Ortho EOR exam questions and answers with complete A solutions

Ortho EOR exam questions and answers with complete A solutions What are the top 3 causes of AVN trauma, chronic steroid use, and alcohol use For an intertrochanteric femur fracture how does the foot/leg look? surgery? it is externally rotated, abducted and shortened. needs surgery If you have a posterior dislocation of hip what is the leg doing? leg is shortened, flexed, adducted and internally rotated If you have an anterior dislocation of hip what is the leg doing mid flexion, abducted and externally rotated What is the more common way to dislocate the hip? posterior How is AVN diagnosed/staged? plain films and then after that would stage with an MRI. That being said you should not order the MRI unless you are going to be the one interpreting it! What is the most common presenting symptom of AVN pain How is AVN treated? either by replacement of the joint or can do bone grafting. There are other options such as core decompression however these are not totally studied Pt. presents with significant edema over the olecranon bursa. It is not warm or angry looking and they have no fever. Of note is that they are constantly hitting it on things or rubbing it against something. What do they have and what should you do to manage? They have bursitis probably non infective therefore do not aspirate. Rather this is a self limited condition so NSAIDs and protecting the bursa are the goals of treatment What are the only 2 indications to aspirate a bursa if it is inflamed. If suspicious of infection or gout What is the most important sign/symptom of carpal tunnel syndrome that should make you think of this? nocturnal pain or paresthesias in the distribution of the median nerve How do you differentiate mild from severe CTS? mild is numbness or tingling in the median nerve distribution but no sensory loss, nocturnal sx, or loss of hand function that impairs ADLs. Severe is when you have Median nerve weakness, loss of ADLs or frequently being awoken at night. What is the initial tx for those with CTS who show mild sx nocturnal wrist splinting. What is the more definitive CTS tx and who would you not do this in? carpal tunnel release and don't do in those that are preggars What are the 6 Ps of compartments syndrome pain, paresthesias, poilkothermia, pallor, pulselessness, paralysis, how do you objectively measure compartments to see if a pt. has compartments syndrome intrapressure monitoring if it comes w/in 10 to 30 mmHg of the diastolic BP What is the tx for compartments syndrome take off any bandages that may be to tight but ultimately faschiotomies What is the physical exam test for De Quervain's synovitis, describe it Finklesteins test, this is where you have the pt. place their thumb in their hand and flex their hand towards the ulnar nerve. Any pain with that is a positive test Pt. presents with pain in their radial styloid region and a positive finklesteins test. What is the 3 step approach to managing their disease 1: splinting as needed with a fore-arm thumb spica splint and NSAIDs for pain relief. 2: glucocorticoid injection. 3: if the above fails then cutting the 1st extensor releasing compartment however this is a self limited disease and most don't choose this option What is a Dupuytren's contracture? a progressive fibrosis of the palmar fascia that eventually leads to joint stiffness and the inability to extend the finger fully and potentially a palpable cord running in the Sub Q skin What are 5 risk factors for developing a Dupuytren's contracture 1: Being a worker exposed to repetitive vibration, 2: diabetes, 3: pyrones disease, 4: smoking, and 5: alcohol What are 4 ways to manage a dupuytren's contracture 1: for mild consider tool modification so like more padding if doing jackhammer stuff, 2: can do corticosteroid injection, 3: injecting a collegnease to digest cord and then coming back to break it up manually (better for <50 degree duputrens). Surgery is an option for severe disease How is a gout attack diagnosed aspirate the joint and see uric acid crystals form. can also do clinical if it is the first MTP joint but may want to aspirate anyways to rule out infection What is the treatment for acute gout attack? NSAIDs and colchicine however glucocorticoids have been shown to work too what is the long term drug used to prevent gout attacks allopurinol for the most part Pt. presents who got hit with a baseball when their finger was in full extension. This causes the finger to flex rapidly. What kind of injury is this and what is the treatment/ when should I get a hand surgery consult. This