12.10.2 The correct answer is "E." Unfortunately, there are no clinical signs or symptoms that have sufficient sensitivity to rule out septic arthritis. Signs and symptoms should raise clinical suspicion, however the only definitive diagnostic modality is arthrocentesis.

You effortlessly obtain 10 mL of cloudy synovial fluid that is sent to the lab for Gram stain, culture, cell count with differential, glucose, and crystal analysis. The Gram stain is negative with cultures pending. The synovial WBC count is 51,000/μL with >90% polymorphonuclear cells. The crystal analysis shows calcium pyrophosphate crystals. You obtain a peripheral WBC count that is 11,000/μL and an ESR is 55 mm/hr.

Question 12.10.3 What is the most appropriate next course of action based on these findings?

A) Prescribe high-dose prednisone for a flair of her rheumatoid arthritis.

B) Start IV antibiotics and obtain emergent orthopedic consultation.

C) Treat her for pseudogout.

D) Recommend rest, ice, compression, and a prescription for oxycodone.

Answer 12.10.3 The correct answer is "B." Various cutoffs for synovial WBC counts have been proposed, ranging from >25,000/μL to >100,000/μL in native joints, with sensitivities ranging from 30% to 77% (Table 12-2). Cutoffs are much lower in patients with prosthetic joints. A prosthetic joint with WBC count of >1,700/μL may be up to 94% sensitive for septic arthritis. A synovial WBC count of 51,000/μL does not rule out septic arthritis in this patient. When the percentage of polymorphonuclear cells is >90%, this significantly increases the likelihood of septic arthritis. Don't let the calcium pyrophosphate crystals dissuade you from suspecting septic arthritis as both gout and pseudogout coexist with septic arthritis up to 25% of the time (J Rheumatol. 2012;39:157).

Objectives: Did you learn to…

• Recognize the clinical presentation of septic arthritis?

• Understand the limitations of using signs and symptoms to rule out septic arthritis?

• Describe the appropriate work-up for a patient with suspected septic arthritis?

A 55-year-old obese female comes to your office complaining of knee pain when she walks. She had an MRI at an urgent care center, which showed some meniscal damage. She is tender inferiorly and medial to the patella on the proximal tibia (but not on the joint line).

Which of the following is true?

A) Washing out her knee by arthroscopy will help to relieve her symptoms.

B) The finding of a meniscal injury on MRI correlates well with symptoms of pain.

C) Based on its location, pes anserinus bursitis is the likely cause of her pain.

D) Baklava is Dr. Wilbur's favorite food.

The correct answer is "C." The pes anserine ("goose's foot") bursa is located on the medial, proximal aspect of the tibia and is where the tendons of the sartorius, gracilis, and semitendinosus attach. It often becomes inflamed causing significant and chronic knee pain. Conservative therapy with rest, ice, NSAIDs, and stretching may be tried initially. However, these often fail; most patients experience significant improvement with corticosteroid injections. "A" is incorrect. Several studies have found that washing out the knee and trimming the cartilage is of no benefit. "B" is also incorrect. MRI of the knee is not particularly useful for determining if a meniscal injury is the source of pain. Similar to herniated disks, many asymptomatic patients have meniscal injuries on MRI limiting our ability to assign symptoms to an MRI finding. This is especially true in the elderly with arthritis where >90% will have meniscal damage. As to "D," it obviously does not relate to the case. We call that "test taking skill." If you chose "D," woe is with you.

The most common organism causing septic arthritis in the teenage years is:

A) N. gonorrhoeae (Gonococcus).

B) Polymicrobial.

C) Salmonella species.

D) S. aureus.

E) Streptococcus species.

The correct answer is "A." Gonococcus is the most common organism isolated from the joints of sexually active, teenage individuals.

A 28-year-old male presents to your clinic for evaluation of lower-back pain (LBP). Yesterday morning he first noticed the discomfort, manifesting as stiffness and soreness in the lower back. The day before had been spent running a floor polisher. He describes his pain as sharp in nature and 8/10 in intensity. He denies radiation of the pain, sensory changes, and constitutional symptoms. He is concerned this may be an injury to a disk and that he may be permanently disabled due to his extreme pain.

