Orthopedics packrat Flashcards
(98 cards)
1
Q
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle? Answers A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis
A
(c) A. Abduction against resistance tests the supraspinatus.
2
Q
A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexion and external rotation at the hip. Which of the following knee maneuvers does this represent? Answers A. Abduction stress test B. Anterior drawer sign C. Lachman test D. McMurray test
A
(c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 15 degrees of flexion and external rotation of the hip.
3
Q
A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is the most striking and consistent abnormality of which of the following? Answers A. Spondylolysis B. Spondolisthesis C. Scoliosis D. Herniated disc
A
(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.
4
Q
Physical exam findings in a 4 year-old child that include blue sclerae and recurrent fractures indicates which of the following? Answers A. Ehlers-Danlos syndrome B. Marfan syndrome C. Achondroplasia D. Osteogenesis imperfecta
A
(c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.
5
Q
A 65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine? Answers A. Radiolucent lesions B. Demineralization C. Chondrocalcinosis D. Subperiosteal resorption
A
(c) B. Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X- ray findings demonstrate demineralization in the spine and pelvis.
6
Q
In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is Answers A. lateral. B. oblique. C. anteroposterior. D. odontoid.
A
(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.
7
Q
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done? Answers A. X-ray of the lower leg and ankle. B. Doppler studies. C. Bone scan. D. Compartment pressure
A
(c) D. Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.
8
Q
A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical exam the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis? Answers A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis
A
(c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.
9
Q
A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh that he noticed about 3 days ago. Physical exam reveals a large annular lesion with a bright red outer border and partial central clearing. Which of the following is the most likely diagnosis? Answers A. Rheumatoid arthritis B. Kawasaki disease C. Lyme disease D. Nongonococcal arthritis
A
(c) C. After an incubation period of 3 to 32 days, erythema migrans develops at the site of the tick bite. Within days or weeks after the onset of erythema migrans the patients develop a severe headache, mild stiffness of the neck, migratory musculoskeletal pain, arthralgias and profound malaise and fatigue.
10
Q
A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis? A. Shin splint B. Stress fracture C. Osgood-Schlatter disease D. Patellofemoral pain syndrome
A
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
11
Q
A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has Answers A. carpal tunnel syndrome. B. radial tunnel syndrome. C. tenosynovitis. D. gamekeeper's thumb.
A
(c) C. Tenosynovitis is diagnosed using Finkelstein maneuver. The patient’s thumb is placed in the palm of the hand and the wrist is abruptly deviated to the ulnar aspect of the wrist, causing pain on the radial aspect.
12
Q
A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has
Answers
A. carpal tunnel syndrome. B. radial tunnel syndrome.
C. tenosynovitis.
D. gamekeeper’s thumb.
A
(c) C. Tenosynovitis is diagnosed using Finkelstein maneuver. The patient’s thumb is placed in the palm of the hand and the wrist is abruptly deviated to the ulnar aspect of the wrist, causing pain on the radial aspect.
13
Q
The most important preventive medicine recommendation for patients with osteoarthritis is which of the following? Answers A. Start an exercise program B. Brace the affected joint C. Rest the joint D. Inject steroids monthly
A
(c) A. Patients with osteoarthritis who exercise are able to maintain range of motion, strengthen periarticular muscles, and improve physical fitness.
14
Q
Bone mass measurement should be considered in all women by what age? Answers A. 30 – 35 B. 40 – 45 C. 50 – 55 D. 60 – 65
A
(c) D. According to the National Osteoporosis Foundation, all women should have a bone mass measurement by age 60 – 65.
15
Q
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen’s test is positive; however, there is no atrophy of the thenar eminence. Which of the following is the initial step in management of this patient? Answers A. Wrist splint for 2-6 weeks B. Corticosteroid injection C. Surgical referral D. Darvocet
A
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
16
Q
Which of the following is the correct treatment for a Grade II ankle sprain resulting from an inversion injury? Answers A. Corticosteroid injection B. Rest, ice, compression, elevation C. Moist heat and a walking cast D. Surgical intervention
A
(c) B. The majority of ankle sprains are treated with RICE (rest, ice, compression and elevation). Corticosteroid injections, moist heat, and a walking cast provide no benefit. Surgical intervention for repair of a ruptured ligament is only necessary in chronically unstable joints.
17
Q
A 4 year-old boy presents to the ED after sustaining a crush injury to his distal third phalanx. Physical exam reveals an associated nail bed injury. Which of the following is the appropriate management?
A. Rest, ice, elevation
B. Immobilize, antibiotics, orthopedics referral
C. Splint for 48 hours, aspirin, ice
D. Surgical referral for amputation of digit
A
(c) B. Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered “open” and the patient should be given antibiotics and follow-up with ortho in one week.
