ROSH REVIEW Orthopedics UPDATED ACTUAL Questions and CORRECT
Answers
1. A 29-year-old woman presents to Correct Answer ( A )
your clinic for fatigue and myal- Explanation:
gias that have been worsening Fibromyalgia is characterized by chronic, widespread
over the past few months. In addi- musculoskeletal pain and stiffness with tenderness at
tion to daily headaches, she feels discrete "trigger points" on physical exam. Points in-
chronic aching and stiffness in her clude the trapezius, medial fat pads of the knees, and
back, arms, and legs. On exam lateral epicondyles of the elbows. A review of systems
she has distinct tender points at will usually show fatigue, frequent headaches, sleep
her buttocks, trapezius, lateral el- disorders, and subjective numbness; co-existing de-
bow epicondyles, and medial as- pression and irritable bowel symptoms are also com-
pects of her knees. Strength test- mon. Fibromyalgia is a diagnosis of exclusion, and re-
ing is 5/5 throughout. An erythro- quires ruling out other rheumatologic conditions in-
cyte sedimentation rate, rheuma- cluding systemic lupus erythematous and rheumatoid
toid factor, TSH, and serum phos- arthritis, as well as underlying hypothyroidism. Treat-
phate level all return within nor- ment is multifaceted. Patient education should empha-
mal limits. Which of the following size that the disease is not progressive; exercise pro-
conditions does she most likely grams and cognitive behavioral therapy may be bene-
have? ficial. Many medications (including amitriptyline, dulox-
etine, gabapentin, and muscle relaxants) show modest
Fibromyalgia symptom relief; corticosteroids and opioids should be
Oncogenic osteomalacia avoided as these have not be proven effective.
Polymyalgia rheumatica
Polymyositis Polymyalgia rheumatica (C) causes musculoskeletal
pain that is concentrated in the shoulder and pelvic
girdle. It is most common in patients over 50, and is
usually associated with an anemia of chronic disease
and an elevated ESR. Polymyositis (D) is more likely to
produce proximal muscle weakness, which this patients
does not have. Additionally, though a quarter of patients
with polymyositis may have concurrent muscle pain and
tenderness, this is rarely the chief complaint.
,
,2. One Step Further Answer: Fibromyalgia may be a complication of sleep
Question: When occurring in apnea, particularly in male patients.
males, which underlying condi-
tion is commonly associated with
symptoms of fibromyalgia?
3. What is the recommended treat- Correct Answer ( C )
ment for polymyositis? Explanation:
Polymyositis is an inflammatory myopathy that is classi-
Antibiotics fied by patient age at onset or by coexisting diseases,
NSAIDs such as myositis associated with neoplasia or myositis
Prednisone associated with collagen vascular diseases (e.g., sys-
Radiation therapy temic scleroderma, systemic lupus erythematous). They
have a bimodal distribution and are seen most often
between age 10 to 15 and 45 to 60 years. Myositis is
most common after age 50. The cause of inflammatory
myopathies is unknown, but evidence suggests a genet-
ic predisposition (associated with certain HLA markers)
combined with an environmental insult, such as viruses,
thereby initiating an autoimmune process. Patients usu-
ally experience progressive, symmetric, proximal muscle
weakness with fatigue, malaise, and morning stiffness.
Muscles often affected are those of the shoulder, neck,
and pelvic girdle. Pulmonary (interstitial pneumonitis or
fibrosis), cardiac (cardiomyopathy, congestive heart fail-
ure, arrhythmias), pharyngeal (dysphagia), and muscu-
loskeletal (myalgias, arthralgias) symptoms might occur,
although most patients do not experience synovitis. CK
as well as aldolase, ALT, AST, and lactate dehydroge-
nase (LDH) levels might be elevated. ESR is elevated
only half the time. Muscle biopsy can also be helpful in
diagnosis. Prednisone, 1 mg/kg/day for up to several
, months, is the drug of choice; the earlier started in the
disease process, the more effective it is. If prednisone
is not suflcient, methotrexate, azathioprine, or another
immunosuppressant is added.
4. A young woman presents with an- Correct Answer ( D )
kle pain and edema. While wear- Explanation:
ing high-heel shoes, she twist- Fracture of the ankle may include injury to the medial
ed her ankle upon stepping off malleolus (tibia), the lateral malleolus (fibula), the pos-
a curb. She is tender about the terior malleolus (tibia), the talus and the collateral lig-
lateral malleolus. Skin and neu- aments. Stability of the fracture depends on how many
rovascular examination are nor- sides are injured. Stable fractures involve only one side
mal. She has no medial tender- of the joint, whereas unstable fractures include both
ness. Ligament testing is neg- sides of the joint. Stable fractures are treated with 4-6
ative. Radiographic examination weeks of a weight-bearing cast or brace
reveals a non-displaced lateral
malleolar fracture below the an-
kle joint. The tibia is unaffected.
Which of the following is the most
appropriate definitive treatment
for this patient?