is mallet finger, splint the finger in the extended position because a true mallet finger won't be able to extend the DIP. consult if there is a fracture associated with the injury A pt. presents who was playing football and had a flexed DIP joint which was suddenly hyperextended. What is this called and what is the management? They have the pathognomonic finding of an inability to flex the DIP joint. this is Jersey finger and is more serious then mallet finger. you will most likely refer this pt. to a specialist however should obtain XRAYS to rule out a fracture. Place in a splint and refer for surgery What are the 4 findings of OA on XRAY? Osteophytes, joint space narrowing, sub-chondral sclerosis, and cysts What is a really good way to determine the difference between OA and RA? If have OA pain stiffness will be less then 30 min once moving, if RA then it will be >30 min What are the initial management techniques for OA? Exercise, weight loss 10% of body weight, and splints/different aids for walking What are pharmocologic methods to manage OA? NSAIDS and Glucocorticoid injections however save these for the bad ones What is the definitive tx for OA arthroplasty What is the deviation of the hand for RA ulnar deviation What is the classic initial joint problem with RA? is it typically symmetric or unilateral symmetric MCP What is the preferred approach to the managment of RA instead of steroid and NSAID use use DMARDS such as biologics or methotrexate to prevent the disease What are the nodes in the DIP called for OA Heberdens nodes What are the nodes in the PIP called for OA Bouchards node What are some ways to differentiate RA from psoriatic arthritis RA is more likely to be symmetric and have no skin manifestations. PA will often have skin manifestations including finger nail abnormalities like pitting and onchyolysis. you may also see the sausage digit in PA. Additional PA is typically RF negative What is a maisonneuve fracture and when should you be looking for it? this is when a pt. fractures their fibula and additionally interrupts the tibial fibular syndysmosis. An isolated fibular fracture needs no surgery but an interrupted syndesmosis of the tibia and fibula needs surgery pt. presents who's finger catches or locks when they are bending it and is demonstrated on physical exam. what is this? trigger finger or stenosing flexor tenosynovitis what is the 3 step approach to managing trigger finger splinting and NSAIDs, but if persists then steroid injection and if that doesn't work then do a trigger finger release surgery A pt. presents who is a weekend warrior and is playing basketball. They do a sweat jump move and fall down writhing in pain in the ankle. They come to see you and you believe that they have an achilles tendon rupture. What classic physical exam finding is seen in this disorder? a negative thompsons test which is lack of plantar flexion when you squeeze the calf and the pt. is lying prone How is complete achilles tendon rupture treated initial by conservative with ice and NSAIDs immobilize and rest but will need surgery A 34 yo male pt. presents with back pain that is insidious in onset. It is not relieved by rest, improves with with exercise and is worse at night (better when wakes up). On Xray you see sclerosing of the SI joint and a bamboo spine (more likely later in the disease). You believe the pt. has this disease and treat them with this. the have anklyosing spondylitis and treat them with NSAIDS Pt. presents with swelling of their popliteal fossa. They have a positive Foucher's sign where the swelling disappears upon knee flexion at 45 degrees. What is this and how should you proceed? this is a bakers cyst and is typically caused from an underlying problem such as OA or RA. It is recommended that you aspirate the joint and inject glucocorticoids (treat the OA) however do not initially aspirate the cyst. Neuropathic or charcot arthropathy is most commonly caused from what and what is it diabetes and then having neuropathy that causes problems with the foot most commonly by losing the arch and having it replaced with bone and having deformity to the foot Pt. presents with diabetes and a deformed foot acutely. they have lack of sensation in their feet. you notice warmth and edema in the foot. you believe the pt. to have this and you manage in this way first a thorough H&P followed by plain films of the affected joint (again think foot), then you will cast the foot until the swelling returns back to what the other foot is. If it is really bad refer to a ortho specilist or podiatrist who specilalizes in diabetic neuropathic