PM&R qbank review Flashcards
(196 cards)
1
Q
What subtype of cerebral palsy is most associated with a risk of epilepsy ?
A
Spastic Quadriplegia
-Epilepsy affects 25-45% of pts w/ CP.
- pts w/ spastic quadriplegia are likeliest to develop seizures, with an estimated incidence between 50-94%
- Spastic Hemiplegia ~30%
-CP pts w/ spastic diplegia, ataxic CP, and dyskinetic CP are less likely to develop seizures
2
Q
Describe what an F wave is
A
F wave is a pure motor, late response which occurs after the CMAP. It is a variable response and not a true reflex since it does not travel through a synapse along its nerve pathway when stimulated.
Produced using supramaximal stimulation -> initiates antidromic motor response to the anterior horn cells in the spinal cord -> which then produces an orthodromic motor response in the recording electrode
3
Q
Describe an H-reflex
A
-EDx analogue of a monosynaptic reflex
-Initiated with submaximal stimulus at long duration
-Preferentially activates IA afferent nerve fibers –> orthodromic sensory response to the spinal cord –> orthodromic motor response back to recording electrode
4
Q
Describe an A (Axon) Wave
A
When performing a CMAP study, a response can be evoked by submaximal stimulation and abolished with supramaximal level.
THe stimulus can travel antidromically along the motor nerve and becomes diverted along a neural branch formed by collateral sprouting due to previous denervation and reinnervation.
Typically occurs between CMAP and F-wave. This waveform represents collateral sprouting following nerve injury.
5
Q
Which type of injury pattern would most likely result in traumatic SCI paraplegia?
A
Acts of Violence
-Almost all recreational sports related SCI result in tetraplegia
- 52% of fall-related SCIs result in tetraplegia usually in the elderly
6
Q
Patient with newly diagnosed HIV presents with neuropathic pain in glove/stocking distribution. What infectious agent is the most likely cause of his neuropathy?
A
CMV –Directly infects peripheral nerves.
Classic presentation of CMV neuropathy is a mononeuropathy multiplex pattern (painful, stepwise, multifocal sensorimotor deficits). May be rapidly progressive –> with nerve injury due primarily to axonal degeneration, although segmental demyelination may be present as well.
7
Q
How would you expect a patient with suspected CMV neuropathy to present clinically and on EDx?
A
CMV –Directly infects peripheral nerves.
Classic presentation of CMV neuropathy is a mononeuropathy multiplex pattern (painful, stepwise, multifocal sensorimotor deficits). May be rapidly progressive –> with nerve injury due primarily to axonal degeneration, although segmental demyelination may be present as well.
8
Q
What type of motor potentials would you expect to find when needling the paralytic side of a patient with Bell’s Palsy?
A
Myokymic Potentials
9
Q
What is the classic presentation of the Miller-Fisher Variant of Guillain-Barre Syndrome?
A
Miller-Fisher Syndrome accounts for appx 5% of cases. Characterized by the triad of:
1. Ophthalmoplegia
2. Areflexia
3. Ataxia
- Fixed, dilated pupils may be present
-25% pts develop LE weakness
-Axonal sensory neuropathy is often detected.
-Unlike classic BGS, motor and demyelinating components are minimal.
-Associated with GQ1a and GQ1b autoantibodies related to C. jejuni infection
10
Q
Pure hemisensory stroke most likely results from infarct of what structure?
A
Thalamus (Ventral posterolateral nucleus of the thalamus)
11
Q
What class of drugs should be avoided in patients with Parkinson Dementia?
A
Dopamine antagonists (Droperidol, metoclopramide, phenothiazines)
12
Q
What is the typical clinical and EDX presentation of a patient with suspected HNPP ?
Pathology?
A
Pts typically present in 2nd-3rd decade of life. PResent with sudden, painless mononeuropathies at compression sites. Weakness typically resolves in days to months.
NCS show prolonged distal motor latencies, focal slowing at compression sites, and reduction of SNAP amplitudes.
Biopsy demonstrates tomacula (focal myelin thickening) , segmental demyelination, and axonal loss.
Most commonly due to AD PMP22 deletion (PMPS pressure 22 y/o’s)
13
Q
The ___ nerve supplies cutaneous innervation to the supraorbital region
The ___ nerve supplies cutaneous innervation to the superolateral portion of the orbit
The ___ nerve supplies cutaneous innervation to the temporal region
The ___ nerve supplies cutaneous innervation to the chin region
A
- Supraorbital nerve
- Supratrochlear nerve
- Zygomaticotemporal nerve
- Mental nerve
14
Q
What sound would you here on needle EMG in a patient with suspected Myokymia?
A
Myokymic Discharges = Marching Soldiers
15
Q
50 presents for EDX of LLE for suspected L5 radiculopathy and low back pain. You note a waveform that starts with an initial positive deflection followed by a quick uprising while testing a muscle. You notice the waveform in another quadrant during needling of the same muscle. You notice the waveform again in two separate muscles that fire regularly.
How would you interpret this EMG waveform?
A
Positive sharp wave/fibrillation potential.
Always has an initial positive deflection, regular rhythm, and sounds like rain on a tin roof. They are generated by a single denervated muscle fiber (NOT A DENERVATED MOTOR UNIT)
16
Q
What is Paget-Schroetter Syndrome?
A
It is an upper extremity DVT, particularly an axillary-subclavian VT that is associated with strenuous and repetitive activity of the upper extremities, and particularly involves the dominant arm.
Risk factors include anatomical abnormalities at the thoracic outlet and repetitive trauma to the endothelium of the subclavian vein
17
Q
What is the mechanism of action of clonidine
A
Alpha-2 agonist that can be used in treatment of sympathetic and neuropathic pain
18
Q
What is the classic presentation of a patient with suspected Legg-Calve Perthes Disease?
A
LCP is avascular necrosis of the femoral head in children ages 2-12
- Most commonly age 4-8
- Boys > Girls
- Painless limp
Treatment
Limiting weight bearing, bracing, and surgery
19
Q
What are the two main subscores when using the Modified Barthel Index?
A
Self-care and mobility. Use FIM scores for paraplegics as the MBI will not be sensitive in detecting small changes of functional ability in those with paraplegia as they can perform many of them independently.
20
Q
Skinny female cross country athlete complains of foot pain. Pain has been persistent for one month and has progressed in intensity and frequency. She is not able to bear weight on her foot.
Diagnosis?
What is the most accurate imaging modality to confirm the diagnosis?
A
This patient has a stress fracture likely 2/2 Female Triad Syndrome.
MRI is the best imaging modality to detect a stress fracture due to its high sensitivity, lack of radiation, and high differentiating power.
21
Q
De Quervain’s tenosynovitis involves what extensor compartment?
A
Entrapment of the EPB and/or APL tendons at the styloid process of the radius. w/in the 1st extensor compartment of the wrist.