Question 12.11.1 Which of the following signs or symptoms would be "red flags" indicating the need for early imaging and/or referral?

A) Pain radiating down one or both legs into the posterior thigh.

B) Severe pain, prompting the patient to request narcotics.

C) Pain greater with active lumbar extension than with forward flexion.

D) New onset erectile dysfunction with back pain.

E) None of the above.

Answer 12.11.1 The correct answer is "D." The onset of erectile dysfunction is suggestive of neurologic involvement and warrants further investigation. None of the other options are suggestive of significant disease requiring immediate intervention ("A" certainly could represent disk disease; however, this does not require immediate intervention). Of note, spontaneous erections without sexual stimulation can also be a sign of neurologic involvement.

Question 12.11.2 Early imaging should be obtained in all of the following presentations of LBP EXCEPT:

A) Neurologic symptoms such as bowel or bladder dysfunction and impotence.

B) History of fever, night sweats, and weight loss.

C) History of cancer.

D) Trauma.

E) Age >30 years.

Answer 12.11.2 The correct answer is "E." Patients over the age of 50 should have early imaging. See Table 12-3 for other criteria that should prompt early imaging.

Upon physical examination, you note the vital signs are normal. Straight leg raise (SLR) testing on the right leg at 55 degrees reproduces the patient's pain in the lower back and a painful "tightness" in the posterior thigh. He complains of the same discomfort on the left at 30 degrees.

Question 12.11.3 Based on these findings, which of the following statements is true?

A) This is a positive SLR test bilaterally and is specific for disk herniation.

B) This is a positive SLR test on the left and is specific for disk herniation.

C) This is a positive SLR test on the right and is specific for disk herniation.

D) This is a negative SLR test bilaterally.

Answer 12.11.3 The correct answer is "D." The SLR test can be performed in several ways, which are listed here.

• Seated active: with the patient seated on the examination table, the patient dorsiflexes the foot and extends the knee.

• Seated passive: with the patient seated on the examination table, the examiner passively extends the knee, and radicular symptoms will be exacerbated with passive ankle dorsiflexion.

• Lying passive: with the patient in a supine position, the examiner holds the knee in full extension and passively flexes the hip, and radicular symptoms will be exacerbated with passive ankle dorsiflexion.

In all cases, the test is positive when radicular symptoms occur (e.g., pain and paresthesias down the leg below the level of the knee—not back or thigh pain from muscle stretching) between 25 and 75 degrees of hip flexion while lying or with knee extension while seated. The symptoms will be exacerbated with active or passive ankle dorsiflexion. However, the SLR is neither sensitive nor specific for disk disease. "Crossover" pain with radicular symptoms in the leg not lifted is very specific for disk disease but is not very sensitive.

Even though SLR is negative, you continue your neurologic examination. You note symmetric patellar reflexes, diminished Achilles reflex on the right, and symmetric strength in the legs except for decreased strength with right foot plantar flexion. You also note decrease in gross sensation to light touch over the right lateral foot.

Question 12.11.4 Which of the following nerve roots is most likely compromised?

A) L3.

B) L4.

C) L5.

D) S1.

E) S2–4.

Answer 12.11.4 The correct answer is "D." A summary of nerve root innervation is given in Table 12-4.

Question 12.11.5 Appropriate initial treatment for this patient's acute back pain should include which of the following?

A) Strict bed rest.

B) Pain control.

C) Corset or lumbar belt.

D) Referral for epidural steroid injection or endoscopic disk resection.

E) A and B.

Answer 12.11.5 The correct answer is "B." In acute mechanical back pain (no longer than 6 weeks), regardless of the method of treatment, 40% are better within 1 week, 60% to 85% in 3 weeks, and 90% in 2 months. Negative prognostic factors include more than three episodes of back pain, gradual onset of symptoms, and prolonged absence from work. Bed rest does not contribute to a return of function and may worsen outcomes. Early mobilization of the patient is best for allowing him to continue activities as tolerated. Acetaminophen is a great drug for pain control and has fewer side effects than do the NSAIDs. Chiropractic care may be useful. Data on acupuncture are mixed.

You prescribe your pain medication of choice and recommend rehabilitation exercises.

