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Flashcards in Joint & Connective Tissue Disorders Deck (54)
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1

What is the best predictor of fractures in a person with osteoporosis?

(a) Low body weight
(b) Recent falls
(c) Low physical activity
(d) Prior fractures

Answer: (d)
Commentary: The best predictor of future fractures is prior fractures. Low body weight is also a
major risk factor. Recent falls and low physical activity are additional risk factors.

Reference: Khosla S, Melton LJ. Osteopenia. N Engl J Med 2007;356:2294-7

2013

2

In a patient with inflammatory arthritis, which type of exercise is LEAST likely to raise the white
blood cell count in the synovial fluid of the affected joint?

(a) Isotonic
(b) Isometric
(c) Isokinetic
(d) Plyometric

Answer: (b)
Commentary: Isometric exercise allows for tension to be generated in the muscle without any
visible joint movement occurring. An example of an isometric exercise would be pushing against
a wall. Isometric exercise does not alter synovial fluid composition, in contrast to other forms of
exercise that can increase white blood cell count and synovial fluid volume in patients with a
history of inflammatory arthritis.

Isotonic exercises use constant external resistance with variable speed of movement. An example of this would be performing a biceps curl with a dumbbell.

Isokinetic exercises are characterized by constant joint speed and variable external
resistance. Special equipment is needed for this type of exercise. In both isotonic and isokinetic exercise, there is visible joint movement.

Plyometric exercise involves fast, powerful movements. An example of a plyometric exercise would be jumping from a squatting position

2013

3

Which pharmacologic and non-pharmacologic treatment combination is the most appropriate
initial program in a patient with fibromyalgia?

(a) Duloxetine (Cymbalta) plus aerobic exercise
(b) Amitriptyline (Elavil) plus high intensity strength training
(c) Diazepam (Valium) plus trigger point injections
(d) Fentanyl (Duragesic) plus cognitive behavioral therapy

Answer: (a)
Commentary: Pharmacologic treatments used for fibromyalgia include tricyclic antidepressants (e.g., amitriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs, e.g., duloxetine, venlafaxine), and some anticonvulsants such as pregabalin. Opiates (e.g., fentanyl) and benzodiazepines (e.g., diazepam) are generally not recommended.

Non-pharmacologic therapies include cognitive behavioral therapy, aerobic exercise (low impact), and complementary therapies. To reduce the pain associated with exercise, it is
recommended to "start low, go slow," with gradual progression in exercise intensity. Patients with fibromyalgia would not likely comply with a high intensity strength training program.

2013

4

An injured worker with complex regional pain syndrome (CRPS), type 1, asks his physician to
prescribe methadone instead of morphine because of ongoing pain. The physician orders blood
work and an electrocardiogram (EKG) first. What finding would be a strong contraindication to
prescribing methadone for this patient?

(a) Hyperkalemia
(b) Hypermagnesemia
(c) QT interval prolongation
(d) Premature atrial complexes

Answer: (c)
Commentary: A prolonged QT interval and serious arrhythmia (torsades de pointes) have been
reported during treatment with methadone. Patients with cardiac hypertrophy, concomitant
diuretic use, hypokalemia or hypomagnesemia are at higher risk for development of prolonged
QT interval because methadone inhibits cardiac potassium channels. Premature atrial complexes
without other cardiac abnormalities that would predispose the patient to QT interval prolongation
would not be considered an absolute contraindication.

Reference: U.S. Food and Drug Administration website

2013

5

A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
has

(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.


Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.


2012

6

What shoe modification can be used to treat medial compartment knee osteoarthritis?

(a) Rocker bottom sole
(b) Solid ankle cushioned heel
(c) Medial wedge
(d) Lateral wedge

Answer: (d)
Commentary: Medial compartment osteoarthritis results in genu varum. A lateral wedge can help
relieve pain by placing a valgus force at the knee. A medial wedge would exacerbate the problem.
Solid ankle cushioned heel is a type of prosthetic foot. A rocker bottom sole is helpful for other
conditions such as forefoot fractures, hallux rigidus, foot arthritis, and insensitive feet.