22
Q
What are the Ottawa knee rules
A
If one of the following is present, XR is indicated:
- Age > 55
- Isolated tenderness of the patella
- Tenderness of the fibular head
- Inability to flex knee 90 degrees
- Inability to take ≥4 weight-bearing steps
23
Q
Patient completely severs the median nerve, but still has 3/5 strength in APB. What is the explanation for this?
A
The APB is innervated by the ulnar nerve
–> Richie-Cannieu anastomosis.
RCA is an anomalous ulnar to median communication in the palm between the deep branch of the ulnar nerve and the recurrent branch of the median nerve.
3 RCA types:
1. All Ulnar hand
2. Motor innervation dominantly by ulnar nerve
3. Some median innervates muscles innervated by ulnar nerve
24
Q
In a flexion fracture of the humerus or hyperflexion fractures of the humerus, which nerve is most likely to be compromised?
A
Flexion type of pediatric supracondylar humeral fractures are rare. Ulnar nerve is at high risk for injury
25
What biomarker has the highest specificity for SLE?
Anti-double stranded DNA
26
Anti-Ro and Anti-La are primarily associated with?
Sjogren Syndrome
27
Anti-histone bodies are associated with?
Drug-induced lupus
28
Physical Exam findings of the hands suggestive of RA? (Most to least suggestive)
1. Atrophy of interosseous muscles of hands
2. Symmetric inflammation of small joints of hands most commonly involving the MCP and PIP joints
3. Ulnar deviation of digits
4. Swan neck deformity
29
Risk factors for developmental dysplasia of the hip
Commonly associated with what other MSK issue?
- Female Gender
- Family history
- breech positioning
- Oligohydramnios
There is correlation between DDH and congenital muscular torticollis (Especially in boys)
30
What structure is at risk for secondary injury following a lunate dislocation injury?
A dislocated lunate typically compresses the recurrent branch of the median nerve --> altered sensation over the palmar aspects of the lateral digits and weakness in thumb opposition.
31
Ottawa Ankle Rules
Plain XR of the ankle indicated for pts who have pain in the malleolar zone and:
1. Have bone tenderness at the posterior edge or tip of the lateral or medial malleolus
2. Are unable to bear weight both immediately after the injury and for 4 steps in the ER or office
**Of note, if the patient can transfer weight twice to each foot ( 4 steps), they are considered able to bear weight even if they have a limp
32
When is a foot XR series indicated in a patient who presents with acute foot pain?
Plain XRs of the foot are only indicated for patients who have pain in the midfoot zone and:
1. Have bone tenderness at the base of the 5th metatarsal or the navicular bone
OR
2. Are unable to bear weight both immediately after the injury, anc cannot walk for than 4 steps in the ED/Office.
33
Young athlete suffers from an aortic dissection. He is tall and lanky. On exam, has pectus carinatum (pigeon chest), and hindfoot valgus.
1. Diagnosis and gene involved?
2. Pts dad asks if the pts siblings need to be screened. What is the best advice?
1. Marfan Syndrome, associated with abnormalities of the aortic root.
- Autosomal dominant inheritance pattern due to a mutation of the gene for the Fibrillin-1-protein (FBN1 gene)
2. Current guidelines recommend that 1st degree relatives of the patient should undergo counseling and genetic testing if there is a known gene mutation associated with aortic aneurysms and/or dissection
If the patient's relative is found to have the mutation they should undergo aortic imaging
34
What is Baxter's Neuritis?
Entrapment of the 1st branch of the lateral plantar nerve between the abductor hallicus and quadratus plantae muscle.
Clinical presentation: Typically complain of foot pain at the end of the day or after prolonged activity. Can have paresthesias laterally across the heel.
Motor weakness of the abductor digiti minimi muscle might be noted.
**Pathognomonic sign is pain on palpation of the nerve between abductor hallucis and quadratus plantae muscles along the medial border of the foot.
EMG is unreliable as well as diagnostic block
35
Describe Salter-Harris Classification
"SALT ED"
S-Straight through; Fx straight thru physis
A-Above; Fx of physis and extends into metaphysis
L-Lower; Fx of physis and extends thru epiphysis
T-Through; Think vertical fx involving metaphysis, physis, epiphysis
ED-Erasure of physis; Crush injury of physis
36
In patients with detrusor-sphicter dyssnergia (DSD), urethral pressure measuremens with typically show an acute urethral pressure rise of ______ within 30 seconds of detrusor contraction
In pts with DSD, urodynamic studies will show an acute urethral pressure rise of > 20 cm H20 within 30 seconds of detrusor contraction
37
Describe the five different phenotypic presentations of Osteogenesis imperfecta (OI)
Stature
Dentinogenesis
Sclerae
Bone fragility
Bone Healing
Time of first Facture
Type I - Mildest form, fxs heal normally ; normal growth; ligamentous laxity is observed
Type II- Most severe; usually lethal in perinatal period. Baby has triangular faces with micrognathia, small chest cage. Death 2/2 pulmonary insufficiency and CHF. Death w/in days-weeks of birth
Type III- Mod severe form; fxs in utero; multiple fx in first 1-2 years of life. Impaired bone healing, very similar to type 3; opalescent sheen on teeth; dark blue sclera; dwarfed
Type IV- Least common; Majority have dentinogenesis imperfecta with normal sclera
Type V- Autosomal dominant; significant for callus formation during fracture healing. Normal teeth and sclera. Calcification of interosseous membrane between ulna and radius -> limited supination/pronation of forearm
38
What neurologic finding is found in ~50% of patients of osteogenesis imperfecta Type I ?
~50% of pts with OI Type I develop progressive hearing loss with both sensorineural and conductive components that begin in the late teens or twenties
39
What is the most common cause of atraumatic hip pain in children? What is the typical clinical presentation?
Transient Synovitis; Most commonly occurs in boys age 3-8. Typically experience symptoms for 1-3 days and present with an antalgic gait and an abducted and externally rotated hip at rest. Pain is exacerbated with internal rotation of the hip
**Pain with internal rotation is less severe in cases of septic arthritis
40
SCFE is characterized by ____.
Demographics?
Presentation?
SCFE is characterized by posterior displacement of the femoral head through the physeal plate. Most commonly occurs in little fat adolescent boys (12-14 y/o) and is bilateral in 20-40% of cases. Pts with SCFE present with hip, groin, thigh, or knee pain that is worse with physical activity and demonstrate altered gait.
41
How does Legg-Calve-Perthes disease usually present?
LCP disease is avascular necrosis of the femoral head. Classically presents with gradually worsening hip pain that may NOT be relieved with rest.
42
When is each foot orthosis indicated?
Deep Heel Cup
Semi-rigid plate
Wide plate
Reverse Morton's
Deep heel cup, semi-rigid plate, wide plate -> medial column overload
Reverse Morton's extension --> Lateral column overload
43
What is a Monteggia Fracture?