18
Q
Which of the following is the antibiotic of choice when treating a patient with osteomyelitis whose culture demonstrates penicillin-resistant, methicillin sensitive Staphylococcus aureus? Answers A. Cefuroxime B. Levofloxacin C. Nafcillin D. Tobramycin
A
(c) C. Treatment for osteomyelitis is as follows: Penicillin G is the drug of choice for the treatment of infections due to penicillin-sensitive staphylococci and streptococci; nafcillin or oxacillin is preferred for penicillin-resistant, methicillin-sensitive staphylococci. Regimens for infections due to susceptible gram-negative rods includes cefuroxime and fluoroquinolones. Tobramycin is effective against Pseudomonas aeruginosa.
19
Q
Which of the following is the most common side effect of methotrexate? Answers A. Hemolysis B. Cardiomyopathy C. Stomatitis D. Diarrhea
A
(c) C. The most common side effects of Methotrexate are stomatitis and gastritis. Other side effects include hepatotoxicity, cytopenia, and interstitial pneumonitis.
20
Q
A 45 year-old male presents with an acute onset of asymmetric arthritis of the lower extremities. Further history reveals an episode of urethritis two weeks ago. Physical exam reveals a swollen tender right knee and left ankle and vesicles on his palms and soles. Which of the following is the initial treatment of choice in this patient? Answers A. Indomethacin B. Interferon C. Sulfasalazine D. Methotrexate
A
(c) A. This patient has reactive arthritis (formerly known as Reiter’s syndrome). In recent years, the term has been used to refer to spondyloarthropathies following and enteric or urogenital infection. Indomethacin is the treatment of choice. Interferon is not indicated in reactive arthritis. Sulfasalazine and methotrexate are used in patients with persistent reactive arthritis.
21
Q
A 25 year-old female presents with a constellation of symptoms including fatigue, chronic headaches, and poor sleep. She also complains of aching pain and stiffness involving her entire body. Minor exertion aggravates the pain and increases her fatigue. Which of the following classes of medications is the most efficacious treatment for this patient's condition? Answers A. Non-steroidal anti-inflammatories B. Opioids C. Corticosteroids D. Antidepressants
A
(c) D. Antidepressants have shown modest efficacy in treating the symptoms of fibromyalgia.
22
Q
Which of the following is the most common side effect of methotrexate? Answers A. Hemolysis B. Cardiomyopathy C. Stomatitis D. Diarrhea
A
(c) C. The most common side effects of Methotrexate are stomatitis and gastritis. Other side effects include hepatotoxicity, cytopenia, and interstitial pneumonitis.
23
Q
A 45 year-old male presents with an acute onset of asymmetric arthritis of the lower extremities. Further history reveals an episode of urethritis two weeks ago. Physical exam reveals a swollen tender right knee and left ankle and vesicles on his palms and soles. Which of the following is the initial treatment of choice in this patient? Answers A. Indomethacin B. Interferon C. Sulfasalazine D. Methotrexate
A
(c) A. This patient has reactive arthritis (formerly known as Reiter’s syndrome). In recent years, the term has been used to refer to spondyloarthropathies following and enteric or urogenital infection. Indomethacin is the treatment of choice. Interferon is not indicated in reactive arthritis. Sulfasalazine and methotrexate are used in patients with persistent reactive arthritis.
24
Q
A 25 year-old female presents with a constellation of symptoms including fatigue, chronic headaches, and poor sleep. She also complains of aching pain and stiffness involving her entire body. Minor exertion aggravates the pain and increases her fatigue. Which of the following classes of medications is the most efficacious treatment for this patient's condition? Answers A. Non-steroidal anti-inflammatories B. Opioids C. Corticosteroids D. Antidepressants
A
(c) D. Antidepressants have shown modest efficacy in treating the symptoms of fibromyalgia.
25
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Why are fractures of the scaphoid bone prone to aseptic necrosis?
Answers
A. Disrupted arterial supply
B. Lack of weight bearing
C. Inadequate immobilization
D. Impaired venous drainage
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(c) A. Scaphoid bone blood supply is from one single vessel that enters distally and once disrupted causes aseptic necrosis.
26
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An elderly patient presents to the ED complaining of right shoulder pain occurring after falling on his right outstretched hand with the elbow extended. On physical examination the arm is pale and pulseless and there is tenderness of the upper arm. Which of the following structures is most likely injured?
Answers
A. Axillary artery
B. Subclavian vein
C. Superior thoracic artery
D. Ulnar vein
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(c) A. Injury to the axillary artery is the most common vascular injury in proximal fractures of the humerus due to the close approximation of the axillary artery to the coracoid process.
27
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An elderly patient presents to the ED complaining of right shoulder pain occurring after falling on his right outstretched hand with the elbow extended. On physical examination the arm is pale and pulseless and there is tenderness of the upper arm. Which of the following structures is most likely injured?
