PAOS 2016-2017 Self-Assessment Activity QUIZ #4 ANSWER KEY

1. Which of the following appears anechoic on ultrasound imaging?

A. fluid B. bone C. tendons D. ligaments E. calcifications

Nobel, V.E., & Nelson, B. (2011). Manual of emergency and critical care ultrasound. Cambridge: Cambridge University Press, page 215. Answer: A. fluid. Ultrasound machines can measure the intensity (amplitude) of the returning echo; analysis of this information affects the brightness of the echo displayed on the screen. Weak returning echoes translate into dark gray or black areas (fluid) on the screen, known as hypoechoic or anechoic respectively. 2. Cellulitis has which of the following characteristic appearances on ultrasound imaging?

A. cobblestone appearance B. anechoic spacing deep to a tendon C. honeycomb appearance D. ring-down effect E. deep hyperechoic echoes

Nobel, V.E., & Nelson, B. (2011). Manual of emergency and critical care ultrasound. Cambridge: Cambridge University Press, page 215. Answer: A. Cobblestone appearance. Soft tissue imaging is used to assess for fluid collections, signs of fasciitis and presence of foreign bodies. Cobblestoning or fluid

tracking throughout the subcutaneous tissue is the prominent appearance in cellulitis. Early in the clinical course of cellulitis, cobblestoning may not be prominent. 3. Which of the following best describes the appearance of a ganglion cyst on ultrasound imaging?

A. anechoic structure with posterior acoustic shadowing B. hyperechoic structure with ring-down artifact C. hypoechoic structure with cobblestone appearance D. anechoic structure with bright echogenic walls E. hyperechoic structure with echogenic hilus

Jacobson, J.A., Wilson, T.J., & Yang, L.J. (2016). Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. Journal of Ultrasound in Medicine, 35(4), 683-693. doi: 10.7863/ultra.15.05061. Answer: A. anechoic structure with posterior acoustic shadowing. On Sonography, an intraneural ganglion cyst will appear as an anechoic, often multilocular fluid collection adjacent to and along the course of the nerve. Posterior acoustic shadowing occurs beyond the cyst due to increased sound wave transmission through the fluid-filled structure (cyst). 4. Which of the following best facilitates the evaluation of the glenohumeral joint using ultrasound for the examination?

A. probe placed in the transverse plane from a posterior approach B. probe placed in the transverse plane from an anterior approach C. probe placed in the longitudinal plane from a posterior approach D. probe placed in the longitudinal plane from an anterior approach E. none of the above; it is not possible to use ultrasound to evaluate the glenohumeral joint

AIUM Practice Parameter for the Performance of a Musculoskeletal Ultrasound Examination (2012). Retrieved July 6, 2016, http://www.aium.org/resources/guidelines/musculoskeletal.pdf

Answer: A. probe placed in the transverse plane from a posterior approach. During the rotator cuff examination, the practitioner should evaluate the glenohumeral joint for effusions, intra-artcular loose bodies, synovitis or other bony abnormalities. This is best viewed with the probe in the transverse plane from a posterior approach. 5. Which of the following best describes the normal appearance of peripheral nerves on ultrasound imaging?

A. fascicles appear hypoechoic, surrounded by hyperechoic connective tissue B. fascicles appear hyperechoic, surrounded by hypoechoic connective tissue C. fascicles appear hypoechoic, surrounded by hypechoic connective tissue D. hyperechoic with a fibrillar or fiber-like appearance E. decreased echogenicity of the connective tissues of the nerve trunk

Jacobson, J.A., Wilson, T.J., & Yang, L.J. (2016). Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. Journal of Ultrasound in Medicine, 35(4), 683-693. doi: 10.7863/ultra.15.05061. Answer: A. The characteristic appearance of nerves is best appreciated with the probe in the short axis relative to the nerve. In this instance, the nerve fascicles appear hypoechoic with surrounding hyperechoic connective tissue. This is similar to a “honeycomb” appearance or “straws-on-end” appearance. This is in contrast to normal tendons, which are hyperechoic with a fibrillar or fiber-like appearance. 6. An 8-year-old boy fell while riding his bike and landed on his outstretched arm.