Question 12.11.6 Which of the following has been shown to be effective at reducing the recurrence of back injury in the workplace?

A) Back support belts.

B) "Back School" that teaches proper lifting techniques, stretches, etc.

C) Increasing physical fitness and muscle tone.

D) A and C.

E) B and C.

Answer 12.11.6 The correct answer is "C." The only thing that has been unequivocally shown to reduce further back injuries is improving the overall fitness of the patient and his muscle tone. Of special note, back support belts, long worn in industry, have equivocal data with most studies being negative. "Back School" also does not seem to help.

Objectives: Did you learn to…

• Generate a differential diagnosis and understand the etiology of lumbar spine pain?

• Evaluate and treat acute LBP?

• Recognize warning signs of LBP?

Spondylolysis commonly occurs in which part of the spine?

A) Cervical spine lateral processes.

B) Thoracic spine pars interarticularis.

C) Thoracic spine lateral processes.

D) Lumbar spine pars interarticularis.

The correct answer is "D." Spondylolysis is characterized by pars interarticularis stress fractures and most commonly occurs in the lumbar region.

Anterior slippage of one vertebra on another is called:

A) Spondylolysis.

B) Spondylolisthesis.

C) Spondylitis.

D) Spondyloarthropathy.

E) Scheuermann disease.

The correct answer is "B." Slippage of one vertebra on another is called spondylolisthesis. "A," spondylolysis, is discussed above. Spondylolysis can lead to spondylolisthesis. Spondyloarthropathy is a nonspecific term referring to inflammation of the spine and encompasses such diseases as ankylosing spondylitis, Reiter disease, enteropathic arthritis, etc. Spondylitis is a more specific term for the same thing (e.g., ankylosing spondylitis). "E," Scheuermann disease, is a process causing kyphosis by compression of the vertebrae (at least 5 degrees of wedging in three consecutive vertebrae). The cause is unknown but it tends to present in adolescence.

Spondylolisthesis is graded based on the degree of slipping of one vertebra on the other. Which of the following patients would need surgical consultation?

A) Grade one (<25% slip) with no symptoms in an early teen (12–14).

B) Grade 2 (25–50% slip) with no symptoms in an early teen (12–14).

C) Grade 3 (50–100% slip) with mild pain in a 20 year-old college gymnast.

D) When slippage is 10% to 15% with no symptoms in a patient >60 years old.

E) When slippage is 25% with no symptoms in a patient >60 years old.

The correct answer is "C." Spondylolisthesis is generally a problem in the late teens and 20s. Patients often become symptomatic when there is 25% slippage or greater. Mild degrees of slip can be treated conservatively, although surgical treatment threshold varies considerably among orthopedic surgeons. Predisposing factors include recurrent lumbar hyperextension (gymnasts, football players, etc.), although many patients do not have an identifiable cause. Any adolescent athlete who presents with back pain that is made worse by hyperextension should raise your suspicion. Older patients who are asymptomatic do not need to be considered for surgical treatment unless the slip is grade 4 (100% or greater).

A 4-year-old boy presents to your office accompanied by his mother who says he has a limp and LBP. This has been getting progressively worse over the past 2 weeks. When the patient sits, he sits in a "tripod" position supporting his weight on his hands. Vitals are normal without a fever and a CBC is normal.

This history is most consistent with:

A) Discitis.

B) Occult fracture.

C) Growing pains.

D) Juvenile rheumatoid arthritis.

E) Mechanical low back strain.

The correct answer is "A." This history is most consistent with discitis. Discitis is an inflammatory process of the disk usually found in children age infancy to 3 years but may occur at any age. The etiology is usually Staphylococcus (low-grade infection) but there may be sterile inflammation. Fever is usually absent in discitis (seen in only 25%), and blood cultures are sterile. The white count is usually normal, although ESR is elevated in 90%. Treatment is not standardized, but most experts would include anti-staphylococcal antibiotics. "B," occult fracture, is unlikely in a child this age. "C," growing pains, does not present with back pain (see the discussion of growing pains earlier in this chapter). Juvenile rheumatoid arthritis presents with small joint involvement as opposed to back pain.