2011

7

A 60-year-old woman with rheumatoid arthritis is concerned about her fingers being crooked.
The ulnar deviation of her fingers at the metacarpal phalangeal joints is due to the rupture of the
(a) lateral retinaculum of the extensor tendon sheath.
(b) central slip of the extensor tendon.
(c) radial retinaculum.
(d) ulnar collateral ligament.


Answer: (c)
Commentary: Rupture of the radial retinaculum produces ulnar subluxation of the metacarpal
phalangeal (MCP) joints. Rupture of the lateral retinaculum of the extensor tendon sheath at the
proximal interphalangeal joints produces swan-neck deformities. Rupture of the central slip of
the extensor tendon produces boutonniere deformities. Rupture of the ulnar collateral ligament
would result in radial deviation of the fingers.

2011

8

In a patient with inflammatory arthritis, which type of exercise is LEAST likely to raise the white blood cell count in the synovial fluid of the affected joint?
(a) Isotonic
(b) Isometric
(c) Isokinetic
(d) Plyometric

Answer: (b)
Commentary: Isometric exercise allows for tension to be generated in the muscle without any visible joint movement occurring. An example of an isometric exercise would be pushing against a wall. Isometric exercise does not alter synovial fluid composition, in contrast to other forms of exercise that can increase white blood cell count and synovial fluid volume in patients with a history of inflammatory arthritis.
Isotonic exercises use constant external resistance with variable speed of movement. An example of this would be performing a biceps curl with a dumbbell.
Isokinetic exercises are characterized by constant joint speed and variable external resistance. Special equipment is needed for this type of exercise. In both isotonic and isokinetic exercise, there is visible joint movement.
Plyometric exercise involves fast, powerful movements. An example of a plyometric exercise would be jumping from a squatting position.

2013

9

What is the best predictor of fractures in a person with osteoporosis?
(a) Low body weight
(b) Recent falls
(c) Low physical activity
(d) Prior fractures

Answer: (d)
Commentary: The best predictor of future fractures is prior fractures. Low body weight is also a major risk factor. Recent falls and low physical activity are additional risk factors

2013

10

A 28-year-old male firefighter sustained deep dermal burns across his lower face, neck, anterior chest, and shoulders. To help manage the formation of hypertrophic scars, you recommend
(a) corticosteroid injections directly into localized, early hypertrophic scars.
(b) compression garments to be worn 12 hours a day.
(c) topical silicone to large areas of hypertrophic scar.
(d) ultrasound treatments with passive stretching.

Answer: (a)
Commentary: Corticosteroid injections directly into localized, early hypertrophic scars can be useful, especially in highly cosmetic locations (face or neck) or in scars that are very pruritic. Compression garments should be worn 23 hours a day until wound erythema begins to abate, usually about 12-18 months after injury. Topical silicone, applied as a sheet, is effective in the
Page 13 of 23
management of small areas of hypertrophic scar. In a prospective randomized double-blind study, the effectiveness of ultrasound with passive stretching versus placebo ultrasound with passive stretching showed no difference in joint range of motion or perceived pain between the 2 treatment groups. This finding suggests that, although widely used, ultrasound may not have a beneficial effect on contractures that form secondary to hypertrophic scarring

2013

11

.   A 60-year-old woman with right medial knee pain has a genu varum deformity that is observed
while she is standing and walking. What shoe modification can help her pain?

(a) Medial wedge
(b) Lateral wedge
(c) Rocker bottom
(d) Arch support

Answer: (b)
Commentary: Medial compartment osteoarthritis causes a genu varum deformity. Lateral heel
wedges can be used for conservative treatment of medial compartment osteoarthritis. A medial
wedge would exacerbate the genu varum. An arch support would help with pes planus (flatfoot)
which may be helpful for genu valgum deformity. Rocker bottoms may be used to offload
pressure from the metatarsal heads.


