Most likely diagnosis
A 25-year-old male presents to the primary care clinic with a history of acute right knee pain following a non-contact injury while playing basketball. He describes a sudden twisting motion of the knee, accompanied by a "popping" sensation. He was unable to continue playing and noticed immediate swelling and instability in the knee. On examination, there is a moderate effusion, and the Lachman test is positive, indicating anterior laxity. The posterior drawer test is negative, and there is no appreciable laxity with varus or valgus stress.
ACL tear
- MRI to confirm
- Early referral to ortho advised
True or false: most patients referred to orthopedic surgery for back pain end up needing surgery within a year of their first visit.
False
Approximately 39% of patients presenting to orthopedic surgery for back pain end up undergoing surgery within one year of their initial visit. This figure is derived from a retrospective analysis of over 8,000 patients with low back pain and/or lower extremity radicular symptoms who presented to a large multidisciplinary spine center.
42 year old female presenting for 2 weeks of lumbar pain. No recent injury and no red flag symptoms. Normal vitals. Full range of motion and no focal deficits on exam
A) Reassurance/observation
B) X-rays
C) Refer to ortho
D) Refer to ER
A) Reassurance and observation, remain active
Consider nonpharmacologic management
Consider NSAIDs/muscle relaxers case-by-case
Most cases resolve within 1-3 months
A 15-year-old male presents with a 3-month history of progressive right leg pain. The pain is described as dull and aching, localized to the distal femur, and is usually the worst at night. The patient denies any history of trauma. On physical examination, there is tenderness over the distal femur with mild swelling but no erythema or warmth. The patient has a slight limp but no significant functional limitation.
What is the most concerning (i.e. red flag) symptom in this patient prompting urgent workup?
A) Slight limp
B) Swelling and tenderness
C) Location of pain
D) Pain at night
D) 3-month duration of symptoms
Osteosarcoma, the most common primary malignant bone tumor in children and young adults, often presents with pain that is D) worse at night.
A 45-year-old male presents to the primary care clinic with a 3-month history of intermittent right hip pain radiating to the buttock and posterior thigh. The pain is described as a dull ache, occasionally sharp, and is exacerbated by prolonged sitting and bending forward. The patient denies any recent trauma or significant weight loss but reports occasional numbness in the right leg.
On physical examination, there is tenderness over the lumbar paraspinal muscles and a positive straight-leg-raising test on the right side, which reproduces the patient's leg pain. Neurological examination reveals no motor weakness, but there is decreased sensation in the right L5 dermatome. Reflexes are normal.
Referred lumbar pain (L5 radiculopathy)
- May occur with conditions such as disc herniation
- NSAIDs, PT, stay active, avoid prolonged sitting, reassurance
- >6 weeks: MRI, referral to consider steroid inj or surgical consultation if necessary
What is the leading cause of disability in the USA?
A) Migraine
B) Depression
C) Low back pain
D) Knee pain
E) Osteoarthritis
Low back pain is the most common orthopedic complaint in adults in the United States. According to the medical literature, up to 84% of adults in the U.S. experience low back pain at some point in their lives, and it is a leading cause of disability-adjusted life years. Additionally, the prevalence of back pain in the past three months among community-dwelling adults is reported to be 33.9%.
A 45-year-old male presents to his primary care physician with sudden onset of severe pain in the posterior aspect of his right ankle after feeling a "pop" while playing tennis. He reports difficulty walking and an inability to push off with the affected foot. On physical examination, there is a palpable gap approximately 2-6 cm proximal to the calcaneal insertion of the Achilles tendon, and the patient is unable to perform a single-leg heel raise on the affected side. The Thompson test is positive, indicating a lack of plantar flexion when the calf is squeezed.
A) Observation/NSAIDs
B) Refer to ER
C) X-ray and non-weight bearing
D) Ultrasound
Achilles tendon rupture
D) Ultrasound to confirm
Management: immobilize in plantarflexed position, referral to orthopedic surgeon, avoid weight-bearing (crutches), monitor for complications (i.e. DVT)
A 35-year-old male presents to the clinic with complaints of left calf pain and swelling for the past week. The patient reports that the pain began after a minor twist of his ankle while playing basketball, which he initially attributed to a calf sprain. He describes the pain as a constant ache, exacerbated by walking and relieved by rest. There is no history of trauma or significant injury to the leg.
On physical examination, the left calf is swollen and tender to palpation, with a circumference 2 cm greater than the right calf. There is no erythema or warmth. He notes severe calf pain with forced dorsiflexion at the ankle.
What is the next step in management of this patient?
A) Compression ultrasound, empiric anticoagulation
B) D-dimer
C) Non-weight bearing, NSAIDs PRN
D) Referral to ER
E) X-ray
A) Compression ultrasound and empiric anticoagulation (i.e. eliquis 5mg BID)
A 25-year-old female marathon runner presents to her primary care physician with a 3-week history of progressive right groin pain. The pain is insidious in onset, exacerbated by running, and relieved by rest. She denies any history of trauma.