Radiographs demonstrate a both bone forearm fracture of the distal third of the

forearm. Which of the following increases the risk of displacement following

closed reduction and casting?

A. Long arm cast immobilization B. Short arm cast immobilization C. Cast index greater than 0.85 D. Conscious sedation during reduction E. Plaster cast immobilization

Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. Webb et. al., JBJS Am. 2006 Jan:88(1):9-17

Answer: C. Pediatric both bone forearm fractures are generally treated with closed reduction and immobilization given the ability of the bone to remodel. Loss of reduction is associated with poorly molded casts 7. You are preparing to cast a child with a both-bone forearm fracture in the emergency room. During cast application, all of the following are directly related to the risk of thermal injury EXCEPT?

A. Layers of thickness of casting material B. Water temperature used to dip casting material C. Placing the limb on a pillow during the cast curing process D. Fiberglass overwrapping of plaster casts E. Type of fracture pattern

Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. Halanski et. al., JBJS Am. 2007 Nov; 89(11):2369-77 Answer: E. Multiple factors are associated with thermal burns. Fracture pattern is not one of them.

8. Which of the following elbow apophyses is the last to ossify/appear on x-ray?

A. Capitellum B. External (lateral) epicondyle C. Radial head D. Internal (medial) epicondyle E. Trochlea

A new look at the sequential development of elbow-ossification centers in children. Cheng et. Al., Journal of Pediatric Orthopedics, 1998 Mar-Apr; 18(2): 161-7 Answer: B. While the external (lateral) epicondyle is the last apophyses to APPEAR on radiographs the apophyses is the last to FUSE. A mnemonic of the order of APPEARANCE of the individual ossification centers of the elbow is C-R-I-T-O-E: Capitellum, Radial head, Internal (medial) epicondyle, Trochlea, Olecranon, External (lateral) epicondyle. 9. The most common nerve injured with extension type pediatric supracondylar fracture innervates all of the following muscles EXCEPT?

A. flexor digitorum profundus index finger B. flexor digitorum profundus middle finger C. flexor pollicis longus D. extensor pollicis longus E. pronator quadratus

Acute neurovascular complications with supracondylar fractures in children. Dormas et. Al., Journal of Hand Surgery Am. 1995 Jan; 20910:1-4. Answer: D. The anterior interosseus nerve (AIN) is the most common nerve injured with extension type pediatric supracondylar. The AIN, a branch of the median nerve, is principally a motor nerve and innervates the Flexor Digitorum Profundus Index and Middle fingers, Flexor Pollicis Longus and Pronator Quadratus. It DOES NOT innervate the Extensor Pollicis Longus, which is innervated by the posterior interosseous nerve, a continuation of the deep branch of the radial nerve. Remember “A-ok” for AIN, and “point and shoot” for PIN. 10. An 8-year-old boy has a cubitus varus (“gun stock”) deformity of his left elbow after a supracondylar humerus fracture was treated in a splint. What is the most common cause of this deformity?

A. Malreduction causing malunion B. Medial epicondyle growth arrest C. Lateral condyle overgrowth D. Medial epicondyle avascular necrosis E. Unrecognized compartment syndrome

A 10-year study of the changes in the pattern and treatment of 6,493 fractures. Cheng et. Al. Journal of Pediatric Orthopedics 1999 May-Jun; 19(3): 344-50. Answer: A. Supracondylar humerus fractures are the most common elbow fractures in children, accounting for 60-80% of pediatric elbow fractures. This usually is the result of malunion caused by failure to reduce a collapsed medial column or failure to correct rotation at the fracture site. 11. You measure the angle formed by lines drawn from the superior aspect of the anterior process of the calcaneous to the superior aspect of the posterior articular surface and from the superior aspect of the posterior articular surface to the superior aspect of the calcaneal tuberosity and get 20 degrees. What is the name of this angle and what is the significance of the value?