Answers
A. Axillary artery
B. Subclavian vein
C. Superior thoracic artery
D. Ulnar vein
```
(c) A. Injury to the axillary artery is the most common vascular injury in proximal fractures of the humerus due to the close approximation of the axillary artery to the coracoid process.
28
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Which of the following tests would be included in the physical exam to evaluate a high ankle sprain with instability?
A. Anterior drawer
B. Lachman
C. Vibratory sense
D. Thompson
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(c) A. Anterior drawer, in addition to compressing the ankle mortise, is most reliable to indicate rupture to the anterior talofibular, anterior inferior tibiofibular and calcaneofibular ligaments.
29
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A 35 year-old male placed in a thumb spica cast for a scaphoid fracture presents complaining of forearm and hand pain that is not relieved with pain medication and elevation. Which of the following is the earliest physical exam sign for his current condition?
A. Slow capillary refill
B. Loss of two-point discrimination
C. Absent peripheral pulses
D. Pain with passive stretch.
```
(c) B. Loss of two-point discrimination can be the earliest sign of compartment syndrome.
30
Which of the following is the most sensitive screening test for systemic lupus erythematosus?
A. Anti-Ribonuclear protein (U1-RNP)
B. Antinuclear antibody (ANA)
C. Anti-double-stranded DNA (anti-ds-DNA)
D. Anti-Smith anti-body (anti-Sm)
(c) B. Antinuclear antibody (ANA) is sensitive in 99% of patients with SLE.
31
Chronic oral steroid use can predispose a patient to which of the following?
A. Charcot’s joint
B. Osteoarthritis
C. DeQuervains syndrome
D. Avascular necrosis of the femoral head
(c) D. Chronic steroid use can predispose a patient to avascular necrosis of the femoral head.
32
A 35 year-old female who was a back seat passenger in a vehicle which was involved in a head-on collision is brought to the ED. She is able to tell you that she is having difficulty moving both of her legs and is experiencing bilateral leg pain as well. She is embarrassed because she has "wet myself." Physical examination reveals markedly diminished sensory and motor function of both legs and decreased rectal sphincter tone. Which of the following is the most likely diagnosis?
A. Herniated disc at L5-S1 and L4-L5 B. An anterior cord lesion
C. Cauda equina syndrome
D. An L2 lesion
(c) C. Cauda equina syndrome is a massive central disc protrusion that causes variable degrees of paralysis. Bowel and bladder function may be impaired with saddle anesthesia. This condition is a surgical emergency.
33
25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and vomiting. He admits to “partying with cocaine all night”. He describes his urine as a dark brown color. Serum creatine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which of the following is the initial mainstay of therapy for this condition?
A. IV rehydration
B. Fasciotomy
C. Toradol (Ketorlac) D. Hydrotherapy
(c) A. IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis.
34
A 34 year-old female presents with complaints of right forefoot pain. She notes the pain as a severe burning accentuated by activity. She notes her dress shoes aggravate the pain and is relieved when she doesn't have them on. Massage of her foot also helps to lessen the discomfort. No foot deformity is noted on exam. To confirm the diagnosis, applying digital pressure along the forefoot would commonly create pain in what area?
A. Between the first and second metatarsal
B. Over the first MTP joint
C. The base of the 2nd MTP joint
D. Between the third and fourth metatarsal
(c) D. Pain between the third and fourth metatarsal upon digital pressure is due to Morton’s neuroma.
35
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A 25 year-old female presents to the ED with an open fracture of the left fibula sustained from an auto accident. The patient has no neurological findings. In addition to stabilization of the patient which of the following should be immediately initiated?
A. Antibiotic therapy
B. Apply a bi-valve cast
C. Reduce the fracture
D. Surgical debridement
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(c) A. Antibiotic therapy should be started immediately along with tetanus if needed.
36
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A patient who has chronic Crohn's disease now complains of a nondeforming asymmetric oligoarthritis of his large joints. The patient also notes that he has been having a flare of his Crohn's disease. Which of the following is the best treatment to alleviate both the inflammatory bowel disease and arthritic symptoms?
A. Indomethacin
B. Methotrexate
C. Infliximab (Remicade)
D. Cyclophosamide (Cytoxan)
```
(c) C. Spondyloarthritides respond to both infliximab and etanercept, where infliximab has greater efficacy in Crohn’s disease.
37
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A 42 year-old male presents with localized dysesthesias on the plantar medial aspect of the left foot. Symptoms are aggravated with activity and relieved by rest. Patient also complains of nocturnal symptoms. Four weeks prior the patient sustained an eversion ankle sprain that is non tender to walk on, but he is left with some residual diffuse swelling. Which of the following is most likely diagnosis?
A. Plantar fasciitis
B. Tarsal tunnel syndrome
C. Peroneus longus tendonitis
D. Bone spur of the calcaneus
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(c) B. Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes behind the medial malleolus. It is aggravated with activity and relieved with rest.
