Pearls in Musculoskeletal Medicine · 2016-09-27 · Pearls in Musculoskeletal Medicine 32yo female...

OAPA Annual Conference - 2016

Pearls in Musculoskeletal

Medicine

R. Matt Dumigan, MD

Brett Purvis, PA-C

Pearls in Musculoskeletal Medicine

❖ 13yo male presents to the clinic with bilateral knee pain, with

onset 6 weeks prior to his appointment. He does not recollect

any specific injury, and states that “it just started hurting after

sports practice.” He and his parents have noted a

bump/fullness over the front of his knee below his knee-cap,

with pain rated 2-4/10 depending on his activity level.

❖ A) Chondromalacia patella

❖ B) Patellar tendonitis (jumper’s knee)

❖ C) Osgood-Schlatter’s disease

❖ D) Infrapatellar plica syndrome

❖ C) Osgood-Schlatter’s disease


❖ 32yo female with two to three months of right thumb pain. She

is 3 months postpartum, and states her pain began shortly after

her new daughter was born. She denies any neurologic

changes in her hand, denies trauma of any kind, and pain is

made worse with lifting her infant. Phalen’s test is negative.

This is the symptom picture for which of the following?

❖ A) Acute carpal tunnel syndrome

❖ B) DeQuervain’s tenosynovitis

❖ C) Trigger thumb

❖ D) Lateral epicondylitis

❖ B) DeQuervain’s tenosynovitis


❖ 62yo male with 8 days of severe left shoulder pain after lifting

farm equipment into the back of his truck. He relates “occasional

soreness” leading up to this injury, but states it has never

impaired his activities of daily living. He has a (+) drop arm test,

no loss of passive range of motion, and no glenohumeral crepitus

noted during exam. What is the most likely diagnosis and which

imaging study will best show his pathology?

❖ A) Glenoid labrum tear; MRI of the shoulder WITH contrast

❖ B) Rotator cuff tear; 3-view X-ray of the shoulder

❖ C) Rotator cuff tear; MRI of the shoulder WITHOUT contrast

❖ D) Glenoid labrum tear; MRI of the shoulder WITHOUT contrast

❖ C) Rotator cuff tear; MRI of the shoulder WITHOUT contrast


❖ A 27yo male is brought to the emergency department after a mountain bike

accident, but declined initial transport by ambulance. He has been unable to

bear weight since his injury, rates his pain at 8-9/10 subjectively, and states

his pain is worsening. His wife states he has complained of a “numb foot”

since getting into the car, and she feels as though his swelling is increasing.

Which of the following is not part of the classic presentation of this

emergent clinical picture?

❖ A) Pulselessness

❖ B) Palor

❖ C) Pain out of proportion

❖ D) Petechia and purpura

❖ E) Poikilothermia

❖ F) Paresthesias

❖ D) Petechia and purpura


❖ An 18yo high school football player presents to your outpatient clinic

with a chief complaint of left wrist pain. He was injured two weeks ago

when landing on an outstretched hand but has continued to “play

through pain.” His initial swelling resolved within 6-7 days, but his pain

has continued and his range of motion has diminished. Your

examination reveals anatomic snuff box pain, a low-grade effusion of

the left wrist, with no pain over the distal radius. He neurologic exam is

intact. The most appropriate initial treatment of this injury is:

❖ A) A brief course of outpatient physical therapy

❖ B) Thumb spica immobilization and return to the office in 2 weeks

❖ C) He has been playing, so allow him to continue football. Return on a PRN basis if pain continues.

❖ D) Inject the radoiocarpal joint and return to the office in 2 weeks.

❖ B) Thumb spica immobilization and return to the office in 2 weeks


❖ A 12yo adolescent male presents to your office with 3-4 weeks of

progressing shoulder pain. He plays baseball in a competitive youth league,

and is a standout pitcher. He has practice each night during the week and

plays tournaments “most weekends.” Physical exam findings include pain

localized deep to the deltoid muscle, pain during muscle testing of the

rotator cuff (with little-to-no weakness), (-) apprehension test, and (-)

O’Brien’s test. Which of the following is your most likely radiographic

finding?

❖ A) Calcification seen near the greater tuberosity (calcific rotator cuff tendinitis)

❖ B) No bony abnormalities seen (This athlete is exhibiting signs of a SLAP (superior labrum) lesion)

❖ C) Salter-Harris I proximal humeral physis (Little-leaguer’s shoulder)

❖ D) Elevation of the distal clavicle in relation to the acromion (AC separation)

❖ E) Axillary lateral shows humeral head anterior to the glenoid (anterior shoulder dislocation)

❖ C) Salter-Harris I proximal humeral physis (Little-leaguer’s shoulder)


❖ Mr. Smith is a 68yo patient you are seeing for a chief complaint of left

knee pain. He reports gradually increasing pain with no known

mechanism of injury. He has tried over the counter medications and an

off-the-shelf knee brace with little symptom improvement. After your

plain film radiographs reveal bone-on-bone osteoarthritis of his medial

tibiofemoral compartment, which of the following is the LEAST

LIKELY to benefit Mr. Smith’s outcome?