A. Bohler’s Angle, possible calcaneus fracture B. Bohler’s Angle, possible talus fracture C. Gissane’s Angle, possible calcaneus fracture D. Gissane’s Angle, possible talus fracture E. Meary’s angle, possible calcaneus fracture

Hak, D. J., & Gautsch, T. L. (1995). A review of radiographic lines and angles used in orthopedics. American journal of orthopedics (Belle Mead, NJ), 24(8), 590. Answer: A. The line described is Bohler’s angle which is typically 25o – 40o. An angle outside of these parameters may indicate a calcaneus fracture. Gissane’s angle is evaluated by calculating the angle of the thick cortical strut of the superior aspect of the

calcaneus and may be indicative of a calcaneus fracture. Meary’s angle is the longitudinal axis of the talus and first metatarsal to evaluates for a cavus deformity. 12. You are evaluating an adult patient with down’s syndrome and suspect possible antlantoaxial instability. What is a normal Atlantal Dens Interval (ADI)?

A. 3 mm B. 5 mm C. 7 mm D. 9 mm E. 11 mm

Hak, D. J., & Gautsch, T. L. (1995). A review of radiographic lines and angles used in orthopedics. American journal of orthopedics (Belle Mead, NJ), 24(8), 590.

Answer: A. Normal ADI in adults is up to 3mm, 4 mm in children. Antlantoaxial

instability is also common in Moroquio’s syndrome, Larsen’s syndrome, achondroplasia,

and spondyloepiphseal dysplasia.

13. Which of the following is not criteria for the NEXUS method of clearing the

cervical spine in presence of trauma?

A. Long bone fracture B. Absence of Midline tenderness C. Awake and Alert Patient D. Lower extremity neurologic deficit E. All the above meet criteria of the NEXUS criteria

Anderson, P. A., Gugala, Z., Lindsey, R. W., Schoenfeld, A. J., & Harris, M. B. (2010). Clearing the cervical spine in the blunt trauma patient. Journal of the American Academy of Orthopaedic Surgeons, 18(3), 149-159.

Answer: D. Patients must have absent neurologic symptoms / signs to be cleared by

the NEXUS criteria. The NEXUS criteria includes absence of intoxication and distracting

injuries, Awake/Lert patient, no cervical pain/midline tenderness, and no neurologic

signs and symptoms.

14. You are preparing to cast a child with a both-bone forearm fracture in the emergency room. During cast application, all of the following are directly related to the risk of thermal injury EXCEPT?

A. Layers of thickness of casting material B. Water temperature used to dip casting material C. Placing the limb on a pillow during the cast curing process D. Fiberglass overwrapping of plaster casts E. Type of fracture pattern

Halanski et. al., Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity.JBJS Am. 2007 Nov; 89(11):2369-77 Answer (E): Multiple factors are associated with thermal burns. Fracture pattern is not one of them. Excessive temperatures of the plaster from an exothermic reaction with water causing skin burns can occur when using water greater than 24 degrees Celsius, higher ply count (greater than 8), or preventing dissipation of the heat (such as elevating on a pillow). 15. The original description of the Quigley maneuver is which of the following?

A. Lower extremity, at rest, with the body supine, lies in external rotation and is suspended by the great toe allowing the ankle and foot to fall into adduction, external rotation and supination. B. Lower extremity, at rest, with the body supine, lies in external rotation and is suspended by the great toe allowing the ankle and foot to fall into adduction, internal rotation and supination. C. Lower extremity, at rest, with the body supine, lies neutral position and is suspended by the great toe allowing the ankle and foot to fall into adduction, internal rotation and supination. D. Lower extremity, at rest, with the body supine, lies in neutral position and is suspended by the great toe allowing the ankle and foot to fall into abduction, external rotation and supination.

E. Lower extremity, at rest, with the body supine, lies in external rotation and is suspended by the great toe allowing the ankle and foot to fall into abduction, internal rotation and pronation.