Fracture of the proximal 1/3 of the ulna with associated dislocation of the radial head
Tx = closed reduction and casting in supination or ORIF or intramedullary nailing
44
Are supracondylar fractures of the humerus considered to be intra or extra articular fractures?
Supracondylar fractures of the humerus are extra articular fractures of the distal humerus.
Type I supracondylar fractures that are nondisplaced can be immobilized with a posterior splint and sling or collar and cuff sling
45
What is a Galeazzi Fracture
Fracture of the distal 1/3 of the radial shaft with associated radioulnar joint injury.
Treatment= ORIF of the radius with stabilization of the distal radioulnar joint
46
What is patellar chondromalacia?
How is it diagnosed?
Treatment?
Softening of the patellar cartilage that results from long-standing patellofemoral pain syndrome.
Diagnosed arthroscopically
47
In Osgood-Schlatter disease, where is the pain localized?
What type of activity increases risk?
Most often seen in preteen and adolescent males who perform repetitive jumping exercises.
Pain is localized over the tibial tubercle
48
What is the best method for determining the level of amputation in pts planned to undergo BKA/AKA?
Transcutaneous oxygen pressure (TcPO2) is used to find the level of amputation with enough blood perfusion to increase chance of successful wound healing and decrease risk of re-amputation.
A median TcPO2 of 28 mmHg is likely to provide sufficient perfusion for successful wound healing.
49
In a patient with C4AIS-A injury, the likelihood of regaining antigravity strength can, in part, be predicted by?
Initial strength of the muscle one level below the neurologic level of injury as well as the rate of recovering antigravity strength.
In pts with no motor strength at the first caudal level, recovery may continue for up to two years after injury
50
In a patient with C4AIS-A injury with no motor strength at the first caudal level, recovery may continue for up to ___ years after injury
Two years post injury
51
Patients with complete cervical SCI lesions usually recover ___levels of function
Patients with complete cervical SCI usually recover one root level of function
52
Sea shell murmur -->
Fat sputtering on frying pan -->
Rain on a tin roof -->
Motor boat engine -->
Dull Thud -->
Seashell murmur --> MEPPs
Fat sputtering on a frying pan --> EPPs
Motorboat/Machine Gun --> CRDs
Dull regular thud --> Positive sharp wave
53
Identify common sites of radial nerve injury associated with UE fractures.
Most frequent site of radial nerve compression?
1. Spiral groove of the humerus
2. Juncture of the middle and distal 1/3 of the arm
3. Radial Tunnel
4. Compression b/w brachioradialis and ECRL
Most frequent site of radial nerve compression is in the proximal forearm in the area of the supinator and involves the PIN branch.
In fractures of the humerus, at the junction of the middle and proximal 1/3 as well as distally on the radial aspect of the wrist
54
What is the most sensitive imaging modality for early detection of heterotopic ossification?
Triple phase bone scan
55
Which vertebral level exhibit pseudosubluxation in almost half of all pediatric patients?
Pseudosubluxation of C2 on C3 is a common variant seen in almost 50% of pediatric patients younger than 8 y/o.
Main cause is increased ligamentous laxity and more horizontally positioned facet joints
Pseudosubluxation is present when the spinolaminar line connecting the anterior portions of the spinous process of C1 and C3 is within 2 mm of the C2 spinous process. If > 2mm, indicates true subluxation.
56
Most cervical spine fractures in children occur at what level?
C1-C3 region
57
The most sensitive clinical exam maneuver to diagnose transient synovitis?
Treatment plan?
Log Roll
Bed rest for 7-10 days, NSAIDs. Advise all pts with transient synovitis to have repeat XR within 6 months to exclude Legg-Calve-Perthes disease
58
What is the most specific screening tool for diagnosing malnutrition?
Most sensitive?
Malnutrition Screening Tool (MST)
Most sensitive = MST and Mini Nutritional Assessment (MNA)
59
How can you differentiate between infantile spinal muscular atrophy and infantile botulism based on physical exam alone?
Infantile SMA symptoms do not include bulbar manifestations (facial and pharyngeal weakness, ptosis, dilated pupils)
60
Synovial fluid findings in osteoarthritis usually suggest a non-inflammatory process if the WBC count is _________
< 2000/mm3
Inflammatory conditions like RA, lupus, or gout usually present with opaque synovial fluid, high proteins, WBC between 2000 - 50,000, and PMNs > 50%
61
What happens to each of the following cardiac parameters as people age:
-Max HR
-Cardiac Output
-LVEF
- Maximal end diastolic Volume
1. HR decreases 2/2 drop out of cardiac pacemaker cells
2. Cardiac output is lower in elderly
3. Ejection Fraction Decreases
4. End diastolic volume increases
62
What is the optimal postoperative dressing for a trans-tibial amputee?
Rigid removable dressing;
Provides compression to control edema and reduce limb volume. Provides protection and can be removed for inspection. It has been shown to reduce the length of hospital stay and increase the likelihood of patient ambulating at discharge
63
What happens to the following parameters during exercise?
Inotropy
Chronotropy
Cardiac output
stroke volume
Preload
Systemic Vascular Resistance
Inotropy (contractility) - Increases
Chronotropy (HR) - Increases
Cardiac Output- Increases
Stroke Volume - Increases
Preload- Increases
Systemic Vascular Resistance- Decreases
64
Identify the following for each of the following muscles:
1. Compartment
2. Innervation
3. Action
Fibularis longus
Fibularis Brevis
Fibularis Tertius
Fibularis longus and brevis are located in the lateral compartment of the leg. Both are innervated by the superficial fibular nerve. Both are involved in foot eversion and plantar flexion.
Fibularis tertius is located in the anterior compartment of the leg. It originates from the distal part of the anterior fibula and inserts onto the dorsum of the shaft of the 5th metatarsal bone. It is involved in foot eversion and dorsiflexion. Innervated by the deep fibular nerve.
65
What is the treatment of choice for children < 6 mo with developmental hip dysplasia?
Infants up to age 6 months are usually treated with a Pavlik Harness. Prevents hip extension and limits adduction; permits hip flexion and abduction
66
What is the treatment of choice for children > 6 mo with developmental hip dysplasia?
The treatment of choice for children > 6 mo with DDH is Closed or Open reduction in the OR under anesthesia with a hip spica cast
67
What is the purpose of a pavlik harness?
Prevents hip adduction and extension in children with developmental hip dysplasia
68
What clinical manifestations are most consistent with neurogenic shock in the setting of an acute SCI?
Fatal consequence of SCI that manifests as hypotension, bradyarrhythmia, and temperature dysregulation with resultant hyperthermia.
Associated with cervical and high thoracic SCI.
Bradycardia 2/2 interruption of autonomic pathways in the spinal cord resulting in decreased vascular resistance.