38
91. Clinical Intervention/Orthopedics/Rheumatology
Which of the following is the most significant complication of a dislocation of the knee?
A. Ligament damage
B. Inability to bear weight
C. Instability of the joint
D. Arterial injury
(c) D. Arterial injury is the most important complication and needs surgical repair immediately.
39
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A 42 year-old male presents with localized dysesthesias on the plantar medial aspect of the left foot. Symptoms are aggravated with activity and relieved by rest. Patient also complains of nocturnal symptoms. Four weeks prior the patient sustained an eversion ankle sprain that is non tender to walk on, but he is left with some residual diffuse swelling. Which of the following is most likely diagnosis?
A. Plantar fasciitis
B. Tarsal tunnel syndrome
C. Peroneus longus tendonitis
D. Bone spur of the calcaneus
```
(c) B. Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes behind the medial malleolus. It is aggravated with activity and relieved with rest.
40
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Which of the following is the most significant complication of a dislocation of the knee?
A. Ligament damage
B. Inability to bear weight
C. Instability of the joint
D. Arterial injury
```
(c) D. Arterial injury is the most important complication and needs surgical repair immediately.
41
A 60 year-old patient who has a 20 year history of diabetes mellitus arrives at the clinic with a complaint of mild to moderate ankle pain. There is no history of trauma. You note on exam that the joint is unstable but not erythematous or warm. On x-ray you would expect to see
A. osteopenia.
B. loss of articular cartilage.
C. disintegration of the joint with osteophytes.
D. subchondral cysts.
(c) C. Various degrees of joint destruction and disintegration with osteophyte formation are usually present with Charcot's joint.
42
A 60 year-old patient who has a 20 year history of diabetes mellitus arrives at the clinic with a complaint of mild to moderate ankle pain. There is no history of trauma. You note on exam that the joint is unstable but not erythematous or warm. On x-ray you would expect to see
A. osteopenia.
B. loss of articular cartilage.
C. disintegration of the joint with osteophytes.
D. subchondral cysts.
(c) C. Various degrees of joint destruction and disintegration with osteophyte formation are usually present with Charcot's joint.
43
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An otherwise healthy 67 year-old Caucasian female presents with a spinal compression fracture after falling down two steps. She has a bone density of 2.1 standard deviations below expected. Which of the following is the best pharmacotherapeutic approach at this time?
A. Alendronate (Fosamax)
B. Estrogen-Progesterone(Prempro)
C. Oxandrolone (Oxandrin)
D. Raloxifene (Evista)
```
(c) A. Alendronate has been shown to improve bone mass and reduce the incidence of vertebral fractures.
44
Adduction is defined as the extremity
A. moving towards the midline.
B. angulating the distal part towards midline of
the body.
C. turning towards the ceiling.
D. rotating about its axis toward midline.
(c) A. Adduction is defined as moving towards the midline.
45
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A 53 year-old female with a history of type 2 diabetes presents with complaints of left shoulder pain and loss of motion. She describes the pain as gradual in onset, localized superiorly with radiation down the deltoid muscle. She notes not sleeping well secondary to pain when lying on the left shoulder. No history of trauma is noted. Active and passive motion is severely restricted in all planes of motion. Neurological and vascular examinations are normal. What is the most likely diagnosis?
A. Thoracic outlet syndrome
B. Rotator cuff tear
C. Adhesive capsulitis
D. Pancoast tumor
```
(c) C. Adhesive capsulitis is restriction of the shoulder and is insidious in onset. It is more common in women and diabetics.
46
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A 60 year-old female presents for pre-op evaluation for surgical treatment of a tri-malleolar fracture of the left ankle. Which of the following puts her at an increased risk for infection post surgery?
A. Recent URI
B. Diabetes mellitus
C. Heart murmur
D. Swelling of the ankle
```
(c) B. Diabetes mellitus puts her at risk for infection post surgery.
47
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Which of the following nerves commonly gets injured with anterior shoulder dislocations?
A. Brachial
B. Ulnar
C. Axillary
D. Radial
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(c) C. The axillary nerve is the most commonly injured with anterior shoulder dislocations.
48
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A 45 year-old patient presents with pain in the left wrist after a FOOSH (fall on outstretched hand) injury. On examination he has snuff box tenderness with limited range of motion. Which of the following immobilization devices is the most appropriate intervention?
A. Sugar tong splint
B. Wrist “cock up” splint
C. Thumb spica splint
D. Short arm ulnar gutter splint
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(c) C. Thumb spica splint is most appropriate as it immobilizes the thumb and wrist. It is utilized for scaphoid fractures or fractures of the thumb.