Rockwood, C. A., Green, D. P., & Bucholz, R. W. (2006). Rockwood and Green's fractures in adults (6th ed.). Philadelphia: Lippincott Williams & Wilkins. 1998. Answer (B): The Quigley maneuver is a reduction assisted maneuver to assist with common ankle fracture patterns. 16. Applying a short leg L & U splint for treatment of acute orthopaedic injuries allows for swelling and immobilization of the extremity reducing the risk of acute compartment syndrome. What is the most sensitive clinical signs of compartment syndrome?

A. Inability to flex and extend great toe B. Capillary refill greater than 2 seconds C. Decreased sensation within the 1st webspace of the foot D. Pain out of proportion to the injury that is aggravated by passively flexing the great toe E. Pallor of the toes

Olson, Steven, Glasgow, Robert: Acute Compartment Syndrome in Lower Extremity Musculoskeletal Trauma. Journal of the American Academy of Orthopaedic Surgeons 2005; 13:436-444. Answer: D. Pain with passive motion of the affected compartment is the most sensitive clinical finding associated with acute compartment syndrome. 17. If the foot and ankle are not kept in a neutral position when applying a short leg splint the patient is at an increased risk of acquiring what type of contracture?

A. Dorsiflexion contracture B. Equinus contracture C. Painful contracture D. Contracture of the midfoot arch E. Flexion contracture of the great toe

Weinstein, S. L., & Buckwalter, J. A. (2005). Turek's orthopaedics: Principles and their application (Sixth edition.). Philadelphia: Lippincott Williams & Wilkins. 101.

Answer : B. An equinus contracture, contracture of the Achilles forcing a fixed plantar flexion of the ankle, is the most common complication of poor positioning of the ankle when immobilizing. 18. When a mold is required for fracture reduction what cast/splinting material is most preferred?

A. Synthetic material such as fiberglass B. Thermoplastic splint C. Plaster of paris D. Aluminum reinforced foam E. Aircast

Weinstein, S. L., & Buckwalter, J. A. (2005). Turek's orthopaedics: Principles and their application (Sixth edition.). Philadelphia: Lippincott Williams & Wilkins. 101. Answer: C. Plaster is the most preferred material for splinting/molding of fracture reductions because it is the most pliable material.

19. A lateral radiograph of the elbow demonstrates a crescentric lucency projecting posterior to the distal humerus (posterior fat pad) which should normally not be visualized. What are common causes of this sign?

A. Posterior displacement of intra-articular, extrasynovial fat around the elbow joint by fluid in the joint

B. Occult supracondylar fracture in pediatrics C. Occult radial head fracture in adults D. All of the above E. None of the above

Norell HG. Roentgenologic visualization of the extracapsular fat. Act Radiol. 1954;42:205–210 Answer: D. The posterior fat pad should not be visualized, However, in the case of an injury, a joint effusion may posteriorly displace the fat from the olecranon process making the posterior fat pad visible. The anterior fat pad should only appear as a lucent stripe. A hemarthrosis in the joint capsule may push the anterior fat superiorly causing the “Sail Sign” or a prominent protrusion of the anterior fat pad that makes it appear like a lucent sail (as opposed to a stripe). 20. Circumferential casts should not generally be used with:

A. Open fractures B. Gradual correction of a deformity with serial casting C. Dislocations

D. Severe sprains E. All of the above

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer (A): Circumferential casting does not allow for swelling, therefore casting of an open fracture is contraindicated because it may lead to compartment syndrome of the casted extremity. 21. A Long Arm Cast will accomplish which of the following when applied correctly?

A. Prevent forearm rotation B. Allows free ROM of thumb & fingers C. Eliminate ulnar/radial deviation D. All of the above

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer (D): Long arm casting is the most restrictive form of immobilization of the upper extremity. This form of immobilization restricts forearm motion, ulnar/radial deviation, but allows for full range of motion of the fingers. 22. In the application of a Short Arm Cast (SAC), the wrist is place in degrees of dorsal extension.

A. 0-15 B. 15-30 C. 30-45 D. 45-90

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer: B. Anatomic immobilization of the wrist is preferred. The neutral anatomic alignment of the wrist is 15-30 degrees. 23. In a short arm cast, which mold is used to prevent movement of the wrist in the cast?