Tachycardia is absent because of loss of sympathetic tone.
Focal neurologic deficit is not necessary for the diagnosis of neurogenic shock**
69
Neurodegenerative diseases pathologically characterized by a-synuclein-positive intracellular inclusions are associated with this sleep-wake cycle disorder?
REM-sleep behavior disorder
70
What it is the treatment of choice for a patient with post traumatic elbow stiffness with normal radiographs?
Functional ROM of the elbow is from 30-130 degrees flexion-extension and from 50 deg supination to 50 deg prnation.
1st line tx = PT with PROM exercises
If PT fails and pt has elbow flexion contracture > 30 degrees or elbow flexion < 130 degrees, static, progressive casting/splinting is indicated
71
Chiari II malformation typically involves displacement of ______________ thru the foramen magnum.
Medulla, cerebellar tonsils, and cerebellar vermis
72
Anti-smith antibodies are associated with _____.
Anti-dsDNA antibodies are associated with _____.
ANti-centromere antibodies are associated with _____.
Anti-Smith --> Lupus
Anti-dsDNA --> Lupus
Anti-Centromere --> CREST Syndrome
73
What is the most common location of a pressure ulcer in a patient with spinal cord injury within 2 years?
Sacrum
74
Explain the "Sign of Benediction"
Median nerve injury
Loss of innervation to lateral 2 lumbricals of the hand and the lateral half of FDP. --> Flexion weakness at PIP joints of 4-5, but MCP flexion at 4-5 remains intact 2/2 lumbricals 4,5.
The EDC is left unopposed --> the MCP joints of digits 2-3 remain extended while attempting to make a fist.
75
A very important distinction when differentiating Intersection Syndrome from De Quervain's is the fact that a patient with Intersection syndrome would display ___________
Pain in the 2nd dorsal compartment several centimeters proximal to the radial styloid, while a patient with De Quervain's occurs directly over the radial head.
76
Risk factors associated with increased prevalence of frailty?
Older age,
Low education level,
current smoker,
non-white,
not married,
current depression,
current use of antidepressants, intellectual ability,
current use of postmenopausal hormone therapy
77
Which type of head injury has the highest risk of developing post traumatic seizures?
Penetrating head trauma
78
Weakly positive birefringence, rhomboid shaped crystals is associated with? Tx?
Pseudogout . Preferred initial management is with joint aspiration followed by intra articular steroid injection
79
In scaphoid fractures, what part of the bone is at most risk for non union?
Majority of the blood supply is the distal 1/3 of the bone. Therefore, the middle and proximal portion of the bone have large nonunion rate
80
Suspicion for an AC joint injury should be initially diagnosed by what modality?
Single AP view of both AC joints
81
Indications for referral to orthopedic surgery for scoliosis include?
- Cobb angle 20-24 degrees in premenarchal females or males age 12-14 y/o
- Cobb angle > 25 deg in any pt
-Progression of a Cobb angle ≥5 degrees in any patient
82
What is a classic XR finding associated with psoriatic arthritis?
Systemic involvement?
Most commonly affects knees and DIPs.
**Arthritis mutilans – osteolysis of the phalanges and metacarpals of the hand resulting in "telescoping of the finger"
Systemic involvement - conjunctivitis, aortic insufficiency
83
Synovial accumulation of calcium pyrophosphate
Antibodies against the Fc fragment of IgG
Inborn error of purine metabolism
Pseudogout
Rheumatoid Arthritis
Gout
84
On MRI, edema indicates an acute fracture. Edmea is ______ on T2; with _____signal intensity on T1, and ______signal intensity on STIR
Acute fracture on MRI
T1 = high signal of fat and low signal for water
T2= Low signal for fat and high signal for water.
In acute fracture i.e edema --> high signal on T2, low signal on T1, and high signal on STIR (Short T1 inversion recovery, which is a fat suppression technique)
85
The most widely used frailty screening tool is the _______. Also known as the __________.
The tool defines frailty phenotype as meeting ≥3/5 of the following criteria:
?
Physical Frailty Phenotype, also known as the Fried or Hopkins Frailty Phenotype.
1. Weight loss of ≥5% of body weight in the last year
2. Exhaustion (measured by positive response to questions regarding effort required for activity)
3. Weakness (assessed by a specialized device to measure grip strength).
4. Slow walking speed (Defined as taking > 6-7 seconds to walk 15 feet)
5. Decreased physical activity (defined in Kcals spent per week, low in males being the expenditure of < 383 Kcals, and low in females < 270 Kcal).
86
In the setting of an amputation, what does "telescoping" refer to?
Telescoping is a phenomenon used to describe phantom limb that is perceived in the location previously occupied by the intact limb and gradually retracts inside the residual limb
87
Which artery provides nearly 2/3rd of the blood supply to the humeral head?
Posterior humeral circumflex artery
In a cadaveric study by Hettrichet al. (2010), 80% of pts with proximal humerus fractures resulted in disruption of the ANTERIOR circumflex artery; however avascular necrosis of the humeral head was exceedingly rare. They reported that 64% of the humeral head was supplied by the posterior circumflex artery (36% by anterior) when using MRI to map blood flow.
88
What is the primary mechanism/target of the following:
-Tizanidine
-Dantrolene
-Baclofen
-Cyclobenzaprine
Tizanidine = alpha-2 adrenergic AGONIST
Dantrolene = Inhibits Ca2+ release from sarcoplasmic reticulum by ANTAGONizing the Ryanodine receptors of skeletal muscle
Baclofen = GABA-B AGONIST
Cyclobenzaprine = works at the spinal level and is a 5-HT2 ANTAGONIST --> resulting in depression of the monosynaptic reflexes
89
The sympathetic supply to the UE is thru the _______ of which nerve root levels? This innervation is thru the ________.
In some cases, the UE sympathetic nervous system maybe supplied by the ___________, which do NOT pass through the stellate ganglion. These are ________ nerve fibers and have been implicated in inadequate relief of sympathetic pain s/p stellate ganglion block.
The sympathetic supply to the UE is thru the grey rami communicantes of C7, C8, and T1.
This innervation is thru the stellate ganglion.
In some cases, the UE sympathetic nervous system maybe supplied by the T2 and T3 grey rami communicantes, which do NOT pass through the stellate ganglion.
These are Kuntz nerve fibers and have been implicated in inadequate relief of sympathetic pain s/p stellate ganglion block.
90
What is the Ely's test (Duncan-Ely Test)? How is it performed?
The Ely's test is used to assess rectus femoris spasticity or tightness.
The pt lies prone in a relaxed state. THe provider stands next to the pt, at the side of the leg that will be tested. One hand should be on the lower back, the other holding the leg at the heel. Passively flex the knee in a rapid fashion. The heel should touch the bottocks. THe test is positive when the heel cannot touch the buttocks, the hip of the tested side rises from the table, and the patient feels pain or tingling in the back, anterior thigh, or medial calf
91
Most volar plate fractures (Mallet finger injury) that involve _____% of the joint may be treated with conservative management without surgery.