A 24-year-old male presents to the clinic 2 days after a collision during a softball game in which he fell on his outstretched right hand ("But I made the play!" he exclaims). He reports he could not continue playing and that his pain has not improved. He has some general edema around the right wrist, poor grip strength secondary to pain, point tenderness over the radial aspect of the wrist ("snuff box tenderness"), and decreased ROM. There is no obvious deformity, and he is neurovascularly intact.

Question 12.12.1 Of the following, what would be the most likely diagnosis for this patient?

A) Colles fracture.

B) Scaphoid fracture.

C) Smith fracture.

D) Extensor carpi radialis strain.

E) Scapholunate sprain.

Answer 12.12.1 The correct answer is "B." Although all of these could be in the differential diagnosis, "B" is the most likely based on mechanism of injury and clinical findings. The scaphoid spans both the proximal and distal carpal row. In this position, it is quite vulnerable to high-impact injuries, such as a fall on an out-stretched hand, and is the most commonly fractured carpal bone. The absence of deformity makes a Colles or Smith fracture less likely (options "A" and "C"). Further, a sprain or a strain (options "D" and "E") are less likely given the bony point tenderness, decreased range of motion, and overall nonimprovement with conservative measures.

Plain film radiographs, including AP and lateral of the hand and wrist as well as scaphoid views, are negative for fracture.

Question 12.12.2 What is the most appropriate next step for this patient?

A) Short-arm thumb spica cast with follow-up in 10 to 14 days.

B) NSAIDs, ice, compression, and elevation followed by physical therapy.

C) MRI or CT to rule out an occult fracture.

D) Orthopedic referral.

E) Return to play within the week.

Answer 12.12.2 The correct answer is "A." Scaphoid fractures are often occult acutely and usually will be evident on plain films after 10 to 14 days due to bony resorption along the fracture line. If repeat films are negative but suspicion remains high, an MRI or CT should be considered.

Repeat wrist radiographs including scaphoid views 2 weeks post injury indicate a nondisplaced fracture of the proximal pole of the scaphoid.

Question 12.12.3 You recommend which of the following treatment plans?

A) Wrist and thumb spica splint and physical therapy because good blood supply at the proximal pole allows fast healing.

B) Thumb spica cast for 6 weeks then repeat x-rays.

C) Short-arm cast excluding the thumb for 4 to 6 weeks.

D) Orthopedics referral for open reduction/internal fixation.

E) B or D.

Answer 12.12.3 The correct answer is "E." It is clear that a spica cast with the thumb included is important; whether a short- or long-arm cast is optimal is still a matter of debate. Open fixation is another option. Generally, an orthopedic surgeon should oversee treatment of scaphoid fractures since the complication rate is high. A proximal pole fracture has high risk for nonunion and avascular necrosis (90%). The blood supply to the scaphoid is through the distal pole, putting the proximal pole at high risk for complications. Evidence of healing may not be well visualized on plain films, and a CT or MRI may be needed to confirm the degree of healing. The closer the fracture line is to the proximal pole, the lower the threshold for orthopedic referral.

Objectives: Did you learn to…

• Recognize a patient at risk for scaphoid fracture?

• Manage a patient with a scaphoid fracture?

A patient presents after "jamming" his index finger while playing basketball. He has mild swelling at the DIP joint. At rest, his DIP is flexed. He has full ROM of all joints except he cannot extend at the DIP.

What is the appropriate treatment and follow-up?

A) RICE therapy, PRN follow-up.

B) A full extension splint of the DIP joint worn at all times with orthopedic follow-up in 1 to 2 weeks.

C) A removable aluminum splint to be worn for comfort, follow-up in clinic in 1 month.

D) Ibuprofen and return to full activities, PRN follow-up.

The correct answer is "B." The patient has suffered an injury to his extensor tendon mechanism, known as a "mallet finger." X-rays are indicated to evaluate for a bony fracture/avulsion. The initial treatment is an extension splint at the DIP joint, and follow-up with an orthopedic surgeon as surgical correction is sometimes required. The splint must be worn at all times. See Figure 12-3 for the anatomy of a mallet finger.

FIGURE 12-3.

A Colles fracture consists of:

A) Fractures of the midshaft of the radius and ulna.