2010

12

Answer: (b)
Commentary: The ATNR is typically present at birth and integrates between 4 and 6 months of
age. An obligatory “fencer” position is abnormal at any age. A persistent or obligatory ATNR
may be an early clue that a child has a disorder of motor control, most often cerebral palsy

Answer: (a)
Commentary: A straight cane should be used on the unaffected side to lessen the force exerted on
the hip with pathology. A Lofstrand crutch is also known as a Lofstrand forearm orthosis. It
includes a cuff placed along the lateral aspect of the forearm. Lofstrand crutches are often used
bilaterally. Because it does not require the use of the hand or wrist, and does not apply pressure
through them, a platform crutch is helpful for patients who need an assistive device and have
wrist/ hand pain or weakness.


2010

13

A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
has
(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.

Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.

2012

14

A 72-year-old woman underwent right total knee arthroplasty 2 days ago. When you see her in
consultation, she tells you that she has numbness along the lateral portion of the incision site.
What is the most likely cause?
(a) Femoral or peroneal nerve injury
(b) Deep vein thrombosis
(c) Cutaneous nerve injury
(d) Temporary side effect from anesthesia

Answer: (c)
Commentary: Cutaneous sensory loss is a very common complication following primary total
knee arthroplasty. One study from 1995 found that 100% of patients had lateral skin flap
numbness, and more recent studies in 2004 and 2009 found 81%-86% of patients had lateral skin flap numbness. In most cases, the numbness does improve with time (50% recovered in 2 years in the 2009
study). Deep vein thrombosis (DVT) and common peroneal nerve palsy are other known
complications of total knee arthroplasty.

2012

15

A 25-year-old man with a history of plantar fasciitis complains of low back and buttock pain.
The pain is worse at rest and better with activity. Schober test (signifying restricted lumbar
flexion) is positive. The laboratory or radiology result that would help confirm your most likely
diagnosis is a positive
(a) antinuclear antibody (ANA).
(b) human leukocyte antigen (HLA) B27.
(c) discogram.
(d) myelogram.

Answer: (b)
Commentary: The patient may have ankylosing spondylitis (AS). Enthesitis, such as plantar
fasciitis, is common in patients with AS. HLA B27 is usually positive in this condition, which is
a seronegative spondyloarthropathy. Schober test is performed by marking a point 5 cm below
the iliac crest line and 10 cm above. On forward flexion, the line should increaseby more than 5
cm. An ANA test, discogram and myelogram would not help to diagnosis AS.

2012

16

A 60-year-old man has first metatarsophalangeal joint pain. Joint fluid analysis confirms your
suspected diagnosis. What lifestyle or medication changes would reduce flare-ups of his
condition?
(a) Increase seafood intake
(b) Decrease alcohol intake
(c) Increase diuretic use
(d) Decrease vitamin C use

Answer: (b)
Commentary: Alcohol increases uric acid production and can provoke an acute gout attack.
Seafood and red meat contain purines which increase serum uric acid levels and thus increase
gout flares. Gout can also be provoked by trauma and drugs such as thiazide diuretics. In
contrast, vitamin C has been found to decrease gout attacks.

2012

17

93. A 35-year-old woman sustained an ischemic stroke and is currently undergoing workup in the
acute care hospital. Systemic lupus erythematosus (SLE) is suspected. An immunoglobulin G
(IgG) or IgM anticardiolipin antibody analysis is ordered to evaluate for which associated
condition?
(a) Antiphospholipid antibody syndrome
(b) Activated protein C resistance
(c) Antinuclear antibody
(d) Antithrombin III deficiency

Answer: (a)
Commentary: Antiphospholipid antibody is associated with systemic lupus erythematosus (SLE)
and can increase risk of thrombosis. SLE is diagnosed with an abnormal serum level of IgG or
IgM anticardiolipin antibodies, positive lupus anticoagulant, or false-positive serologic test for
syphilis. Activated protein C resistance and antithrombin III deficiency are risk factors for
thrombosis and stroke, but do not have the same association with SLE. Antinuclear antibody is
usually positive in SLE and is part of the diagnostic criteria, but is not associated with
thrombosis.