<30%; initial tx = conservative management with splinting and hand exercises in order to prevent stiffness
Splinting of the DIP in extension for 8 wks if patient develops Mallet finger
92
Which opioid produces the greatest incidence of delayed respiratory depression?
8 mg epidural, preservative-free morphine
93
What is Blount disease?
Blount disease results from disruption of normal cartilage growth at the medial aspect of the proximal tibial physis. Patients present with an angular varus deformity of the proximal tibia with progressive genu varum.
XRs show fragmentation of the medial epiphysis of the tibia with an angular deformity of the medial portion of the proximal tibia.
Mainstay of treatment = Surgical intervention with hemiepiphysiodesis or tibial osteotomy
94
Which lab marker, when tracked over time, best correlates with the progression of rheumatoid arthritis?
CRP value, overtime, correlates with radiographic disease progression in RA. ESR and CRP serve as helpful indicators of response to treatment.
RF ANA, and anti-CCP, along with XR, aid in work up for diagnosis of RA.
95
Regarding cardiovascular status of pt after acutely sustaining an SCI, it is important to....
1. Maintain MAP ≥85 mmHg as it is associated with enhanced neurologic recovery
2. UOP should be maintained at >30 cc/hr 2/2 risk for neurogenic pulmonary edema
96
How as the incidence rate of acute, traumatic SCI in the US changed between 1993 and 2012?
The total number of cases has increased; however, the incidence rate has remained relatively stable
97
Based on CMAP studies of facial/trigeminal blink studies, which parameter is associated with good vs poor recovery?
When CNAP amplitude is >10% compared to the uninvolved side, 90% of patients will have satisfactory recovery.
Axonal sparing of 10-30% results in recovery within 2-8 months with mild to moderate facial dysfunction being anticipated.
98
What is the most common etiology of reversible cognitive decline?
Depression
99
Which medications increase risk for acute gout flare up?
Which meds decrease risk?
Loop diuretics, thiazide diuretics increase risk.
Losartan reduces serum uric acid levels --> Decreases risk
100
Which EDX component is useful in differentiating central vs peripheral lesions, especially in setting of an acute SCI?
Somatosensory evoked potentials (SSEP) may be especially helpful in an unresponsive or uncooperative patient to determine if they have a spinal cord injury, and in the differentiation between SCI and conversion reaction.
Presence of SSEPs is not always associated with motor recovery since the SSEP represents spared sensory fibers of the posterior column. Motor activity depends on the anterolateral portion of the spinal cord.
101
What is Commotio cordis?
Commotio cordis is cardiac arrhythmia that results from a direct blow to the chest
102
What is the most common cause of mortality in SCI patients?
Respiratory issues. Mortality rates are significantly higher during 1st yr after injury
103
Current evidence suggests that _______ after major trauma, UE fracture, or surgery for both UE and LE may prevent development of CRPS
50-day regimen of at least 500 mg daily vitamin C
104
What is the most likely organic cause of depression in a patient who is now 6 months post-stroke?
Catecholamine depletion
Stroke lesions may damage the noradrenergic, dopaminergic, and serotonergic projections in the frontal lobes, leading to depletion of catecholamines which can induce an organic depression
105
What is the best initial diagnostic evaluation in a patient with suspected neuromuscular disease?
End tidal CO2 levels. This will provide insight into hypoventilation especially when the patient complains of morning headache and daytime fatigue
106
Describe how to perform Ortolani maneuver vs Barlow maneuver
Ortolani's sign is positive when there is hip relocation and clunk with abduction of the legs and lifting up the trochanters.
Barlow's sign is positive when there is hip DISLOCATION and clunk. The hips are flexed to 90 degrees and abducted.
107
What is most frequently affected muscle in hamstring injury?
Biceps Femoris
108
What is the medication of choice in a pediatric patient with dystonia?
If generalized dystonia is suspected in children, a trial of carbidopa-levodopa should be administered.
Dopa-responsive dystonia is characterized by a diurnal variation of symptoms. The age of onset is 4-8 y/o and the initial features can be foot dystonia or abnormal hand posturing.
The increased tone and posturing progress to include arms and legs and is commonly diagnosed as cerebral palsy. If generalized dystonia is suspected in children, a trial of carbidopa-levodopa should be administered.
109
What is the diagnostic criteria required for diagnosis of SLE?
Presence of ≥4/11 following critieria per ACR:
1. Malar Rash
2. Discoid Lupus Rash
3. Photosensitivity
4. Oral or nasal mucocutaneous ulcerations
5. Non-erosive arthritis
6. Nephritis
7. Encephalopathy
8. Pleuritis or pericarditis
9. Cytopenia
10. +ANA
11. Immunologic phenomena (dsDNA, anti-Smith Abs)
110
What is the management for pulmonary contusion 2/2 blunt force sports-related injury?
Supplemental Oxygen to maintain SaO2 > 95%, airway support, fluid management, analgesia
111
Most common infection that occurs in up to 2/3rds of patients 1-6 months s/p heart transplant are 2/2 what pathogen?
Prophylactic treatment?
Transplant patients are at highest risk for CMV infection and often receive prophylaxis with Ganciclovir
112
What is Uhtoff's phenomenon?
What is it indicative of?
Uhtoff's phenomenon refers to greater impairment of visual acuity with an increase in body temperature in patients with multiple sclerosis.
It is indicative of prior optic nerve injury or subclinical demyelination.
113
17 y/o with mononucleosis asks if he can still play hockey. What is the best recommendation?
Avoidance of all contact sports for ≥3 weeks from the start of symptoms. He may return once all symptoms have resolved.
3 wks b/c this is when splenomegaly typically improves.
114
3 y/o is evaluated for intoeing. Pts mother is concerned that he is not as athletic as his daycare classmates. She states he is clumsy but is able to keep up with the other children.
Physical exam is remarkable for both patellae facing forward and bilateral intoeing. He does trip once while walking and does NOT trip while running in the office.
What is the diagnosis?
Treatment/Recs?
This child has in-toeing 2/2 tibial torsion.
Internal tibial torsion is the most common cause of in-toeing and a variation in normal child development under 5 years of age.
Child with tibial torsion walks with the hips and patella facing forward but the feet pointing inwards.
Tibial torsion is often asymmetric.
In 90% of cases, tibial torsion spontaneously resolves w/o treatment by 8 years of age.
115
If the goal is for an externally powered prosthesis, an amputation that preserves ____% of the residual limb is preferred.
60-70% residual limb length
116
Which physical exam maneuver would make suspicion for a tibial stress fracture less likely?
Negative Fulcrum test; high suspicion when positive
117
What hormones/labs are associated with frailty?