B) Fractures of the head of radius and ulna that is displaced dorsally and is angulated.

C) Fractures of the head of the radius and ulna that are displaced ventrally and is angulated.

D) None of the above.

The correct answer is "D," none of the above. OK, some of you may have chosen "B." However, the head of the radius is at the elbow and not at the wrist. Thus, none of the answers is correct. A Colles fracture is a fracture of the distal radius at the metaphysis, which is displaced dorsally and often angulated. It is the most common wrist fracture in adults. The ulnar styloid is often involved, and there may be intra-articular involvement as well.

Which of the following physical examination findings would be associated with the diagnosis of De Quervain tenosynovitis?

A) Positive Finkelstein test.

B) Positive Phalen test.

C) Positive Tinel sign.

D) Sensory loss over the C7 dermatome.

E) Weakness of the intrinsic muscles of the hand.

The correct answer is "A." De Quervain tenosynovitis is a tendonitis of the abductor pollicis longus, the extensor pollicis brevis, and occasionally the extensor pollicis longus. Full flexion of the thumb into the palm and ulnar deviation of the wrist produces exquisite tenderness over the radial aspect of the wrist (positive Finklestein test). Other findings may include soft-tissue swelling and pain over the abductor pollicis longus and extensor pollicis brevis tendons near the radial styloid. Crepitus may also be palpable or audible with ROM.

The appropriate treatment of De Quervain tendonitis includes which of the following?

A) Thumb spica splint.

B) NSAIDs.

C) Steroid injection.

D) Surgical decompression of the tendon.

E) All of the above.

The correct answer is "E." All of the above treatments have been used successfully for the treatment of De Quervain tendonitis. It is of note that some prefer steroid injection as the first-line therapy rather than NSAIDs. Surgery is obviously a last choice.

A 19-year-old male was mad at his computer and decided to punch the wall. "He fought the wall and the wall won." Radiographs demonstrate a fifth metacarpal fracture with some angulation.

What is the maximal acceptable angulation and rotation for a boxer fracture, fourth or fifth metacarpal, to maintain full hand function?

A) 10 degrees of dorsal angulation and 10 degrees of rotation.

B) 30 degrees of dorsal angulation and 5 degrees of rotation.

C) 40 degrees of dorsal angulation and 0 degrees of rotation

D) 90 degrees of dorsal angulation and 0 degrees of rotation.

The correct answer is "C." Any degree of rotation, or >40 degrees of dorsal angulation, may result in significant functional deficits. Reduction should be attempted if angulation is >10 degrees. Patients should be advised that with angulations >10 to 15 degrees, there will likely be a loss of metacarpophalangeal (MCP) prominence, although there should be no loss of function. If this is unacceptable to the patient, referral is recommended.

The next patient in the ED is an 18-year-old high school football player. He was playing in a football game this evening when he was tackled from the side and landed directly on the lateral aspect of his right shoulder. He states that he can actively move his arm, but is limited by pain on the top of his shoulder. He has also noticed a small painful bump on top of the right shoulder and is concerned that he "broke his collarbone."

Question 12.13.1 Based on the mechanism of injury and patient history, the most likely injury would be?

A) Acromioclavicular (AC) sprain.

B) Biceps tendon rupture.

C) Glenohumeral dislocation.

D) Rotator cuff tear.

E) Scapula fracture.

Answer 12.13.1 The correct answer is "A." Although any of these injuries may be present, an AC sprain is the most likely based on the history and the way the patient fell. A thorough examination should be able to further distinguish between these injuries. "B" is not likely, given the mechanism of injury. The deformity associated with biceps tendon rupture (a defect in tendon with pain and deformity in the muscle belly representing the contracted, detached muscle) would be on the upper arm or at the elbow, not on the "top" of the shoulder. "C" is incorrect. The deformity and loss of ROM of a glenohumeral dislocation (shoulder dislocation) is usually obvious. The mechanism of injury is typically a forced abduction and external rotation. "D" is less likely. A rotator cuff tear will present with pain more laterally over the subacromial space and should not have an associated deformity. The ROM is generally markedly limited by pain. "E" is unlikely. Scapula fractures are uncommon and are usually the result of high velocity blunt trauma such as a blow from a baseball bat or motorcycle accident. Plain film radiographs should be obtained to rule out a clavicle fracture, especially when any deformity is present.