2012

18

A 55-year-old woman comes to your office with a 2-month history of aching and stiffness of her neck and shoulders. Recently, she has had similar symptoms in her hips. She describes difficulty moving in the morning for at least 1 hour after arising. Upon further questioning, she also has fatigue, loss of appetite, and jaw pain with eating. On exam, she has limitation in active range of motion of her shoulders and hips due to pain, but does not have joint synovitis. Plain radiographs are unremarkable. You order laboratory tests and expect to find:

A. normal C-reactive protein (CRP) level.
B Elevated ESR
C Normal hemoglobin and hematocrit
D presence of antinuclear antibodies

Option b is correct.

This woman has polymyalgia rheumatica. Diagnostic criteria include age greater than 50 years, bilateral aching and stiffness for more than 1 month in the shoulder and hip girdle, elevated erythrocyte sedimentation rate, morning stiffness lasting more than 1 hour, rapid response to prednisone and absence of other disease that may cause musculoskeletal symptoms. Patients also demonstrate on laboratory findings mild to moderate anemia of chronic disease and elevated CRP. Antinuclear antibodies are usually negative.

2014

19

A patient's dual-energy x-ray absorptiometry (DXA) scan shows a T score of -1.5 at the lumbar spine, -2.0 at the femur, and -1.2 at the radius. This patient has

A. normal bone density.
B Osteopenia
C Osteomalacia
D Osteoporosis

Option b is correct.

The T score is the number of standard deviations above or below the mean bone mineral density of normal young adults. Normal bone density is less than 1 standard deviation below the mean. Osteopenia is defined by the World Health Organization as -1 to -2.5 standard deviations below the mean. Osteoporosis is -2.5 or more standard deviations below the mean. Osteomalacia is a softening of bone from decreased mineralization, frequently from vitamin D deficiency.

2014

20

What is the most frequent pulmonary complication of polymyositis and dermatomyositis?

A. Aspiration pneumonia
B. Interstitial lung disease
C Pulmonary arterial hypertension
D Spontaneous pneumothorax

B is correct

Interstitial lung disease occurs in up to 65% of patients with myositis and is a significant contributor to morbidity and mortality. Patients with myositis have further pulmonary complications with respect to muscle weakness and vascular disease resulting in secondary complications of aspiration pneumonia, infection, respiratory muscle failure, pulmonary edema and pulmonary arterial hypertension. Spontaneous pneumothorax is not commonly associated with myositis.


2014

21

Which factor signals and increased risk for underlying malignancy in dermatomyositis?

A Male gender
B Age younger than 40 years
C Elevated CRP
D Erythroderma (exfoliating dermatitis)

Option c is correct.

Dermatomyositis is associated with underlying malignancy in approximately 25% of patients. The erythrocyte sedimentation rate and C-reactive protein are generally elevated in persons with underlying malignancy. The risk of malignancy is higher in older patients and gender does not appear to be a risk factor. Erythroderma may be a presenting symptom of dermatomyositis but does not appear to be a risk factor for malignancies. Several other features of the rash, such as cutaneous necrosis, ulceration or vasculitis, may be associated with underlying malignancy.

2014

22

In trying to differentiate psoriatic arthritis (PA) from rheumatoid arthritis (RA), persons with PA have as a distinguishing characteristic

A dactylitis.
B involvement of the metacarpophalangeal joints.
C erosions on radiographs.
D positive family history.

Option A is correct

Dactylitis (diffusely swollen digits due to tenosynovitis and arthritis) are distinguishing characteristics of PA and not RA. The other choices occur in both psoriatic arthritis and rheumatoid arthritis patients.