49
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A 6 year-old female presents to the clinic with her parents because of lower back pain and difficulty walking for one week. The pain is described as a dull ache that is constant in the midlumbar region with radiation into the abdomen. She has a low grade fever of 100 degrees F which the parents note has been persistent for several days. Upon exam it is noted that the child has restricted forward flexion and extension secondary to pain. She has tenderness over the L3 vertebrae. An area of cellulitis from an insect bite is discovered over her left scapula. Which of the following is the most likely diagnosis?
A. Scheurmann’s disease
B. Discitis
C. Lyme disease
D. Osteitis condensans ilii
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(c) B. Discitis is an infectious disease that occurs in the mid lumbar region of children at the age of about 6 years old. Symptoms are low back pain that radiates into the abdomen or lower extremity. A low-grade fever with nausea and vomiting occasionally occur.
50
When instructing a patient on the correct way to use crutches, the patient should be advised to
A. keep crutch height two hand widths below the axilla.
B. report paresthesias of either upper extremity C. advance one crutch at a time
D. descend stairs with the normal extremity first,
followed by the crutches.
(c) B. Patients need to be educated about brachial plexus injury or crutch palsy due to placement and pressure of the pads against the thorax instead of the axillae.
51
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A patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of the following portions of the spinal column are most likely affected?
A. Lateral spinothalamic tract
B. Ventral spinothalamic tract
C. Posterior column
D. Transection of the cord
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(c) C. The posterior column affects proprioception (position sense) and vibration sense.
52
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In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis?
A. Femur
B. Humerus
C. Vertebral spine
D. Tibia
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(c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach
the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection
53
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Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase?
A. Probenecid (Benemid)
B. Allopurinol (Zyloprim)
C. Colchicine
D. Indomethacin (Indocin)
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(c) B. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid.
54
Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions?
A. Rheumatoid arthritis of the knee B. Osteoarthritis of the knee
C. Olecranon bursitis
D. Gouty arthritis
(c) B. Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis
of the knee that have failed other therapies. Although the onset of action of this medication is slower than
injected glucocorticoids, it has a sustained length of activity outlasting the injected glucocorticoids.
55
A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibial plateau. Which of the following is the most likely diagnosis?
A. Pes anserine bursitis B. Prepatellar bursitis
C. Infrapatellar bursitis
D. Trochanteric bursitis
(c) A. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults.
56
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A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis?
A. Rheumatoid arthritis
B. Septic arthritis
C. Gouty arthritis
D. Osteoarthritis
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(c) B. Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels.
57
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A 53 year-old patient presents with severe pain at the base of the thumb and no other finger involvement. The pain is worse with activity and lasts a short period of time following rest. There is no specific history of trauma to the thumb but the patient admits working with her hands as a typist. Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Osteoarthritis
C. Hemochromatosis
D. Pseudogout
```
(c) B. The base of the thumb is typically involved with osteoarthritis as are the DIP joints of the other fingers.
58
Which of the following is the treatment of choice for a torus (buckle) fracture involving the distal radius?
A. Open reduction and internal fixation
B. Ace wrap or anterior splinting
C. Closed reduction and casting
D. Corticosteroid injection followed by splinting
(c) B. A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as
painful as unstable fractures. They heal uneventfully in 3-4 weeks.
59
An 80 year-old female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use?
A. Calcitonin (Miacalcin) nasal spray
B. Alendronate (Fosamax)
C. Raloxifene (Evista)
D. Combined estrogen and progesterone (Prempro) therapy
(c) A. Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body.
60
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Which of the following views on plain films is preferred to identify spondylolysis?
A. Anterior
B. Posterior
C. Oblique
D. Lateral
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(c) C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
61
A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?
A. Open reduction and internal fixation
B. Continuous extension of the DIP with splinting
C. Continuous flexion of the PIP with splinting
D. Application of short arm cast
(c) B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via
splinting for 6 to 8 weeks.
62
A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?
A. Open reduction and internal fixation
B. Continuous extension of the DIP with splinting
C. Continuous flexion of the PIP with splinting
D. Application of short arm cast
(c) B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via
splinting for 6 to 8 weeks.
63
A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered?
A. Inability to extend the wrist against resistance
B. Numbness over the deltoid muscle in the shoulder
C. Winging of the scapula
D. Weakness of the rotator cuff
(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.
64
An 18 year-old male presents with pain in his wrist after he fell off of a moving motor cycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of the wrist. Which of the following is the recommended treatment for this patient?
A. Ace wrap of the wrist
B. Closed reduction of the fracture site
C. Thumb spica cast application
D. Open reduction of the fracture site
(c) C. Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical
snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for
all presumed nondisplaced scaphoid fractures.
65
```
A 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the emergency department. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?
A. Anterior plain film of knee
B. Sunrise view of the knee
C. Measurement of compartment pressures
D. Angiography
```
(c) D. The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and
should be evaluated with an arteriogram despite the presence of pedal pulses.
66
Which of the following preventive strategies against osteoporosis-associated vertebral fractures has a known side effect of increasing the incidence of hot flashes when used in a perimenopausal female?