Decreased IGF-1
Decreased DHEA-S
Increased Cortisol levels
Decreased sex steroids
Decreased 25-OH vitamin D
118
Muscle fiber types
Type 1 - slow twitch, aerobic
Type 2a- Fast twitch, anaerobic + aerobic
Type 2b- Fast twitch, purely anaerobic
119
Emery-Dreifuss Muscular Dystrophy
Genetics:
Clinical Features:
Genetics: X-linked form- nuclear membrane protein emerin
- AD form for the nuclear membrane protein laminin A/C.
Clinical Features: Contractures of elbows, ankles, and neck. Muscle weakness in the upper arms and shoulder girdle muscles first and later the pelvic girdle and distal leg muscles.
Cardiac conduction defects, requiring pacemaker placement.
There is usually family history of early death due to cardiac disease in males.
There is no pseudohypertrophy of the calves, IQ is normal.
Tx: PT with home exercises
120
What are the most common sites of avulsion fractures?
Sudden, forceful muscle contraction causes separation of the develooing apophysis from the remaining bones.
The most common injury sites are the ASIS due to sartorius contraction
AIIS due to rectus femoris contraction
Ischial tuberosity due to hamstring (biceps femoris; 2nd = semitendinosus)
Lesser trochanter- Iliopsoas
121
9 year old boy with R shin pain. Worse at night and improved with ibuprofen. Physical exam reveals focal tenderness over the anterior aspect of the pt's RLE.
XR shows a dense sclerotic lesion without cortical disruption or periosteal reaction.
Diagnosis?
Osteoid Osteoma- Benign bone tumor of osteoblast origin. They can be found in any bone but MC in long bones (femur, tibia). They are also commonly seen in the posterior elements of the spine.
Age: 5-24 y/o
Pain is classically worse at night and relieved with NSAID use.
XRs show a sclerotic lesion with an occasional central lucency or nidus
122
What is a Brodie abscess
Brodie abscess is subacute focal osteomyelitis that may persist for years before converting to a florid infection. It should be considered with osteoid osteoma.
Most common site of involvement is the distal tibia.
123
XR of tibia shows a lytic,bone-producing tumor with a florid periosteal reaction (described as a sunburst appearance; also described as Codman's triangle).
Osteosarcoma
124
12 y/o presents with R knee effusion after being tackled at recess. Exam is completely normal and XR is negative. What is the best next step in management?
Any child with a joint effusion must be assessed further than H&P. --> Order MRI for evaluation and diagnosis of soft tissue injury
125
Normal 25-OH levels in children are _____
25-OH Insufficiency?
25-OH Deficiency?
Normal: > 20 ng/dl
Insufficiency: 12-10 ng/dl
Deficiency: <12 ng/dl
126
What is a Segond Fracture?
Typical mechanism of injury?
What other structures are commonly involved with this type of fracture?
Avulsion fracture off the lateral tibial condyle
Typically occurs following internal rotation and varus stress
ACL and medial meniscus
127
Pt with refractory phantom limb pain asks about a dorsal nerve root rhizotomy/spinal ganglionectomy/ dorsal root entry zone lesion procedure.
What is the best advice to give her regarding these procedures?
These procedures are effective for phantom limb pain, but result in a high recurrence rate and return or worsening of phantom limb pain
128
Which sport/recreational activity accounts for most SCI?
Diving (57%)
Skiing is 2nd (10%)
Surfing 3rd (4.1%)
129
Avulsion fx of the extensor digitorum tendon from the DIP will result in what deformity?
Mallet Finger
130
Avulsion fracutre of the FDP tendon is also known as?
Jersey Finger
131
Transverse fx of the 5th metacarpal that is minimally comminuted is known as?
Boxer's Fracture
132
Forced hyperflexion injury of the PIP while the PIP joint is actively extended (Jammed finger) ?
Other common mechanism of injury?
Central slip extensor tendon injury --> Bounonniere deformity
Volar dislocation of the PIP joint can also cause central slip ruptures
133
What is the Elson's test?
Used to assess for central slip extensor tendon injury.
From a 90 degree flexed position over the edge of a table, the pt tried to extend the PIP joint of the involved finger against resistance. The absence of extension force at the PIP and fixed extension at the DIP joint are immediate signs of a complete rupture of the central slip.
134
Which pharmacotherapy option provides the best short-term relief in the chronic phase of CRPS?
Intranasal calcitonin
Bisphosphonates helpful for pain in the acute inflammatory phase of CRPS-1
IV Mg - Helps provide ~12 weeks of relief
135
What structures are commonly injured in little leaguer's elbow?
Medial epicondyle stress fractures
Ulnar collateral ligament injuries
Flexor-Pronator mass strains.
Younger pts more likely to have avulsion injury or apophysitis > UCL disruption
136
What is the recommendation to give kids, adolesence who play baseball, to avoid little leaguer's elbow?
USA Baseball Medical and Safety Advisory Committee?
The AAP recommends limiting the number of pitches to 200 per week; 90 per outing
USA Baseball medical safety commitee --> 75-125 pitches per week ; 50-75 pitches per outing
137
When is surgery indicated for little leaguer's elbow?
Treatment is generally conservative with rest for 4-6 weeks. Most athletes return to competitive pitching after 12 weeks.
Surgery is indicated if there is elbow joint instability with associated UCL injury and medial epicondyle avulsion fracture
138
What are the 4 anatomical parts of the scaphoid bone of the wrist?
Where do most fractures occur?
What is tx for fx of each?
Tubercle, waist, proximal pole, and distal pole.
70% fx at waist of scaphoid
Distal pole and tubercle fractures usually heal well with casting
Nondisoplaced waist and proximal pole fx --> casting with long cast for 6 weeks. If no healing at 9-12 weeks --> ORIF
Displaced proximal pole and waist fractures --> Surgery
139
Pt presents to your clinic for 1st time and you have high suspicion for dx of fibromyalgia. What lab tests should be ordered?
Order CBC, CRP, and ESR to rule out underlying systemic inflammatory etiologies
140
What is the treatment of choice for little leaguer's shoulder?
Rest, Ice, PT, and avoidance of pitching until asymptomatic
141
What is the purpose of employing the use of contralaterally controlled functional electrical stimulation (CCFES)?
CCFES utilizes intention-driven movement in order to obtain the maximum amount of synchronization between the central and peripheral neurons, which when repetitive may promote synaptic remodeling and encourage bilateral cortical activity, furthermore giving the patient the illusion of the restoration of motor control beyond the current capabilities of the affected limb
142
True or False:
Medicare or Medicaid third-party sponsorship of care (in SCI) is a significant predictor of mortality during the first year of injury.
True
143
How would you expect the leg to be positioned in a pt with an anterior vs posterior hip dislocation
Anterior (10%) limb will be hyper-abducted with hip extension
Posterior (90%) Affected limb is shortened and internally rotated. Hip flexion, adduction, and internal rotation will produce posterior dislocations.