A. Interosseous B. Palmar C. Olecranon D. Arch E. None of the above

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer: A. A good interosseous mold should be applied to all casting that involves the forearm. The interosseous mold accentuates the soft tissue space between the radius and ulna. The mold reduces micromotion of the wrist. 24. The short arm cast is applied how many inch(es) distal to the antecubital space?

A. 1 B. 2 C. 3 D. 4 E. 5

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer: B. The short arm cast should terminate proximally approximately 2 inches distal to the antecubital space to allow for uninhibited flexion of the elbow. 25. In the application of a long arm cast, the elbow is placed in what degree of flexion?

A. 0 B. 45 C. 90 D. 135 E. None of the above

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer: C. The elbow should be immobilized in the neutral position to eliminate a contracture in flexion or extension. 26. Long Arm Cast immobilization extends from the distal palmar crease/MCP joints to what distance from the axilla?

A. 1 B. 2 C. 3 D. 4 E. 5

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing

Answer: C. The long arm cast should terminate 3 inches distal to the axilla to allow uninhibited motion of the shoulder joint. 27. A Long Arm Cast will restrict all of the following EXCEPT?

A. Thumb and finger ROM B. Pronation/Supination C. Radial/ulnar deviation D. Forearm rotation E. All are restricted by the Long Arm Cast

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer: A. The long arm cast does not restrict thumb and finger range of motion. 28. In the application of a long arm cast, which mold is used to prevent movement of the humerus in the cast?

A. Bicipital B. Interosseous C. Supracondylar D. Subscapular

Orthopeadic Immobilization Techniques: A step-by-step guide for casting and splinting, Brown et al. Sagamore Publishing Answer: C. A supercondyler mold is applied just proximal to the condyles of the distal humerus to prevent humerus motion. 29. The cast index is calculated by which of the following measurements:

A. Outer diameter of cast on anteroposterior radiograph/Inner diameter of cast on lateral radiograph. B. Inner diameter of cast on anteroposterior radiograph/Inner diameter of cast on lateral radiograph. C. Outer diameter of cast on anteroposterior radiograph/Outer diameter of cast on lateral radiograph. D. Inner diameter of cast on lateral radiograph/Inner diameter of cast on anteroposterior radiograph.

Bhatia M, Housden PH. Re-displacement of paediatric forearm fractures: role of plaster molding and padding. Injury Int J Care Injured. 2006;37:259-268. Answer: D. The cast index is measured by the inner diameter of the cast on lateral radiograph divided by the inner diameter of the cast on the AP radiograph. 30. A risk factor for loss of reduction on a pediatric forearm fracture is an inappropriate cast index. An appropriate cast index for splinting or

casting performed on a pediatric forearm fracture after reduction should be which value?

A. less than 0.8 B. more than 0.8 C. less than 1.1 D. more than 1.1 E. equal to 1.1

Bhatia M, Housden PH. Re-displacement of paediatric forearm fractures: role of plaster molding and padding. Injury Int J Care Injured. 2006;37:259-268. Answer: A. A cast index of more than 0.8 is a risk factor for loss of reduction in pediatric forearm fractures. 31. A 30 year male presents to your acute care department with an obvious wrist deformity and paresthesias to his thumb and index finger after a bad parachute landing. This is an isolated injury. His wrist radiographs demonstrate disruption of the “Gilula’s Lines.” What is the appropriate next step in management?

A. MRI to assess the median nerve B. Closed reduction C. Open reduction internal fixation D. CT scan of the wrist Perilunate injuries: diagnosis and treatment. Kozin SH. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):114-20. Answer: B. This patient presentation is classic for a perilunate dislocation. The next step is urgent closed reduction. If close reduction is not successful, the patient should be taken to the OR for urgent open reduction. 32. The classification system used to describe the stages and pathomechanics of perilunate injuries is:

A. Hawkins classification B. Milch classification C. Frykman classification D. Mayfield classification Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg [Am] 1980;5:226-241. Answer: D. The Mayfield classification system is used to describe the stages of injury associated with a perilunate dislocation.