arthropathy Pt. presents with pes cavus (a champaign bottle looking calf), they have foot drop and distal sensory deficits and absent distal reflexes and also weakness. They also have gait abnormalitiesWhat is this disease and how do you manage it/dx it this is the genetic disease called charcot-marie-tooth disease. It has no cure but can be helped with therapy and splinting to improve quality of life. It is slowly progressive. to dx this you start with EMG and then genetic testing after this What does CREST stand for Calcinosis cutis, Raynauds, esophogeal dysmotility, sclerodactly, and telangitasias. What is metatarsus adductus and when should it resolve by/ what is the tx? It is intoeing of the feet giving them a C-shape. it is the most common cause of intoeing in children less than 1 year old but most of the time intoeing is not a problem and resolves by 2 years of age even if it doesn't and does not require orthotics or surgery What is internal tibial torsion and when should it resolve by/ what is the tx? It is the most common cause of intoeing in a child from 1 year to 3-4 years when they learn to walk and should resolve by 5 years old. You shouldn't need to do anything and refer to surgery only in rare cases just reassure parents What is femoral neck anteversion and when should it resolve by/ what is the tx? A painless cause of intoeing between the age of 3-6 caused from increased internal rotation of the hip and decreased external rotation of the hip. These are the egg beater running kids. most kids can be treated by reassurance as it should resolve by 11 years old What population of people are at an increased risk of developing frozen shoulder? diabetics also think trauma where shoulder is immobilized Pt. presents with an inability to move their shoulder in external rotation and abduction. Of note is that they were in a car accident and injured their shoulder a year ago. Since then they have had pain in their shoulder but now that has gone away and they are stiff. What is this and how would you manage this disease? This is frozen shoulder or adhesive capsulitis. The best way to manage this is corticosteroid injection followed by physcial therapy to get that arm moving. Can do surgery to manipulate under anesthesia if too painful but this can cause the humerus to snap in the osteoporotic. Additionally NSAIDs, Ice and control yo shugaz Pediatric pt. presents with insidious onset of hip pain and a limp. Pt. is a 7 yo male. What could this disease be and how do you dx it? this could be legg-calve-perthes disease which is idiopathic AVN of the hip. Xray would typically be done first however MRI or bone scan would be the definitive dx as XRay would not show stuff early on. How do you treat leg-calve-perthes disease make child non-weight baring and refer to ortho peds. Typically this is treated by splinting the hip to contain the femoral head within the acetabulum and sometimes they have to do this with surgery what is the most common soft tissue tumor of the hand a ganglion cyst Pt. presents with a solid wrist cyst on the dorsum of their hand. It is firm, smooth rounded and rubbery. It transilluminates. how should you treat this pt. because they have this this is a ganglion cyst so observation is preferred if they are not having sx. about half will go away. Aspiration is only indicated for those having sx but about half will return so not super helpful Injury to what 2 muscle tendons would result in tennis elbow AKA lateral epicondylitis the extensor carpi radialis brevis and possibly extenor digitorum Injury to what 2 muscle tendons would result in golfers elbow or medial epicondylitis pronator teres and flexor carpi radialis The patient makes a fist, pronates the forearm and radially deviates and extends the wrist while the physician applies a resisting force at the fist. They elicit a positive pain response over their lateral epicondyle. What is this a positive sign for tennis elbow or lateral epicondylitis Pt. presents with pain over the medial epicondyle that is increased with wrist flexion and forearm supination performed against resistance. what is this a positive sign for medial epicondylitis or golfers elbow What is the initial management for tennis or golfers elbow? counter bracing, activity modification, and NSAIDs. PT as well. Steroid injections probably won't help in the long run A 12 yo male pt presents wit pain over his tibial tuberosity. It has been progressing and has gotten worse since he began soccer season. What is this and what is the cause of this disease? this is Osgood-Schlatter disease which is an overuse injury of