A. Calcitonin (Miacalcin) nasal spray
B. Alendronate (Fosamax)
C. Estrogen/progesterone (Prempro)replacement
D. Raloxifene (Evista)
(c) D. Raloxifene has effects on bone turnover and bone mass and has been shown to decease vertebral fractures. It
has anti-estrogen effects on the non-skeletal portions of the body and increases hot flashes in perimenopausal females.
67
```
A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected?
A. L3-L4
B. L4-L5
C. L5-S1
D. S1-S2
```
(c) C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc
affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles.
68
```
Endotracheal intubation should be performed with caution in patients with which of the following underlying conditions due to the propensity to cause subluxation of C1 on C2?
A. Rheumatoid arthritis
B. Osteoarthritis
C. Gout
D. Pseudogout
```
(c) A. Patients with advanced rheumatoid arthritis will have synovitis of the atlantoaxial joint (C1-C2) which may
damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation).
69
A 55 year-old secretary presents and she must shake her hand to regain feeling in it. Which of the following physical examination signs will be present?
A. Hypothenar atrophy
B. Weakness of finger abduction
C. Inability to maintain wrist extension against resistance
D. Weakness of thumb abduction
(c) D. Median nerve injury causes weakness of thumb abduction (measured by thumb opposition strength) along with thenar atrophy. Tinel's and Phalen's signs will also be positive with carpal tunnel syndrome.
70
```
Which of the following is the treatment of choice for stage one Lyme disease in a patient less than 12 years of age?
A. doxycycline
B. amoxicillin
C. chloramphenicol
D. azithromycin
```
(c) B. Amoxicillin is first line therapy in a patient less than 12 years of age due to the harmful effects of doxycycline on teeth and bones in children.
71
Which of the following leads to retropatellar pain?
A. increased Q angle
B. increased quadriceps tone and strength
C. Osgood-Schlatter Disease
D. hamstring stretching
(c) A. Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome.
72
```
A 14 year-old male who is overweight presents with complaints of left knee and anteromedial thigh pain for the past month. He states the pain gets better with rest and denies any known trauma. On examination of the gait, a slight limp is noted. X-ray films of the left knee are normal. The most likely diagnosis is
A. genu valgum.
B. Legg-Calve-Perthes disease.
C. Osgood-Schlatter disease.
D. slipped capital femoral epiphysis.
```
(c) D. Slipped capital femoral epiphysis is most common in overweight adolescent males who present with complaints of pain that is referred to the thigh or medial side of the knee associated with a limp. X-ray films of the knee are normal since the condition involves the hip.
73
```
Which of the following fractures is associated with the greatest risk of avascular necrosis of the femoral head?
A. intertrochanteric
B. femoral neck
C. subtrochanteric
D. pelvic rim
```
(c) B. Femoral neck fractures lead to the greatest disruption of arterial blood supply to the femoral head.
74
```
A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 20 degrees of flexion and the tibia is forced forward while the femur is stabilized. Which of the following knee maneuvers does this represent?
A. abduction stress test
B. anterior drawer sign
C. Lachman test
D. McMurray test
```
(c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 20 degrees of flexion.
75
Which of the following would demonstrate rotational misalignment in a patient with a fracture of the fourth metacarpal?
A. base of the ring fingernail and index fingernail line up in the partially closed hand
B. fingernails of the open hand form an asymmetric arc
C. ring finger of the closed hand overlaps the little finger
D. ring finger of the open hand is shortened
(c) C. All fingernails should point to the same spot when the hand is closed. Overlapping of one finger over the other indicates rotational misalignment.
76
```
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen's test is positive; however, there is no atrophy of the thenar eminence. Which of the following is the initial step in management of this patient?
A. wrist splints
B. corticosteroid injection
C. surgical referral
D. propoxyphene (Darvocet)
```
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
77
```
A 67 year-old female presents with progressive pain in her left knee that is worse with activity and relieved with rest. She notes stiffness of the knee that last about 20 minutes after activity is resumed. She exercises regularly. No known drug allergies. On physical exam she is 5' 5", 225 pounds. Her left knee exam reveals mild effusion without erythema or warmth. Radiographs of the left knee reveal medial joint space narrowing and subchondral bone sclerosis. Her sodium is 138 mEq/L, potassium 4.3 mEq/L, bicarbonate 24 mEq/L, chloride 104 mEq/L, BUN 23 mg/dl and creatinine 1.8 mg/dl. Which of the following medications is most appropriate for this patient's worsening pain?
A. naprosyn
B. prednisone
C. acetaminophen
D. methotrexate
```
(c) C. Acetaminophen is recommended as first-line pharmacotherapy in patients with osteoarthritis.
78
```
An 18 year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis?
A. avascular necrosis
B. myositis ossificans
C. compartment syndrome
D. reflex sympathetic dystrophy
```
(c) C. Compartment syndrome is characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture.