33. A patient presents to your clinic with a nondisplaced transverse fracture of the patella. Your clinical exam reveals an intact extensor mechanism. The appropriate treatment for this condition is:

A. Open reduction internal fixation B. Hinged knee brace locked in extension C. Closed reduction percutaneous pinning D. Knee arthroscopy Melvin JS, Mehta S. Patella Fractures in Adults. JAAOS. 2011. 19:198-207. Answer: B. Hinged knee braces provide sufficient support for acute injuries of the patella and can be used to advance ROM after initial immobilization. 34. The classification system of ankle fractures based on foot position and direction of the force applied at the time of injury is known as:

A. Lauge-Hansen B. Weber C. Broos D. Hawkins Lauge-Hansen, N. (1954). Fractures of the Ankle III. Genetic Roentgenologic Diagnosis of the Fractures of the Ankle. The American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine, 456-471. Answer: A. The Lauge-Hansen classification system was the first classification system described for ankle fracture patterns. The system describes patterns based on anatomic foot position (supination vs. pronation) and force applied during injury. 35. A patient presents with an acute non-displaced scaphoid fracture after a fall on outstretched hands. You counsel the patient appropriately on outcomes of surgical vs. non-surgical treatment. The patient elects to proceed with non-surgical treatment. The appropriate non-surgical treatment is:

A. Short arm cast B. Long arm cast C. Thumb spica cast D. Sugar tong splint Correct Tada K, Ikeda K, Okamoto S, Hachinota A, Yamamoto D, Tsuchiya H. Hand Surg. 2015;20(2):204-9.

Answer: C. Thumb spica casting is the appropriate immobilization for non-surgical treatment of non-displaced, stable scaphoid fractures. 36. You have a 40 year old male that reports with a history of Debuytren’s disease and a contracture of their web space, what cord do you suspect is affected by the disease process?

A. Pretendinous Cord B. Natatory Cord C. Spiral Cord D. Central Cord E. Lateral Cord

Black, E. M., & Blazar, P. E. (2011). Dupuytren Disease: An Evolving

Understanding of an Age‐old Disease. Journal of the American Academy of Orthopaedic Surgeons, 19(12), 746-757. Answer: B. Natatory cord usually is affected in patients with web space contracture.

Pretendinous cords present with MCP contracture, Spiral cords present with MCP

contracture + PIP contracture, Central cords present with PIP flexion contracture,

Lateral Cords can present as either PIP or DIP flexion contractures.

37. Which of the following patients would not be considered a "high risk" patient for developing complications secondary to cast/splint application (eg. Pressure sores, compartment syndrome, stiffness)?

A. 4 yo female with a transverse fracture of the tibial diaphysis B. 49 yo diabetic male with a posterior malleolus fracture of the left ankle C. 22 yo male involved in MVA with multiple injuries and comatose D. 24 yo otherwise healthy male with left bimalleolar fracture E. 35 yo female involved in MVA with suspected spinal cord injury and medial malleolus fracture of the left ankle

Halanski, Matthew, Noonan, Kenneth J.: Cast and Splint

Immobilization: Complications. Journal of the American Academy of Orthopaedic Surgeons 2008; 16:30-40. Answer: D. High risk patient populations for casting or splinting are polytrauma, patients with systemic disease such as diabetics, pediatric patients, or individuals that cannot communicate appropriately.

38. 67 y/o female presents to clinic complaining of continued pain and weakness

in the right shoulder for the last 3 months. She had a fall landing with the right

arm outstretched above her head and has noticed continued pain and weakness

in the shoulder since this time. During the clinical exam you are suspicious of a

tear of the rotator cuff. All the test below are for the rotator cuff except.

A. Lift-off Test

B. Jobe’s Test

C. Empty Can Test

D. O’Brien’s Test

E. All are tests for evaluating the rotator cuff

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences,

2006. Print

Answer: D. The O’Brien’s test is for evaluation of superior labral pathology and tear.

The lift off test evaluates subscapularis strength. Answers B and C evaluate

supraspinatus weakness.