causing pain of the proximal patellar tendon. This often occurs after a large growth spurt What is the best treatment for Osgood-Schlatter? this is typically a benign condition that will resolve once the growth plate is ossified. best to treat this conservative with NSAIDs, PT, and must continue activity as inactivity can dead to reconditioning and increase risk of other injury What are the 4 must not miss dangerous causes of lower backpain Aortic dissection, cauda equina, spinal mets, osteomylitis,(up to date also says spinal epidural abscess) What 5 cancers are the most common to have mets to the back 1: breast, 2: prostate, 3: lung, 4: thyroid, 5: kidney Pt. presents with an acute vertebral compression fracture, what is the appropriate way to manage them For the most part conservative with lower pain meds (NSAIDs, tylenol) but for severe pain can use opioids. However they should return to activity ASAP and maybe do therapy. vertebroplasty is pry not useful a positive patellar apprehension test tests for what patellar tracking and subluxation of the patella What is the biggest and really only red flag for mets to the back with low back pain a history of cancer what are 4 red flags that may point more towards a vertebral compression fracture, if a pt. has these what type of imaging would you do? older age, chronic use of steroids, hx of trauma, bruising at the site, Xray pt. presents with back pain <4 weeks in origin. they have no cauda equina symptoms but they have a fever with a history of cellulitis. What are we going to do for them. depends seems like high suspicion so MRI but if we were moderate to low do a ESR and then a plain film if XRAY normal but ESR is high do an MRI pt. presents with acute back pain. The provider before you elected to treat conservatively as there were no indications for imaging. They return to you and it hasn't gone away. They have had no changes in it and now they want an MRI because they think they missed something. What do you do? Do a thorough history and physical exam explaining that you have assessed for any concerning etiologies and not found any. Then explain who incidental findings will be found on MRI and they pry are not the cause. They will be more likely to be satisfied by that What are the best treatments for chronic back pain start with NSAIDs (not tylenol), not sleeping on a hard mattress, and activities that keep them moving (bedrest is bad). If it is very bad for awhile consider behavioral therapy and multidicinplinary approach. Only low dose opiods in those at low risk for abuse for short term and it is only for severe exacerbation of pain. A female pt. presents 4-6 weeks after a traumatic injury to their arm. They are experiencing pain that is significant however should not be there at this time. They are also having sensory changes, autonomic temp changes, and motor impairment of the affected limb along with edema. What is this disorder and how do you dx it? this is complex regional pain syndrome that you dx with a thorough H&P. This almost always follows a fracture or soft tissue injury and the pain can be debilitating. How is complex regional pain syndrome best treated? by prevention actually with Vit C orally. along with that physical therapy. Additionally if the pt. already has it then give meds like NSAIDS, gabapentin, TCAs, or bisphosphonates whatever works to decrease pain so they can do PT For infants less than 4 months of age what is the imaging study of choice for DDH? ultrasound For infants greater than 4 months of age what is the imaging study of choice for DDH? XRAY A positive ortalani test and barlow test are what and what do they indicate? Barlow you start with legs out and bring to 90 degrees (adduct) then you push down and it dislocates hip causing it to pop out (audible clunk) with the ortalani you start at 90 and abduct then push up anteriorly to pop it back in (audible clunk) indicates DDH for infants younger than 6 months with persistently dislocateable or subluxible hips or just dislocated hips what is the recommended treatment with splinting with the Pavlik harness most commonly usually for a few months A younger pt. presents with tenosynovitis of hands, polyarthralgias and pustular lesions. What is this and what is the treatment this is disseminated gonococcal infection give IV cephtriaxone along with azithromycin A female pt presents with foot pain. On PE you see a laterally deviated first metatarsal. how should you manage this pt. as they have this Hallux valgus, start with conservitive measures like night splinting, better shoes, NSAIDs, ice, stretching, and orthotics. These