Orthopedics Final – 1991 – answers not verified



Orthopedics Final – 1991 – answers not verified

Questions 1-5 – use the following answers

a. if major nerve root involved is L3

b. if major nerve root involved is L4

c. if major nerve root involved is L5

d. if major nerve root involved is S1

1. Diminished ankle jerk – S1

2. Weakness of big toe (first) dorsiflexion – L5

3. Due to L4-5 disc lesion – L5

4. Weakness in foot inversion – L4

5. Weakness in foot eversion – S1

6. In differentiating meniscal from patellar pain which pain pattern is most likely to increase doing DOWN steps?

a. meniscal

b. patellar

c. neither

7. In differentiating between meniscal and patellar pain patterns which has a more likely history of an acute twisting injury that doesn’t hurt when sitting?

a. meniscal

b. patellar

c. neither

d. both

8. One difference between osteitis condensans ilii and blastic mets to the sacrum is that the pain associated with the benign process usually doesn’t occur at night while “neoplastic” pain is common at night.

a. true

b. false

9. Although pelvic fractures make up only a small fraction of all skeletal fractures they are second only to skull fractures for morbidity.

a. true

b. false

10. Because of the predominately major source of blood from the lateral epiphyseal arteries, adduction fractures of the femoral neck have a greater incidence of avascular necrosis of the head as compared with abduction fractures.

a. true

b. false

11. A neuropathic spine, despite having destruction, disorganization and excess ossification is usually hypermobile.

a. true

b. false

12. Osteitis pubis is almost always due to an infection spread from pevlic surgery, especially prostatectomy.

a. true

b. false

13. A coxa-valgus hip deformity can result in a force greater than seven times body weight acting through the affected femoral head during walking.

a. true

b. false

14. Osteoarthritis of the hip usually leads to a flexion, adduction and internal (??external) rotation deformity.

a. true

b. false

15. Osteonecrosis of the femoral head is often bilateral and is more common in men.

a. true

b. false

16. Which of the following are possible non-mechanical causes of low back pain. (multiple answers possible)

a. prostatitis

b. endometriosis

c. large vowel carcinoma

d. retroperitoneal lymphoma

e. renal stones

17. The #1 cause of disc calcification is:

a. degenerative disc

b. alkaptonuria

c. ochronosis

d. ankylosis and spondylitis

e. gout

18. Which of the following statements are true of spina bifida?

a. may be a cause of Arnold-Chiari Syndrome

b. defect occurs during the 21st to 29th day of fetal life

c. dimpling, pigmentation and hypertrichosis may be seen over area of spine

d. may be cause of spastic paralysis and foot deformities

e. all of the above

19. The “critical zone” of the spinal cord is where the canal space is smallest and the blood supply is least. Which one of the following is the “critical zone”?

a. C1-C7

b. T1-T4

c. T4-T9

d. T10-L1

e. L2-L5

20. Which statements are true regarding adolescent kyphosis (Scheuerman’s disease)?

a. x-rays show Schmorl’s nodes and anterior body wedging

b. most common in lower T-spine

c. if present – examine for spondylolisthesis

d. a and b

e. all of the above

21. Which of the following statements are true of ankylosing spondylitis (AS)?

a. chin-on-chest deformity is due to C1-C2 dislocation

b. 20 times more common in offspring of AS parents

c. lower thoracic and upper lumbar first site of vertebral body involvement (begins T/L junction)

d. b and c

e. all of the above

22. Which one of the following is not a likely cause of osteoporosis?

a. adrenal cortex formone increase

b. pituitary basophilic adenoma

c. gastrointestinal malabsorption

d. sex hormone increase

e. inactivity

23. A “gibbus” deformity of the spine is classically seen in:

a. lymphosarcoma of the spine

b. tuberculosis of the spine

c. spina bifida occulta

d. rheumatoid arthritis of spine

e. ankylosing spondylitis

24. The 45 year old veterinarian (D.V.M.) across the street comes in complaining of low back pain for 2 months. ON further questioning he admits to chills, headaches, and spiking fevers. Examination reveals splenomegaly. X-ray shows L2-L3 disc decreased with irregular adjacent vertebral end plates. TB test was negative. Two months later x-rays show L2-L3 bodies fused. He most likely has:

a. fibrositis

b. lymphoma

c. brucellosis

d. eosinophilic granuloma

e. AIDS

25. A ten year old girl present with a one month history of moderate back pain and fatigue. Examination reveals muscle spasm and tenderness of the L1 spinous. Xray reveals a wafer-thin L1 body with good disc spaces. The ESR was normal. The most likely cause is:

a. tuberculosis

b. brucellosis

c. ankylosing spondylitis

d. eosinophilic granuloma

e. metastasis from Wilm’s tumor

26. Which of the following looks identical to ankylosing spondylitis on spine radiographs?

a. psoriatic arthritis

b. Reiter’s disease

c. Rheumatoid arthritis

d. enteropathic arthritis

e. none of the above

27. Which of the following tumors are classically seen in the anterior portion (body) of the vertebra? (Know what is anterior (malignant) and posterior (benign except hemangioma)

a. eosinophilic granuloma

b. anuerysmal bone cyst

c. hemangioma

d. b and c

e. a and c

28. A 16 year old soccer star presents with pain in right groin and weakness in flexing his right thigh and flexing his right knee. X-ray shows irregularity of the ASIS. He most likely has:

a. avulsion fracture of sartorius

b. avulsion fracture of rectus femoris

c. avulsion fracture of all the quadriceps

d. avulsion fracture of hamstrings

e. avulsion fracture of gracilis

29. Which of the following findings require a more detailed workup and/or consultation in a patient with low back pain?

a. signs/symptoms above L4

b. multiple root symptoms

c. indolent progressive signs and symptoms

d. presumed disc but with failure to improve

e. all the above

30. Which is the most common pelvic fracture?

a. pubic rami (inferior ischial ramus??)

b. Duverney (wing of illium)

c. transverse sacrum fracture

d. Malgaigne

e. straddle fracture

31. Radiographs are used to determine swelling of the capsules of the hips in such diseases as synovitis, infection and Legg-Calve-Perthes disease. The distance from the medial femoral head to Kohler’s teardrop should be no greater than _____ and the difference between sides no greater than _____.

a. 5 mm, 2mm

b. 11 mm, 2 mm

c. 1.1 inches, .2 inches

d. 5 cm, 2 cm

e. I missed that day and didn’t read the book

32. Which one of the following is not a typical finding in advanced osteoarthritis of the hip?

a. cysts in acetabulum

b. decreased subchondral bone (lucent subchondral region)

c. decreased joint space

d. large inderior medial osteophytes

e. cysts in femoral head

33. Which one of the following does not point toward a poor prognosis in Legg-Calves-Perthes disease?

a. being a female

b. age under 6 (8??)

c. horizontal epiphyseal plate

d. lateral subluxation of femoral head

e. advanced when first diagnosed

34. Which one of the following is the leading cause of secondary protrusio acetabuli?

a. osteoarthritis

b. tuberculosis

c. Rickett’s

d. rheumatoid arthritis (in females)

e. Paget’s

35. Which of the following is the joint most commonly affected by osteoarthritis?

a. knee

b. elbow

c. hip

d. shoulder

e. ankle

36. Osteochondritis dissecans of the knee is classically (most commonly) at the:

a. medial aspect of lateral femoral condyle

b. lateral aspect of medial femoral condyle

c. medial aspect of medial femoral condyle

d. lateral aspect of lateral femoral condyle

e. ischial spine

37. Osteoarthritis of the knee usually begins first at the:

a. femoral patellar articulation

b. medial femoral-tibial articulation

c. lateral femoral-tibial articulation

38. Which one of the following is a good rule for success?

a. associate with criminals

b. diagnosis before treatment

c. fail state boards

d. don’t take state boards

e. borrow 1 million dollars before age 30

39. Which one of the following is not associated with osteonecrosis of femoral head?

a. sickle-cell anemia

b. alcoholism

c. hemophilia

d. fractures of femoral neck

e. gout

40. Of the following, the most likely cause for a painful scoliosis in an adolescent is:

a. giant cell tumor

b. osteoid osteoma

c. chondrosarcoma

d. multiple myeloma

e. hemangioendothelioma

MATCHING

41. slipped femoral capital epiphysis – Frohlich type obesity

42. Legg-Calve-Perthes disease – peak age 6 years

43. Congenital dysplasia of the hip – more common in females

44. Chondrolysis – often follows slipped femoral capital epiphysis especially if manipulated

45. Femoral torsion (anteversion) – may be underlying cause of idiopathic osteoarthritis of hip

46. Transient synovitis of hip - #1 cause of painful hip before age 10

MATCHING –

a. disc problem (classic)

b. facet syndrome (classic)