79
```
A 58 year-old male presents complaining of anterior right shoulder pain the day after performing extensive yard work. The pain is localized over the anterior proximal humerus with distinct point tenderness. There are no visible abnormalities. The patient has full range of motion and strength with all shoulder movements. The pain is reproduced by asking the patient to resist the examiner during supination of the right elbow. Which of the following is the most likely diagnosis?
A. supraspinatus tendonitis
B. subacromial bursitis
C. rotator cuff tear
D. bicipital tendonitis
```
(c) D. Bicipital tendonitis presents with anterior shoulder pain that is reproduced by palpating the tendon in the humeral bicipital groove and through resisted motion of the biceps muscle (elbow flexion or supination).
80
```
A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is most consistent with which of the following?
A. spondylolysis
B. spondylolisthesis
C. scoliosis
D. herniated disc
```
(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.
81
```
The most reliable site from which to identify the causative organism in cases of osteomyelitis is the
A. base of ulcer.
B. blood.
C. sinus tract.
D. bone.
```
(c) D. Samples from needle aspiration of pus in the bone, or from a bone biopsy, are essential to determine the exact causative agent.
82
```
Which of the following osteoporosis therapies is so poorly absorbed that it must be taken alone and on an empty stomach?
A. raloxifene (Evista)
B. alendronate (Fosamax)
C. calcitonin (Miacalcin)
D. teriparatide (Forteo)
```
(c) B. Fosamax should not be coadministered with any other medication or food.
83
A 43 year-old male with a history of a right medial meniscectomy and a strong family history of osteoarthritis presents to the clinic for a routine physical exam. He states he is very active and runs 20-25 miles a week and competes routinely in 5 km races. He is 5' 10" and 160 lbs, BP is 128/76 and P 72. His physical examination is unremarkable. Which of the following would you recommend to this patient to delay the onset of osteoarthritis?
A. weight loss
B. corticosteroid injections
C. 1500 mg of calcium daily
D. consider swimming or biking instead of running
(c) D. Swimming and biking would promote excellent joint motion and muscle strength and void the high-impact of competitive short-distance running.
84
```
A 20 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on during practice. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis?
A. shin splint
B. stress fracture
C. Osgood-Schlatter disease
D. patellofemoral pain syndrome
```
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
85
A 36 year-old male has a history of recurrent low back pain. When lifting a stack of books yesterday, he experienced sudden, severe pain in the lumbar area. He denies radicular pain. His lower extremity examination is unremarkable, and his back examination is remarkable for paraspinal muscle tenderness and increased pain with flexion at the waist. Which of the following management options should be instituted at this time?
A. refer the patient to orthopedic surgery
B. continue ordinary activities as tolerated
C. confine the patient to bed with traction
D. recommend sleeping on a softer mattress
(c) B. Continuation of activities as tolerated is recommended during the acute phase. After symptoms resolve, an exercise program should be initiated to strengthen the back.
86
```
A 42 year-old female experiences pain on the plantar surface of her left foot in the area of the third metatarsal head. The pain is associated with wearing tight shoes and is relieved by removing shoes. Examination reveals a palpable mass and reproduction of pain with deep palpation of the third intermetatarsal space. The patient has tried wearing wider shoes with metatarsal cushions and taking NSAIDS but her symptoms persist. What is the best therapeutic option at this point?
A. Casting of the involved foot
B. Physical therapy
C. Steroid injection
D. Surgical excision
```
(c) C. Steroid injection is the treatment of choice for Morton's neuroma when conservative measures fail.
87
```
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle?
A. Supraspinatus
B. Infraspinatus
C. Teres minor
D. Subscapularis
```
(c) A. Abduction against resistance tests the supraspinatus.
88
```
A 26 year-old male who is an avid swimmer has been experiencing right shoulder pain for the past month. On examination, pain is elicited with palpation below the anterior acromion. Anterior shoulder pain is also reported when the patient flexes and extends his arm. Which of the following diagnostic tests is most appropriate at this time?
A. Shoulder x-ray
B. Shoulder arthroscopy
C. Shoulder MRI
D. Subacromial lidocaine injection
```
(c) D. Subacromial injection of lidocaine leading to a transient but dramatic improvement in pain with shoulder extension makes the diagnosis of impingement highly likely.
89
```
A 22 year-old female complains of worsening pain, swelling, and tenderness in her left heel for 1 week. She sustained a penetrating injury to the heel two weeks ago when she stepped on a nail while running in tennis shoes. Examination reveals a draining puncture wound with surrounding erythema and exquisite tenderness. X-ray of the left foot demonstrates periosteal reaction associated with the wound. Which organism is classically responsible for this infection?