144
Which type of amputation is the fit of the socket most important?
Amputations which are performed through the bone since it involves indirect load transfer.
Amputations through a joint, such as a syme amputation or thru knee joint amputations, do not require an intimate fit, as it involves direct load transfer.
145
Patient presents with acute T11-T12 compression fracture. He complains of band-like paresthesias. What is the best next step in management?
Suggests instability --> Surgery to stabilize spine
146
What is the likely etiology of the following subtypes of CP?
Diplegic
Hemiplegic
Quadriplegic
Choreoathetotic
Ataxic
Diplegic (~44%), caused by injury in the centrum semiovale, typically superior and lateral to the caudate. Lesions affect he LE corticospinal tract fibers more so than UE fibers
Hemiplegic (33%) often caused by stroke that may be due to placental emboli, periventricular hemorrhagic infarcts, and malformations. In appx 70% of cases, the left hemisphere is affected due to flow thru the patent ductus arteriosus entering the left carotid artery. Appx 50% will have seizures
Quadriplegic (6%) caused by malformations and hypoxic-ischemic injury
Choreoathetotic (12%) 2/2 Rh incompatibility leading to kernicterus; idiopathic injury to the basal ganglia
Ataxic (4%); most often 2/2 genetic disorders
147
What is the recommendation for athletes participating in sports with a single kidney?
Participation varies based on the type of sport and individual athlete; appropriate protective equipment should be worn during participation.
Typically, full-contact sports such as boxing, hockey, football, extreme sports are not advised.
148
What percentage of body strength is usually lost by people between ages of 50-70?
Muscle weakness beings after age 30 .
People between 50-70 lose ~15% of their strength
70-80 lose 30% of their strength
149
What urodynamic marker is predictive of upper urinary tract injury and renal decline?
Detrusor leak point pressure > 40 cm H20
150
23 y/o athlete with leg pain. XR revels moth-eaten lucent erosions of the tibial shaft with onion-skinning appearance of the periosteum
Ewing Sarcoma
151
Patient with very strong suspicion for a hip fracture with negative XR. Unable to bear weight and is in extreme pain. What is the best next step in management?
Clinical suspicion for hip fx with negative XR --> MRI; T1-weighted coronal MRI is the best sequence for identifying fracture (100% sensitivity)
152
What percent of maximum heart rate is the commonly used target in an exercise tolerance test?
85% of Max HR
Treadmill testing has sensitivity 73-90%; specificity 50-74% (Modified Bruce Protocol)
Nuclear stress test has sensitivity of 81%, specificity of 85-95%
153
A ____ chart is a graph that provides a graphic depiction of the progress of a quality improvement activity over time.
Run Chart; Changes in the process and their relationship to quality measures can be easily seen when using a run chart.
154
When is allopurinol employed in the treatment of gout?
~4 wks after an acute attack for chronic ppx therapy
155
1st line treatment for acute gout flare?
NSAIDs
156
Patient with L5 radic.
When would you first expect to find denervating potentials on EMG? Which muscle?
10-14 days in most proximal muscles to the lesion (lumbar paraspinals)
2-3 wks (TFL )
3-4 wks; more distal involvement (TA)
157
At what prolonged supra capillary pressure does local soft tissue ischemia over a bony prominence occur?
Continuous supra capillary pressure > 70 mmHg for ≥2 hrs results in occlusion of microvessels of the dermis leading to subsequent ischemia of the tissue and risk for development of pressure ulcers
158
How many days should elapse before using the same site for placement of a buprenorphine transdermal patch?
How long is a patch worn?
After buprenorphine transdermal removal, wait for a minimum of 21 days before reapplying to same skin site.
Buprenorphine patch is intended to be worn for 7 days
159
Which MRI findings have a higher prediction of negative prognosticators for neurologic recovery in the setting of acute spinal cord injury?
Presence of spinal cord hemorrhage, edema, and compression are (INDEPENDENT of clinical exam) significant negative prognosticators of neurologic recovery as measured by the ASIA grade
160
How would you expect the mobility of the subtalar joint to change in a patient with rheumatoid arthritis
Joint stiffness and ankylosis of the joint is expected
161
What are the domains tested on the mini-mental state exam (MMSE)?
What is the maximum score?
What score constitutes MCI?
Delirium?
- Orientation
- Recall
- Attention
- Calculation
- Language manipulation and constructional praxis
Max score on MMSE is 30 pts.
26-30; Mild cognitive Impairment
Score of ≤24 indicates dementia/delirium
*20-25: Early, mild dementia
10-19; Middle, moderate dementia
0-9; Late, severe dementia
162
Pediatric Fracture along the epiphyseal plate and exiting through the metaphysis with a positive Thurston-Holland sign?
Salter-Harris Type II
163
What is a Thursto-Holland sign pathognomonic for?
The Thurstan Holland fragment (or Thurstan Holland sign) is an eponymous radiological sign depicting a triangular portion of the metaphysis remaining with the epiphysis in a physeal fracture. This fragment indicates that a type 2 Salter-Harris fracture has occurred.
164
What are the most common types of fractures in children?
Metaphyseal, epiphyseal, and apophyseal fractures (I.e. Salter-Harris Fractures)
165
An avulsion fracture of which pelvic/hip location in an adult is considered pathognomonic for a pathologic fracture?
In the absence of trauma, an isolated fx of the Lesser Trochanter should suggest an underlying pathological process, particularly a primary or metastatic tumor
166
What time of the year has the lowest incidence of SCI?
February
167
What is a Cryoglobulin?
Which conditions is neuropathy associated with cryoglobulinemia?
How would it present on EDX studies?
Cryoglobulins refer to Igs that become solid or gel-like at low temperatures and dissolve upon warming.
Cryoglobulin-containing immune complexes lead to vasculitis of small and medium-sized vessels --> Fatigue, arthralgias, purpura, glomerulonephritis, and neuropathy
Disorders associated with cryoglobulinemia include:
- Leukemia
- Multiple Myeloma
- Mycoplasma pneumonia
- Rheumatoid Arthritis
- SLE
-Other chronic inflammatory disorders, such as hepatitis C.
On EDX, present as sensorimotor polyneuropathy, mononeuropathy, or mononeuropathy multiplex.
Tx= Tx of underlying disease and/or plasmapheresis
168
What is the management of a patient found to have a bipartite patella?
What would help r/o patellar fracture?
Variation of normal development. Asymptomatic in most pts.
MRI, which shows articular cartilage at the patellar-fragment interface and lack of bone marrow edema helps rule out fx.
169
In young, sexually active pts with septic arthritis, the most common causative pathogen is?
N. gonorrhoeae
170
What is the clinical presentation of a patient with vacuolar myelopathy?