47. Positive SLR (sciatica) and Valsalva – a.

48. Scleratogenous pain pattern – b.

49. Accompanied by SI osteoarthritis – b.

50. Prefers to stand or lie down – a.

HAND WRITTEN NOTES

Tumors –

Benign – most common hemangioma (findings like a disc) – blood tremor inside the book

Malignant – most common mets, pelvis and lumbar spine

Bone forming – posterior of spine

Osteoma – skull, pelvis

Osteoid osteoma – child with pain with scoliosis (??)

Osteoblastoma

Malignant – need blood supply (flat bones – ribs, skull, pelvis - , ends of big bones)

Osteosarcoma – kids - knee pain, rare but a killer; older – Paget’s, old fracture, old infection

Cartilage tumor – enchondroma – most common in hand, can tell because it fractures

Chondrosarcoma – likes flat bones (pelvis) – cartilage and bone ossified – “popcorn in pelvis” – looks like fibroma but not in soft tissue

Cancer rates

1. 31% lung

2. breast

3. colon

4. pancreas

Table 9-6 and 9-7 from book – page 382

Lumbar root syndromes

Root Dermatome Muscle Weakness Reflexes/Special Paresthesias

Tests Affected

L1 Back, over tro- None None Groin, after holding

Chanter, groin posture, which

causes pain

L2 Back, front of Psoas, hip ad- None Occasionally front

Thigh to knee ductors of thigh

L3 Back, upper but- Psoas, quadriceps Knee jerk sluggish, Inner knee, anterior

tock, front of - thigh wasting PKB positive, pain lower leg

thigh and knee, on full SLR

medial lower leg

L4 Inner buttock, Tibialis anterior, SLR limited, neck- Medial aspect of

outer thigh, inside extensor hallucis flexion pain, weak calf and ankle

of leg, dorsum of knee jerk, side

big toe flexion limited

L5 Buttock, back and Extensor hallucis, SLR limited to one Lateral aspect of

Side of thigh, lat- peroneals, gluteus side, neck-flexion leg, medial three

eral aspect of leg, medius, ankle dor- pain, ankle jerk toes

dorsum of foot, siflexors, ham- decreased, crossed-

inner half of sole strings – calf wast- leg raising-pain

and 1st, 2nd and ing

3rd toes

S1 Buttock, back of Calf and ham- SLR limited Lateral 2 toes, lat-

thigh, and lower strings, wasting eral foot, lateral

leg of gluteals, pero- leg to knee, plantar

neals, plantar aspect of foot

flexors

S2 Same as S1 Same as S1 Same as S1 Lateral leg, knee,

Except peroneals heel

S3 Groin, inner thigh None None None

to knee

S4 Perineum, geni- Bladder, rectum None Saddle area, geni-

tals, lower sacrum tals, anus, impo-

tence

Manipulation and traction are contraindicated if S4 or massive posterior displacement causes bilateral sciatic and S3 pain.

PKB = prone knee bendings. SLR = straight leg raising

MYOTOMES OF THE LOWER LIMB

Nerve Root Test Action Muscles

L1-L2 Hip flexion Psoas, iliacus, sartorius, gracilis, pectineus, adductor

longus, adductor brevis

L3 Knee extension Quadriceps, adductor longus, magnus and brevis

L4 Ankle dorsiflexion Tibialis anterior, quadriceps, tensor fasciae latae,

adductor magnus, obturator externus, tibialis posterior

L5 Toe extension Extensor hallucis longus, extensor digitorum longus,

gluteus medius and minimus, obturator internus,

semimembranosus, semitendinosus, peroneus tertius,

popliteus

S1 Ankle plantar Gastrocnemius, soleus, gluteus maximus, obturator

flexion, ankle internus, piriformis, biceps femoris, semitendinosus,

eversion, hip popliteus, peroneus longus and brevis, extensor dig-

extension, knee itorum brevis

flexion

S2 Knee flexion Biceps femoris, piriformis, soleus, gastrocnemius,

flexor digitorum longus, flexor hallucis longus, intrin-

sic foot muscles

S3 Intrinsic foot muscles (except abductor hallucis),

flexor hallucis brevis, flexor digitorum brevis, ex-

tensor digitorum brevis

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