really don't do much but if the pain is so bad she can hardly walk then refer for surgery Pt. presents with acute back pain. They have pain that extends down the lateral aspect of the leg into the foot. they have reduced strength in foot eversion/inversion and in dorsiflexion. they have sensory loss to the lateral aspect of the lower leg. Intact reflexes bilaterally. They do not have any of the warning signs for back pain. How should you manage this pt. as they have this they have an acute radiculopathy pry from a herniated disc. Best managed with NSAIDs and activity modification can try manipulation or PT to learn stretches or even acupuncture. That being said most will improve in 4-6 weeks w/o treatment so no imaging unless persists past this An young athlete starts track for the first time. They go out for triple jump. They are increasing the miles they run and the activity they are doing. They have pain under both patellas and around it. They describe it as a dull ache not a sharp pain. Its worse on squatting and stairs. They feel like it is buckling or giving away. there is no effusion on PE and you notice pain over the patella on lateral and medial sides. What is this and how would you treat it this is patellofemoral pain so it is best treated with activity modification, NSAIDS, and ice. It may help to do some PT to learn how to strengthen the muscles that are tight or atrophied. Pt. presents with pain from excessive jumping. It is located on the inferior pole of the patella and they have swelling over this area. no other knee effusion or ligamentous laxity is seen. They can take 4 steps and have no pain on quad contraction what is this and how do you treat it? This is Sinding-Larsen-Johannson disease or patellar apophysitis. This is not a patellar sleeve fracture because they can take 4 steps. It is best treated with Ice and NSAIDS. probably activity modification to when they have pain however not complete stoppage. should resolve in 12-18 months its the same as osgood-schlatter Pt presents with a burning pain in their 3rd intermetatarsal space (between the 3rd and 4th metatarsal). The burning radiates towards the toes and the pt. gets numbness and tingling when they exercise in the toes. What is this pry how would you dx it and treat it? a mortons neuroma dx with US. best treated conservatively with inserts that decrease pressure on the metatarsal heads. If that doesn't work can do steroid injection dorsally. After 9-12 months if still persists can consider surgically removing. When is a mortons neuroma considered clinically significant when greater than 5mm A young male pt. presents with difficulty running, jumping, and walking up steps. When arising from the floor, he uses hand support to push himself to an upright position (gowers sign). An unusual waddling gait, lumbar lordosis, and calf enlargement. He also has leg pain. What is this the classic description of Muscular dystrophy probably duchenes Why does Duchene muscular dystrophy presents the way it does because it affects proximal and lower muscles first What orthopedic problems do those with muscular dystrophy often have fractures because of falling What is the prognosis and treatment for Muscular dystrophy most die before 3rd decade of life due to cardiomyopathy or respiratory problem. The best disease modifying treatment is glucocorticoids however you need to be aware of fracture increase so do exercise and Pt to prevent this. What is osteochondritis dessicans this is osteonecrosis of the subchondral bone most frequently of the knee or elbow or school aged children When should osteochondritis dessicans be referred for surgery? 1: If the pt. has fused growth plates, 2: if the bone is unstable, 3: if it covers a large area, 4: it occurs in a joint other than knee or elbow What is osteogenesis imperfecta? a rare inherited connective tissue disorder that causes multiple fractures with minimal or no trauma Short stature Scoliosis Basilar skull deformities Blue sclerae Hearing loss Opalescent teeth that wear quickly Increased laxity of the ligaments and skin Wormian bones (small, irregular bones along the cranial sutures) Easy bruisability are all findings of what osteogenensis imperfecta What is the mainstay of treatment of osteogenesis imperfecta bisphosphonate therapy How is symptomatic Pagets disease of the bone treated with bisphosphonates how is asymptomatic pagets disease of the bone treated with bisphosphonates if in an area that could be a problem eg weight bearing bones, skull, spine, or joint lines How is pagets disease of the bone followed by alk-phos levels Pt. presents with