AClosed reduction
BDebridement
CNon-weight-bearing orthosis
DWeight-bearing cast
5. One Step Further Answer: The fibular head. External rotation forces at the
Question: Examination of which ankle can cause a Maisonneuve fracture, a compilation
Answers
1. A 29-year-old woman presents to Correct Answer ( A )
your clinic for fatigue and myal- Explanation:
gias that have been worsening Fibromyalgia is characterized by chronic, widespread
over the past few months. In addi- musculoskeletal pain and stiffness with tenderness at
tion to daily headaches, she feels discrete "trigger points" on physical exam. Points in-
chronic aching and stiffness in her clude the trapezius, medial fat pads of the knees, and
back, arms, and legs. On exam lateral epicondyles of the elbows. A review of systems
she has distinct tender points at will usually show fatigue, frequent headaches, sleep
her buttocks, trapezius, lateral el- disorders, and subjective numbness; co-existing de-
bow epicondyles, and medial as- pression and irritable bowel symptoms are also com-
pects of her knees. Strength test- mon. Fibromyalgia is a diagnosis of exclusion, and re-
ing is 5/5 throughout. An erythro- quires ruling out other rheumatologic conditions in-
cyte sedimentation rate, rheuma- cluding systemic lupus erythematous and rheumatoid
toid factor, TSH, and serum phos- arthritis, as well as underlying hypothyroidism. Treat-
phate level all return within nor- ment is multifaceted. Patient education should empha-
mal limits. Which of the following size that the disease is not progressive; exercise pro-
conditions does she most likely grams and cognitive behavioral therapy may be bene-
have? ficial. Many medications (including amitriptyline, dulox-
etine, gabapentin, and muscle relaxants) show modest
Fibromyalgia symptom relief; corticosteroids and opioids should be
Oncogenic osteomalacia avoided as these have not be proven effective.
Polymyalgia rheumatica
Polymyositis Polymyalgia rheumatica (C) causes musculoskeletal
pain that is concentrated in the shoulder and pelvic
girdle. It is most common in patients over 50, and is
usually associated with an anemia of chronic disease
and an elevated ESR. Polymyositis (D) is more likely to
produce proximal muscle weakness, which this patients
does not have. Additionally, though a quarter of patients
with polymyositis may have concurrent muscle pain and
tenderness, this is rarely the chief complaint.
,
,2. One Step Further Answer: Fibromyalgia may be a complication of sleep
Question: When occurring in apnea, particularly in male patients.
males, which underlying condi-
tion is commonly associated with
symptoms of fibromyalgia?
3. What is the recommended treat- Correct Answer ( C )
ment for polymyositis? Explanation:
Polymyositis is an inflammatory myopathy that is classi-
Antibiotics fied by patient age at onset or by coexisting diseases,
NSAIDs such as myositis associated with neoplasia or myositis
Prednisone associated with collagen vascular diseases (e.g., sys-
Radiation therapy temic scleroderma, systemic lupus erythematous). They
have a bimodal distribution and are seen most often
between age 10 to 15 and 45 to 60 years. Myositis is
most common after age 50. The cause of inflammatory
myopathies is unknown, but evidence suggests a genet-
ic predisposition (associated with certain HLA markers)
combined with an environmental insult, such as viruses,
thereby initiating an autoimmune process. Patients usu-
ally experience progressive, symmetric, proximal muscle
weakness with fatigue, malaise, and morning stiffness.
Muscles often affected are those of the shoulder, neck,
and pelvic girdle. Pulmonary (interstitial pneumonitis or
fibrosis), cardiac (cardiomyopathy, congestive heart fail-
ure, arrhythmias), pharyngeal (dysphagia), and muscu-
loskeletal (myalgias, arthralgias) symptoms might occur,
although most patients do not experience synovitis. CK
as well as aldolase, ALT, AST, and lactate dehydroge-
nase (LDH) levels might be elevated. ESR is elevated
only half the time. Muscle biopsy can also be helpful in
diagnosis. Prednisone, 1 mg/kg/day for up to several
, months, is the drug of choice; the earlier started in the
disease process, the more effective it is. If prednisone
is not suflcient, methotrexate, azathioprine, or another
immunosuppressant is added.
4. A young woman presents with an- Correct Answer ( D )
kle pain and edema. While wear- Explanation:
ing high-heel shoes, she twist- Fracture of the ankle may include injury to the medial
ed her ankle upon stepping off malleolus (tibia), the lateral malleolus (fibula), the pos-
a curb. She is tender about the terior malleolus (tibia), the talus and the collateral lig-
lateral malleolus. Skin and neu- aments. Stability of the fracture depends on how many
rovascular examination are nor- sides are injured. Stable fractures involve only one side
mal. She has no medial tender- of the joint, whereas unstable fractures include both
ness. Ligament testing is neg- sides of the joint. Stable fractures are treated with 4-6
ative. Radiographic examination weeks of a weight-bearing cast or brace
reveals a non-displaced lateral
malleolar fracture below the an-
kle joint. The tibia is unaffected.
Which of the following is the most
appropriate definitive treatment
for this patient?
AClosed reduction
BDebridement
CNon-weight-bearing orthosis
DWeight-bearing cast
5. One Step Further Answer: The fibular head. External rotation forces at the
Question: Examination of which ankle can cause a Maisonneuve fracture, a compilation