Question 12.13.2 Your patient is worried that he broke his "collarbone." If he did sustain a nondisplaced clavicle fracture, which of the following would be appropriate treatment?

A) Rest, ice, and NSAIDs for pain control.

B) A sling for comfort only.

C) A figure-of-eight splint.

D) A and B

E) External fixation with molded plaster to maintain alignment.

Answer 12.13.2 The correct answer is "D." While the traditional teaching has been that a figure-of-eight splint is required, it adds nothing to the treatment of a clavicle fracture. Pain control and using a sling works just as well. Additionally, figure-of-eight splints often increase a patient's pain and can cause a brachial plexus injury. Thus, a sling is preferable. Complete immobilization is not necessary for nondisplaced clavicle fractures, thus making "E" incorrect.

Question 12.13.3 The proper treatment for a clavicle fracture that is minimally displaced is:

A) Closed reduction and then a sling.

B) Open reduction and immobilization.

C) Open reduction and early mobilization.

D) A sling.

E) None of the above.

Answer 12.13.3 The correct answer is "D." The ends of a displaced clavicle fracture need not be 100% approximated for healing to occur and for function to return. Thus, reduction is generally not necessary.

You send the patient for x-rays. AP radiographs show slight widening of the AC joint on the injured side. The examination and radiograph confirm your suspicion of an AC injury.

Question 12.13.4 For this patient with an AC sprain, you offer:

A) Sling for comfort, ice, and NSAIDs or analgesics for pain control.

B) Referral for open fixation.

C) Figure-of-eight strap for 4 to 6 weeks.

D) Corticosteroid injection followed by physical therapy.

E) Manual reduction, then sling-and-swath immobilization for 6 to 8 weeks.

Answer 12.13.4 The correct answer is "A." Conservative management is appropriate for low-grade AC joint sprains. AC sprains are graded I to VI. Grades I to III are generally treated conservatively, while grades IV–VI may need to be treated surgically. Signs of high-grade (IV–VI) AC sprains include posterior or inferior displacement of the clavicle and widening of 100% or more of the coracoclavicular space. Just like with clavicle fractures, figure-of-eight straps have largely fallen out of favor for treatment AC joint injuries. Corticosteroid injections are not the treatment of choice for acute AC joint injuries. An injection may be considered as an adjunct treatment for degenerative arthritis of the AC joint at some distant point in the future. Sling-and-swath immobilization is not indicated.

Objectives: Did you learn to…

• Differentiate between causes of shoulder injuries?

• Treat a clavicular fracture?

• Manage AC injuries?

A 65-year-old male presents with left shoulder pain and weakness, which started 2 weeks ago after he put a new roof on his house. He does not recall a specific injury. The pain is worse with reaching for and lifting objects as well as with overhead activities. Nighttime pain is present. He describes himself active and healthy, and he only takes acetaminophen when needed for shoulder pain. You suspect that he may have rotator cuff tendinopathy.

Question 12.14.1 If this is the case, what do you expect to find on examination?

A) Tenderness to palpation of the greater tuberosity of the humerus.

B) Limited active ROM.

C) Normal passive ROM.

D) Shoulder shrug with attempted abduction (such as with a frozen shoulder).

E) Any of the above.

Answer 12.14.1 The correct answer is "E." Ok, so this might fit under the category of "trick question," but the shoulder examination can be normal in a patient with a rotator cuff tear or tendinopathy, or it can include any of the elements listed in "A" through "D." Notably, normal PASSIVE ROM ("C") does not rule out rotator cuff pathology.

Question 12.14.2 Which of the following muscles is NOT a part of the rotator cuff?

A) Supraspinatus.

B) Infraspinatus.

C) Subscapularis.

D) Teres major.

E) Teres minor.

Answer 12.14.2 The correct answer is "D." The rotator cuff consists of the other four muscles listed and functions to rotate the arm and stabilize the humeral head.

Question 12.14.3 Which of the following muscles is the most commonly torn in the rotator cuff?