bone pain and arthritis in their skull and long bones. They describe the pain as a mild to moderate ache that is present throughout the day and at rest. How would you work up this pt? do an XRAY should be dx. Can get a serum alk phos. also would do an baseline bone scan to see the extent of the disease because this sounds like Pagets. What are 3 common causes of peripheral neruopathy HIV, Diabetes, and alcohol abuse symmetric distal sensory loss, burning, or weakness with hyporeflexia and weakness is the classic signs of what peripheral neuropathy how should a peripheral neuropathy initially be tested EMG How are peripheral neurpathies managed treat the underlying process can also use TCAs or gabapentin for pain Male pt. presents with heal pain that is worst in the morning when they take their first steps that gets better with activity. They have pain when you dorsiflex the foot and palpate the heel. What is this and how is it best managed (6 ways) plantar fasciitis best managed with 1: stretching, 2: good shoes, 3: possibly inserts, 4: decreasing aggrivating activity and 5: NSAIDs, 6: steroid injection if doesnt improve what are the crystals made of in pseudogout calcium pyrophosphate how is pseudogout treated initially joint aspiration and intraarticular glucocorticoid , if not with that can use NSAIDs. can use colchicine for prophylaxis Complex regional pain syndrome in which there is no peripheral nerve injury is also called what reflex sympathetic dystrophy idiopathic scoliosis is common in younger females at age 10. how is it diagnosed inspection, then have bend over and look for rib hump and if abnormal measure with scoliometer when are XRAYs indicated for abnormal scoliometer readings when greater then 7 degrees of curve noted When should bracing/observation/surgery be done for scoliosis if <29 degrees then observation if Risser 1 or 2. If 30-49 degrees then bracing. over 50 will do surgery however may consider surgery from 30-49 pt. presents with a fever and a swollen erythamatous knee. how should you treat them/manage them kneed to tap the joint and show bacteria. then treat with vanco and drainage of the joint. most commonly it is from staph! if it is a gram neg rod though then ceftriaxone What is Sever disease a calcaneal apophysis that is insidious in onset and related to overuse from activity like jumping how do you diagnose Sever disease, how do you treat it? by history and physical exam treat with a heal cup, NSAIDs, decreasing painful activity, and ice as needed The empty can test or drop arm test test for strength in what muscle of the rotator cuff suprapinatus The external rotation test of the arm tests for strength in what muscle of the rotator cuff infraspinatus and maybe a little teres minor The internal rotation test of the arm tests for strength in what muscle of the rotator cuff subscapularis Active painful arc test, painful drop arm sign, and weakness in external rotation together are indicators of what a rotator cuff tear passive painful arc test or neers test is used to assess for what shoulder impingement What 2 imaging studies can dx a rotator cuff tear US and MRI what will people present with for sx of a rotator cuff tear pain, weakness, and difficulty with overhead activities however many present asymptomatic How should rotator cuff tears be managed if they are older maybe more conservative with NSAIDs, PT, and activity modification. If they are young and it is acute then surgery would be appropriate How is a labrum classically torn in the humerus? how is it managed? it is from pitchers who are overusing their arms. Refer the high level athletes to ortho surgery for possible sugery Speeds test (forward flexing the shoulder 30 degrees against the clinicians resistance), and yergasons test arm adducted with elbow at 90 try to supinate against resistance test for what bicep tendon rupture or injury How are proximal and distal bicep tendon ruptures managed proximal is usually conservative with PT and activity modification as won't have much problems except the classic popeye deformity Distal refer for surgical consult as some will need this An obese adolescent with a complaint of nonradiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of preceding trauma. The pain is increased by physical activity and may be chronic or intermittent. what is this and how do you dx it? this is a Slipped capital femoral epiphysis dx with XRAYS how do you treat a SCFE by surgically securing both hips because most unilateral will go bilateral otherwise you have to follow the other hip closely What is the difference between spondylolysis and spondylolisthesis spondylolysis typically represents a fracture of the posterior arch in the lower lumbar spine due to overuse and is a relatively common cause of low back pain. Spondylolisthesis involves anterior displacement of a vertebral body due to bilateral defects of the posterior arch and is less common than spondylolysis. 