39. Which test would we use to asses for Teres Minor Weakness?

A. Belly Press Test

B. Lift-off Test

C. Lag Sign

D. Horn blowers Test

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences,

2006. Print

Answer: D. Horn blowers this test does isolate the teres minor muscle. Answers A and

B are both for subscapularis weakness. C, is typically for infraspinatus or supraspinatus

deficiency.

40. A 36 y/o male semi pro tennis player presents to the office complaining of

anterior shoulder pain that is worse with overhand activities and serving. He has

no fall or injury, that pain has progressively gotten worse over the last 8 weeks,

describes the pain primarily in the lateral shoulder area, dull ache with occasional

sharp pain with overhead use. Which test do you suspect to be positive with this

patient?

1. Hawkin’s 2. Neer sign 3. Speed’s Test 4. Drop Arm Test

A. 1 B. 2 C. 3&4 D. 1&2

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences, 2006. Print Answer: D. Both the Hawkin’s and Neer signs are for Impingement of the shoulder which would be suspected in this patient with this history. The speed’s test Is for proximal biceps pain and pathology. The drop arm is for Supraspinatus pathology. 41. 16 y/o male presents to clinic after dislocating his shoulder during a wrestling

match. This was his first dislocation and was reduced in the emergency room. He

has been in a sling for the last 3 weeks and now was referred to your office by his

pediatrician for evaluation and continued treatment. When performing a clinical

exam for shoulder instability you would use all the following tests except.

A. Load and Shift B. Dynamic Sheer

C. Anterior Apprehension D. Sulcus sign

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences, 2006. Print Answer: B. The dynamic sheer test evaluates for labral pathology and possible superior labral tear, B,C,D are all test for instability and laxity in the shoulder. 42. 36 y/o female presents to the office with increasing shoulder pain and

stiffness. She is a type 2 Diabetic with a BMI of 36. She has no fall or trauma prior

to the start of the shoulder pain. The pain has progressively gotten worse and

now has started to notice stiffness and loss of motion in the shoulder. Based on

the history you suspect Adhesive Capsulitis, which physical exam findings would

help confirm the diagnosis.

A. Painful Arc with active motion above shoulder level B. Decreased and equal Active and Passive range of motion of the shoulder C. External rotation lag sign in the shoulder D. Increasing shoulder pain with cross body adduction

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences, 2006. Print Answer: B. This is a classic presentation of Adhesive capsulitis and one of the most common clinical exam findings is that the patients passive and active range of motion are equal and decreased. A, is more indicative of impingement syndrome with a painful arc above the shoulder level. External rotation lag sign is suggestive of a supraspinatus tear of the shoulder. D, This is typical of AC joint pathology and pain in the shoulder.

43. 45 y/o male presents with increased shoulder pain for the last 3 months with a

gradual onset. He has been a very active weight lifter for the last 10 years. He

states the pain started gradually and is worse with incline bench press activities.

Pain is within the anterior and top aspect of his shoulder. On clinical exam he

has increasing pain with cross body adduction and superficial pain with Obrien’s

test. Based on this history and exam what is the most likely diagnosis?

A. AC joint osteolysis B. Rotator Cuff Tear C. Superior Labral tear D. Shoulder Impingement

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences, 2006. Print Answer: A. AC joint pain is provoked by cross body abduction and Superficially with Obrien’s test, if is also very common in weight lifters. B&C do not fit this clinical description and although a positive Obrien’s test is noted is with superficial pain. D, could be the right answer in this patient but impingement exam findings are not documented and location of pain is not consistent. 44. All of the test below are helpful to diagnosis proximal biceps tendinitis

except?

A. Upper Cut Test B. Speed’s test C. Yergason’s test D. Hawkin’s Test

Johnson, Darren. Clinical Sports Medicine. 1st ed. N.p.: Elsevier Health Sciences, 2006. Print Answer: D. Hawkins test is for Impingement syndrome of the shoulder. A,B,&C, are all tests to assess the proximal biceps. 45. Which of the following ligaments assits in stabilizing the long head of the bieps in the midrange of motion?