A. Escherichia coli
B. Streptococcus pyogenes
C. Pseudomonas aeruginosa
D. Staphylococcus aureus
```
(c) C. Pseudomonas aeruginosa is frequently associated with osteomyelitis involving puncture wounds of the foot. This is believed to result from direct inoculation with P. aeruginosa via the foam padding found in tennis shoes.
90
```
Which of the following is an established risk factor for osteoporosis?
A. Parity status
B. Carbohydrate intake
C. Lactation history
D. Low body weight
```
(c) D. Established risk factors for osteoporosis include low body weight, female sex, advanced age, Caucasian race, and bilateral oophorectomy before menopause without estrogen replacement.
91
```
A 60 year-old female injured her right wrist when she slipped and fell onto her outstretched hand. Radiographs show a fracture through the metaphysis of the distal radius with dorsal displacement and angulation. Which of the following splints is the best method of temporary immobilization?
A. Dorsal forearm
B. Ulnar gutter
C. Volar forearm
D. Volar with thumb spica
```
(c) C. The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures and is the splint of choice for Colles' fracture.
92
```
A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical examination the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis?
A. Gout
B. Pseudogout
C. Acute rheumatic fever
D. Septic arthritis
```
(c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.
93
An obese 15 year-old male presents with complaint of a limp and right knee pain for two weeks. He denies recent trauma or history of previous injury. Physical examination of the right knee is unremarkable. Examination of the right hip reveals pain with passive range of motion and limited internal rotation and abduction. Flexion of the hip results in external rotation of the thigh. Gait is antalgic with the right hip externally rotated. Which of the following radiographic findings supports the most likely diagnosis?
A. Displacement of the femoral epiphysis
B. Irregularity and fragmentation of the joint space
C. Capsular swelling of the joint
D. Dislocation of the hip
(c) A. This patient has slipped capital femoral epiphysis (SCFE) and the classic x-ray findings will demonstrate displacement of the femoral head rotation of the femoral neck anteriorly.
94
```
A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory deficits and weakness along with decreased rectal sphincter tone. Which of the following is the most appropriate intervention?
A. Epidural steroids
B. Oral NSAIDs
C. Physical therapy
D. Surgery
```
(c) D. Cauda equina syndrome is a rare but serious surgical emergency because the duration of nerve compression is inversely correlated with the likelihood of full neurologic recovery.
95
Which of the following is the most sensitive to determine whether there is a small effusion in the knee?
A. Compress the patella and move it against the femur, noting any crepitus
B. Flex the knee to about 90 degrees and palpate for tenderness over the joint line
C. Milk the medial aspect of the knee, press lateral margin of the patella, and note a bulge of returning fluid medial to the patella
D. Force fluid into space between the patella and the femur, tap the patella over the femur to detect a click
(c) C. A small bulge of returning fluid after milking fluid upward from the knee is useful for detecting small effusions.
96
```
A 41 year-old female complains of 3 weeks of gradually worsening pain at the base of the thumb and radial aspect of the wrist. She and her husband have been renovating their home for the past 2 months and it has become increasingly difficult for her to hold a hammer. She denies numbness or tingling. She denies any history of previous trauma to the wrist. On examination, there is tenderness over the distal radial styloid and pain reproduced with ulnar deviation of a fist clenched over the abducted thumb. Which of the following is the most likely diagnosis?
A. Carpal tunnel syndrome
B. deQuervain's tenosynovitis
C. Ganglion cyst
D. Volar flexor tenosynovitis
```
(c) B. deQuervain's tenosynovitis typically results from repetitive activity involving pinching the thumb while moving the wrist. There is often pain and tenderness over the radial styloid and Finkelstein's is positive in this patient.
97
A football player complains of burning pain, numbness, and tingling extending from the left shoulder down into the hand after he tackled a player. These symptoms resolved spontaneously in minutes. Following resolution of the symptoms, he has full strength and normal sensation in the left arm. What is the most likely etiology of his symptoms?
A. Acute muscle strain
B. Mild concussion
C. Stretching of nerve roots and brachial plexus
D. Thoracic outlet obstruction
(c) C. Brachial plexus neurapraxia, commonly called "stinger" injuries, results from stretching of the cervical nerve roots and brachial plexus by a mechanism such as that described in this question.
98
```
A 13 year-old girl reports two weeks of worsening right knee pain with no history of antecendent injury or recent trauma. She reports frequent episodes of nighttime awakening with knee pain in the past two weeks. Examination of the knee reveals edema and a tender mass over the anterior proximal right tibia. Her knee exam is otherwise within normal limits. Radiographs of the right knee show a lytic mass with a multi-laminated periosteal reaction involving the proximal anterior tibia. What is the most likely diagnosis?
A. Ewing sarcoma
B. Osteochondroma
C. Multiple myeloma
D. Osteoid osteoma
```
(c) A. The distinctive feature of Ewing sarcoma is the radiographic appearance of a periosteal "onion skin" reaction.