❖ A) Corticosteroid injection placed intra-articularly

❖ B) MRI of the knee to rule out meniscal pathology

❖ C) Consistent course of NSAID use

❖ D) Outpatient physical therapy

❖ E) Referral to an orthopedic surgeon for surgical consideration

❖ B) MRI of the knee to rule out meniscal pathology


❖ A painful mono-articular manifestation of pain is the

hallmark of gouty arthropathy. The onset can be

attributed to diet, alcohol intake, genetic predisposition,

chronic kidney disease, and multiple myeloma. Joint

fluid aspirate to confirm the diagnosis will reveal:

❖ A) Calcium pyrophosphate crystals

❖ B) Gram positive cocci

❖ C) Articular cartilage debris

❖ D) Sodium urate crystals

❖ D) Sodium urate crystals


❖ You have confirmed median nerve entrapment, carpal tunnel

syndrome, in a middle-aged male with electromyography. The

appropriate treatments may consist of splinting the affected

wrist, use of NSAIDs, corticosteroid injection, or referral for

surgical release of the transverse carpal ligament. This patient

most likely presents with which of the following symptoms?

❖ A) Numbness over the hypothenar eminence and small finger

❖ B) A painful, round mass over the dorsal aspect of the wrist

❖ C) Painful popping and catching over the ulnar aspect of the wrist

❖ D) Numbness and pain affecting the thumb, index, and middle fingers

❖ D) Numbness and pain affecting the thumb, index, and middle fingers


❖ A high school athlete presents to your office Monday morning after

being injured in a game the prior Friday night. He reports a twisting-

type injury that immediately caused pain but he was able to continue

participating. Low-grade swelling occurred over the next 24-36 hours,

weight bearing is possible but painful, and terminal extension of the

knee is very difficult. Which special test exam finding is most likely

positive(+) for this knee pathology?

❖ A) Anterior drawer test

❖ B) Valgus stress test

❖ C) Apley’s compression test

❖ D) Homan’s sign

❖ E) Patellar apprehension test

❖ C) Apley’s compression test


❖ A man in his 30’s presents to your office with a chief complaint of

back pain. His symptoms have developed insidiously and are

worse in the morning before he “gets up and going.” Your physical

exam findings reveal no neurologic component, marked stiffness

with lumbar flexion and extension, and additional joint

involvement. You begin to suspect this diagnosis, and therefore

order a serum HLA-B27 with your laboratory workup.

❖ A) Septic osteoarthritis

❖ B) Ankylosing spondylitis

❖ C) Herniated nucleus pulposus

❖ D) Spinal stenosis

❖ B) Ankylosing spondylitis


❖ After a fall on an outstretched hand, a young female presents to

your office with elbow pain and limited range of motion. She

splints her upper extremity by her side held in 90 degrees of

elbow flexion, and pronation/supination of the forearm is

significantly limited due to pain. You suspect a fracture of the

elbow and are very likely to see this pathognomonic finding on

lateral x-ray.

❖ A) Sail sign / fat pad sign

❖ B) Osteophyte formation at the tip of the olecranon

❖ C) Widening of the medial epicondylar physis

❖ D) Soft tissue shadow of enlarged olecranon bursa

❖ A) Sail sign / fat pad sign


❖ A recreational athlete has sustained an inversion ankle injury

and presents to your office for evaluation. He has an antalgic

gait but doesn’t use crutches for assistance. Exam findings

reveal point tenderness over the lateral aspect of the foot,

with edema and ecchymosis overlying the area of

tenderness. Which of the following diagnoses is of primary

concern?

❖ A) Achille’s tendon rupture

❖ B) Jones fracture

❖ C) Deltoid ligament avulsion

❖ D) Navicular fracture

❖ B) Jones fracture


❖ The Ottawa ankle rules provide guidelines for ordering x-

rays to diagnose possible fractures in the setting of foot and

ankle pain in adults. Their introduction has helped to reduce

the number of unnecessary x-rays, reducing costs and

radiation exposure for patients. The Ottawa ankle rules DO

NOT INCLUDE which of the following?

❖ Bone tenderness at the posterior edge or tip of the distal 6cm of the lateral malleolus

❖ Inability to take 4 complete steps both immediately after injury and in ED

❖ Diffuse edema and ecchymosis within 2 hours of injury

❖ Bone tenderness at the posterior edge or tip of the distal 6cm of the medial malleolus

❖ Diffuse edema and ecchymosis within 2 hours of injury

Pearls in Musculoskeletal Medicine · 2016-09-27 · Pearls in Musculoskeletal Medicine 32yo female...

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Transcript of Pearls in Musculoskeletal Medicine · 2016-09-27 · Pearls in Musculoskeletal Medicine 32yo female...