A. Superior glenohumeral ligament B. Middle glenohumeral ligament C. Inferior glenohumeral ligament D. Transverse humeral ligament E. A and D

Streubel, P. N., Krych, A. J., Simone, J. P., Dahm, D. L., Sperling, J. W., Steinmann, S. P., ... & Sanchez-Sotelo, J. (2014). Anterior glenohumeral

instability: a pathology-based surgical treatment strategy. Journal of the American Academy of Orthopaedic Surgeons, 22(5), 283-294.

Answer: E. The superior glenohumeral and transverse humeral ligament both stabilize

the long head of the biceps. Middle glenohumeral ligament Inferior glenohumeral

ligament provides anterior stability in external rotation.

46. Which of the following ligaments is most likely to be affected in a humeral avulsion of the glenohumeral liagament (HAGL) lesion?

A. Superior glenohumeral ligament B. Middle glenohumeral ligament C. Inferior glenohumeral ligament D. Transverse humeral ligament E. None of the above

Streubel, P. N., Krych, A. J., Simone, J. P., Dahm, D. L., Sperling, J. W., Steinmann, S. P., ... & Sanchez-Sotelo, J. (2014). Anterior glenohumeral instability: a pathology-based surgical treatment strategy. Journal of the American Academy of Orthopaedic Surgeons, 22(5), 283-294.

Answer: C. The Inferior glenohumeral ligament is the most commonly affected

ligament in HAGL lesions.

47. A 52 year old perimenopausal female presents to your office with a distal

radius fracture following a ground level fall. Her DXA T-score for spine is -2.4,

with a femoral neck T-score of -1.8. She has a family history of hip fracture, a BMI

of 17, and smokes a pack/day. This is her second low energy fracture, and she

developed DVT after a tibial plateau fracture last year. Which treatment option

would be contraindicated in this patient?

A. Bisphosphonate

B. Raloxifene

C. Denosumab

D. Calcitonin

Lippuner, et al; Eur Spine J. Recommendations for raloxifene use in daily clinical practice. 2012 Dec; 21(12): 2407–2417. Published online 2012 Jun 28. doi: 10.1007/s00586-012-2404-y

Answer: B. Raloxifene increases the risk of VTE and is contra-indicated in patients with

present or past deep vein thrombosis, retinal vein thrombosis, pulmonary embolism, or

presenting typical risk factors for VTE.

48. An acute phase reaction (flu-like symptoms) may occur with which of the

following OP medications?

A. Calcitonin

B. Raloxifene

C. Teriparatide

D. Zoledronic Acid

Reid et al; J Clin Endo Metab. Characterization of and Risk Factors for the

Acute-Phase Response after Zoledronic Acid.

http://press.edocrine.org/doi/abs/10.

Answer: D. zoledronic acid (Reclast) infusion can cause an acute phase reaction

including myalgia, arthralgia, fever and headache lasting up to 3 days.

49. Which of the following OP medications has been found to have analgesic

effect in some patients with acute vertebral fractures?

A. Alendronate

B. Calcitonin

C. Teriparatide

D. Raloxifene

Osteoporos Int. 2012 Jan;23(1):17-38. doi: 10.1007/s00198-011-1676-0. Epub 2011

Jun 10.

Answer: B. Calcitonin has proven efficacy in the management of acute back pain

associated with a recent compression fracture.

50. Which of the following drugs may be the best choice for patients with

impaired renal function?

A. Calcitonin

B. raloxifene

C. Denosumab

D. Alendronate

Ther Clin Risk Manag. Long term treatment of osteoporosis:safety and efficacy

appraisal of denosumab. 2012; 8: 295–306. Published online 2012 Jun 19. doi:

10.2147/TCRM.S24239 PMCID: PMC3387828

Answer C. Denosumab has been shown to decrease the risk of vertebral, hip, and

nonvertebral fractures in women with postmenopausal osteoporosis. Therefore, it could

be considered as an effective alternative to previous bisphosphonate treatment as well

as first-line treatment of severe osteoporosis.