2014

23

In contrast to adults with rheumatoid arthritis, which joints are more commonly involved in children with juvenile idiopathic arthritis?

a. Metacarpophalangeal
b Shoulder
c. Interphalangeal
d Temporomandibular

Option d is correct.

Temporomandibular joints (TMJ) are involved in 50% of children with juvenile idiopathic arthritis (JIA) and this involvement can affect development of the mandible, leading to micrognathia. Shoulder involvement in JIA is infrequent, as is involvement of the small joints of the hand.

2014

24

Which medication is most likely to cause osteoporosis?

a Atorvastatin
B. Enalapril
C Phenytoin
d Metformin

Option c is correct.

Anticonvulsants such as phenytoin cause the liver to increase metabolism of 25-hydroxyvitamin D to inactive metabolites, resulting in metabolic bone disease and osteoporosis.Many medications can contribute to bone loss. These include corticosteroids, thyroxine, anticonvulsants such as phenytoin and carbamazepine, cholestyramine, barbiturates, heparin, warfarin, cyclosporine, aromatase inhibitors, and gonadotropin-releasing hormone agonists.

2014

25

A ballet dancer is seen in clinic complaining of knee pain. On physical examination, her knees hyperextend more than 10 degrees. What additional physical exam finding would help support your diagnosis of joint hypermobility syndrome?

a. Extend the 5th digit to 90 degrees.
b. Abduct the thumb to 90 degrees.
c. Touch fingertips to the floor when standing.
d. Appose the posterior heels 180 degrees.

Option a is correct.

A 9-point Beighton score, as described below, can be used to assess for joint hypermobility syndrome. Passive dorsiflexion of the fifth metacarpophalangeal joint to 90o or more (1 point per side).Opposition of the thumb to the volar aspect of the ipsilateral forearm (1 point per side).Hyperextension of the elbow to 10o or more (1 point per side).Hyperextension of the knee to 10o or more (1 point per side).Placing of hands flat on the floor without bending the knees (1 point). A Beighton score of 4 or greater is a major criterion in the Brighton criteria for joint hypermobility syndrome.

2014

26

3. A 45-year-old woman is currently hospitalized for an acute flare of her dermatomyositis. On
consultation, you recommend

(a) passive range-of-motion exercises.
(b) isometric strengthening exercises at the bedside.
(c) ambulation with a walker in the hallways.
(d) aquatic therapy

Answer: A
Commentary: Passive range of motion to maintain joint movement is recommended during periods of acute flares. With resolution of the flare, active-assisted exercises may be started, progressing to strengthening exercises

2009

27

The most significant risk factor for continued structural destruction of the knee in osteoarthritis is
(a) joint malalignment.
(b) obesity.
(c) prior surgery.
(d) occupational bending and lifting.

(a)
Joint malalignment is the most significant risk factor for further joint deterioration, since it creates uneven focal loading.

2008

28

A 35-year-old man with history of psoriatic arthritis complains of localized low back pain of insidious onset. The pain is worse in the morning and improves as the day progresses. What is the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis

(b)
Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis. The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many inflammatory arthropathies.

2008

29

A forty-year-old woman with rheumatoid arthritis (RA) complains of right wrist pain that limits her ability to use her computer and phone at work as a computer analyst. On exam, she has metacarpal phalangeal ulnar deviation, wrist radial deviation, and several boutonniere deformities in her fingers. There is no active synovitis. You suggest occupational therapy and
(a) oral prednisone.
(b) short forearm cast.
(c) a resting wrist orthotic.
(d) finger splints.

(c)
Resting wrist splints provide light support for a painful joint and are well tolerated. They are the most commonly prescribed orthotic in RA.

2008

30

The arthropathy in persons with systemic lupus erythematosus (SLE) generally is in the wrists, knees and small joints of the hands. It is also
(a) symmetric and non-erosive.
(b) symmetric and erosive.
(c) asymmetric and non-erosive.
(d) asymmetric and erosive.

(a)
The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due to its involvement of the para-articular tissues.

2008