HIV pts with low CD4 count; typically presents as a posterolateral spinal cord syndrome often limited to the thoracic cord. It manifests as a slowly progressive, painless spastic paraparesis with sensory loss, imbalance, and sphincter dyssynergia. Typically non-painful.
Often associated with AIDS dementia complex and peripheral neuropathy
171
What is the treatment for a grade III MCL tear?
Majority of MCL injuries are managed non surgically; Tx = PT and hinged knee brace
172
What is a Sprengel deformity?
Sprengel deformity refers to the congenital elevation of the scapula, which can be associated with a webbed neck, low posterior hairline, and Klippel-Feil Syndrome.
173
What is a Riche-Cannieu anastomosis?
Ulnar to median anastamosis in the palm of the hand. Has a communication between the deep palmar branch of the ulnar nerve and the recurrent branch or main motor branch of the median nerve in the palm
174
The primary genetic defect in Marfan syndrome?
Ehlers-Danlos?
FBN1 gene --> abnormal fibrillin in elastic and non-elastic tissues
Ehlers-Danlos --> Type I collagen (also involved in Osteogenesis imperfecta)
175
What is a segond fracture? What other injury is it associated with?
Segond fracture is an avulsion fracture of the knee that involves the lateral aspect of the tibial plateau and is very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament (ACL). On the frontal knee radiograph, it may be referred to as the lateral capsular sign.
Contrary to the more common causes of an ACL tear, which typically involves valgus stress 3, a Segond fracture usually occurs as a result of internal rotation and varus stress --> ORDER MRI
176
14 y/o girl found to have left convex scoliosis. What condition should be ruled out with MRI of the spine?
About 80% of scoliosis cases appear as a right thoracic curve.
A left-sided pattern is associated with a risk for intraspinal syrinx or tumor, which can be detected on MRI.
177
What muscles and nerves comprise the deep posterior compartment of the leg?
1. Tibialis posterior
2. Flexor Digitorum
Longus
3. Flexor Hallucis Longus
4. Tibial Nerve
178
Fat 14 y/o boy diagnosed with SCFE. In addition to an orthopedic consult, what else should be ordered?
Endocrine work up
179
How are SCFE's graded?
Grade 1: < 33% slippage
Grade 2: 33-50% Slippage
Grade 3: >50% slippage
180
What structures make up Guyon's Canal?
The hook of the Hamate forms the lateral (radial) border of Guyon’s canal, while the pisiform forms the medial border. The hypothenar muscles form the floor of Guyon’s canal along with the flexor retinaculum.
181
Which carpal bone fracture in the wrist can cause ulnar neuropathy?
Hook of the Hamate (makes up the medial border of Guyon's canal).
182
In a case of axonotmesis of the median nerve at the wrist on EMG/NCS, 1 month after injury you detect decreased CMAP amplitude proximally and distally to the site of injury in addition to decreased recruitment. 2 years later, which of the following findings would you reasonably expect to discover?
In axonotmesis, even though the axons have died due to crush/stretch injury (leading to decreased CMAP distally and proximally) the epineurium is still intact, which will serve as a guide path for the axons to regenerate along and ultimately find their target muscle fibers again. Thus, months to years later, you may detect a repaired, normal CMAP due to axonal regeneration. (Normal CMAP amplitude distally and proximally)
183
Which structures are contained within the lateral compartment of the lower leg?
What actions do they perform?
Lateral Compartment of the lower leg:
- Fibularis longus and brevis
- Superficial fibular nerve
- Plantar flexion and Eversion of the ankle
184
What does the Stinchfield test, assess for?
Stinchfield Test (or resisted hip flexion test) is designed to help distinguish between intraarticular and extra-articular hip pathology
185
What are the two types of stress fractures of the femur?
What is the treatment for each?
Compression-side fractures (on inferior/medial side of femoral neck) are more common than tension-side fractures (fractures along superior/lateral femoral neck) and can be treated with non-weight-bearing for a period of time, then gradual weight-bearing as tolerated, then gradually increase activity. Tension-side fractures are less stable and require orthopedic surgery consult for ORIF.
186
Which type of dermatomyositis is associated with cancer?
Dermatomyositis Type 3
187
What is Synkinesis?
Synkinesis is the inappropriate regeneration of the facial nerve after it is damaged, leading to the nerve reinnervating muscles inappropriately in such a fashion that the patient may end up doing two “facial nerve” activities at once when the patient only means to do one of these.
188
During nerve conduction studies, why do we refer to the CMAP as the “compound” muscle action potential?
Because the CMAP records an electrical summation of all muscle fibers of a single muscle contraction
189
During an EMG study, you notice on the screen that with forceful muscle contraction by the patient, there are 2 motor units displayed: one firing at 40 Hz, and the other firing at 50 Hz. What type of pattern is this congruent with?
This question describes a decreased recruitment pattern, which can be found in cases of conduction block or axonal loss: essentially neuropathies. This is sometimes called a neuropathic recruitment pattern for this reason, as decreased recruitment is generally not seen in myopathies
190
Other than rheumatoid arthritis, which other common rheum condition has + RF ?
Rheumatoid factor (RF) can be found in rheumatoid arthritis patients as well as those with Sjogren syndrome.
191
You are examining a patient and decide to perform the Schober test. What does this exam test for?
The Schober test demonstrates limited lumbar flexion. It is performed by having the physician mark a spot on the skin roughly at the L5 level, then mark a spot 10cm superior to this spot and 5cm inferior to it. With forward lumbar flexion these spots should separate, and the distance between them (normally 15cm) should increase to greater than 20cm. In ankylosing spondylitis (AS) patients this lumbar flexion will be so limited that the distance may only increase by under 5cm, indicating a positive test in support of the AS diagnosis.
192
How would you describe the position of a mallet toe?
A Mallet toe is a toe demonstrating MTP normal, PIP normal, and DIP flexion; it is typically due to shoes being too small/tight, or trauma; treatment involves proper footwear with enough room to accommodate the toes, in rare cases surgery.
193
How would you describe the position of a hammer toe?
A Hammer toe is a toe demonstrating MTP extension, PIP flexion, and DIP extension, typically due to shoes being too small; treatment involves providing proper footwear with a toe box that is high and long enough to accommodate the toes.
194
Which of the following juvenile idiopathic arthritis (JIA) diseases carries the worst prognosis?
Polyarticular, RF+, JIA
195
Which of the following juvenile idiopathic arthritis (JIA) subtypes requires ophthalmology referral?
Oligoarticular JIA requires ophthalmology referral, as this subtype is associated with iridocyclitis/uveitis.
196
On exam you happen to note that his toes demonstrate MTP extension, PIP flexion, and DIP flexion deformities. What is the name of this toe deformity?
This toe description is that of a claw toe. Claw toes arise from intrinsic foot muscle weakness secondary to typically a neuropathy such as diabetes or Charcot-Marie-Tooth disease.