13 yo Pt. presents with low back pain that is insidious in onset. It is worst with lumbar extension. on PE you see pain with lumbar extension; pain is further increased by hyperextension performed while standing on one leg. what is the initial imaging for this pt. has they appear to have this plain XRAYs of lumbar spine however pry only if pain persists past 3 weeks. either a spondylolysis or spondylolsithesis What is the initial treatment for spondylolysis and spondylolisthesis rest for up to 90 days. If does not get better w/in 2-4 weeks then can to XRAY but look up if you need to refer to surgery unlikely you would for spondylolysis maybe for spondylolisthesis if very anteriorly dislocated How would a wrist sprain happen and how should you treat it/get better? it is an injury often from lifting something heavy overhead. Often it will get better with splinting/ice/gentle exercise w/in a couple weeks What are the 3 ottawa rules for imaging an ankle sprain 1: if the pt. cannot bear weight on it right after and can't take 4 steps in emergency room 2: if pt. has pain in mallolear zone/pain on lateral and medial maleolous 3: if pt has pain in the midfoot region and bone tenderness at the base of the fifth metatarsal or at the navicular How should an ankle sprain initially be treated Rest, Ice, compression, and elevation. refer for fractures/dislocations/tendon rupture/ or syndesmosis How does a muscle strain happen and what should you do for it? when a muscle gets stretched too quick or works to hard to fast just RICE it will heal within a few days or couple of weeks What causes stress fractures? occurs when a bone breaks after being subjected to repeated tensile or compressive stresses. This is because it is not getting adequate time to rest and grow how does a stress fracture classically present history of localized pain of insidious onset that increases with activity and focal tenderness limited to the stress fracture site. What should the initial imaging be for a stress fracture plain films How do you treat stress fractures decrease your activity and conservative measures followed by gradual return to activity when pain free What is synovitis? an inflammation of the synovial lining it can occur from many different ways but it often hurts when moving the joint. Often has joint fluid in it What is tendinitis or tendinosis as one may call it it is an overuse injury from tendon thickening from chronic use. how do you treat tendinitis rehabilitation programs to treat chronic tendinopathy emphasize slow, progressive, heavy load exercise What are the 3 causes of out-toeing in a child femoral anteversion (uncommon usually obese kids) external tibial torsion and external rotation contracture of the hip How should children with out-toeing be managed mostly reassurance. Most out-toeing resolves with growth and those that don't will usually not have functional problems. The only indications to treat are if they have sx (pain) What lifestyle modification can be undertake to prevent osteoporosis (4) Lifestyle measures include adequate calcium and vitamin D, exercise, smoking cessation, counseling on fall prevention, and avoidance of heavy alcohol use. What is the initial first line treatment for osteoporosis bisphosphonates What women should be treated with bisphosphonates for osteoporosis 1: those with hx of fragility fractures 2: those with T scores <-2.5 on dexa scan 3: those with Tscores between -1 and -2.5 and a risk for fracture >20% on the FRAX score The posterior drawer sign tests for what ligament of the knee and what is a postive test it tests for PCL injury and it is positive when it wiggles back an forth basically there is no firm endpoint What does the valgus stress test check for the integrity of the medial colateral ligament of the knee Pt. presents who was playing soccer and sustained a valgus blow to their knee. They now have valgus instability. What is this and how would you treat it if this was the only positive physical exam sign? this is an MCL injury and because it is isolation treat conservatively with RICE and analgesics. only refer for surgery if other ligaments are injured too. Most can return to play w/in a few weeks The lachman test, anterior drawer and pivot shift all test for the integrity of what the ACL