On physical examination, she exhibits an antalgic gait and tenderness to palpation over the anterior hip region. Range of motion testing reveals pain at the extremes of hip abduction, external rotation, and flexion.
Initial plain radiographs of the hip are unremarkable. Given high clinical suspicion, you order an MRI which confirms your diagnosis.
Femoral neck stress fracture
The patient is advised to avoid weight-bearing activities and is provided with crutches. A follow-up plan includes serial imaging to monitor healing and a gradual return to activity. The patient is also referred to a sports medicine specialist for further management and to address any underlying risk factors, such as training modifications and nutritional assessment.
Orthopedic surgery was first performed approximately:
A) 125 years ago
B) 250 years ago
C) 4,500 years ago
D) 30,000 years ago
Orthopedic problems have been a constant throughout human history.
Remains of a young adult who lived at least D) 31,000 years ago were discovered in 2022 in Liang Tebo cave in Indonesian Borneo. The remains indicate the young adult survived the amputation of their lower left leg just above the ankle most likely when they were a child, an estimated 6 to 9 years prior to their death. Evidence of the successful amputation was determined by the remodeled bone at the site of the amputation and the lack of evidence of infection, which suggests the use of unexpectedly advanced medical practices.
The individual's survival after the procedure was also confirmed by the nature of the remodeled bone, which showed signs of the person continuing to use the lower left leg as the bone reshaped.
A 65-year-old woman presents to your clinic with complaints of progressively worsening pain, swelling, and erythema in her right knee, 3 weeks after undergoing total knee arthroplasty (TKA). On examination, the knee is warm to touch, with significant effusion and limited range of motion due to pain. You order a CBC, ESR and CRP. Knee aspiration yields turbid synovial fluid. You send the fluid for analysis.
A) Refer to ER for immediate workup
B) Refer back to operating ortho
C) Start oral antibiotics and pain meds with close follow-up
D) Start prednisone
B) Notify operating ortho promptly
Periprosthetic joint infection (PJI)
- Leading cause of failure of modern TKAs
- Start empiric IV abx
- Debridement, antibiotics, and implant retention (DAIR) procedure, which involves thorough surgical debridement and irrigation of the joint, along with exchange of the polyethylene liner
- Cultures from the synovial fluid shows MRSA
Which of the following is NOT a symptom suggestive of cauda equina syndrome (CES)?
A) Fecal incontinence OR retention
B) Urinary incontinence OR retention
C) Saddle anesthesia
D) Diminished lower extremity reflexes
E) Severe low back pain
F) All of the above are suggestive of CES
F) All of the above
Cauda equina syndrome occurs with compression of multiple nerve roots in the cauda equina, leading to multi-system symptoms as described. Early diagnosis and prompt management is necessary to prevent permanent loss of function.
A 28-year-old female presents to the primary care clinic with a 6-month history of chronic, deep, aching pain in the anterior groin region, which is exacerbated by prolonged sitting and physical activities such as running and pivoting. She reports occasional sharp pains during activity and a sensation of catching or popping in the hip. She denies any history of trauma.
On physical examination, there is a positive Flexion-Adduction-Internal Rotation (FADIR) test, which reproduces her groin pain. The patient also exhibits restricted internal rotation of the hip. Radiographic imaging reveals a cam-type deformity with a non-spherical osseous prominence at the femoral head-neck junction.
Femoroacetabular impingment (FAI)
Underdiagnosed cause of chronic hip pain in young adults
- Physical therapy
- Image-guided steroid injection
- Arthroscopic surgery
A) 305
B) 270
C) 206
D) 199
C) 206
A 13-year-old male presents to the primary care clinic with a 2-month history of right hip pain and a noticeable limp. The pain is described as a dull ache, occasionally sharp, and radiates to the groin and knee. The patient reports difficulty with weight-bearing activities and has been avoiding sports due to the discomfort. There is no history of trauma.
On physical examination, the patient exhibits an antalgic gait and limited internal rotation of the right hip. Passive hip flexion results in obligatory external rotation. There is tenderness over the anterior hip joint, and the patient has difficulty bearing weight on the affected leg.
A) X-ray
B) Observation with NSAIDs as needed
C) Physical therapy
D) Ultrasound
A) Bilateral hip radiography
Stable slipped capital-femoral epiphysis (SCFE)
- Most common hip disorder in age 8-15
- Often associated w/obesity, rapid growth spurts
- Early diagnosis and ortho referral important to prevent complications such as avascular necrosis and chondrolysis
A patient with moderate right knee osteoarthritis on x-ray is considering treatment with a steroid injection. While discussing potential risks and benefits, you highlight which of the following as the most common complication of intra-articular steroid injections?
A) Skin hypopigmentation and/or atrophy
B) Infection (septic arthritis)
C) Post-injection flare
D) Tendon rupture
E) Accelerated progression of arthritis
All answers are possible complications, but C) post-injection flare is the most common. This condition is characterized by an increase in pain and swelling in the joint shortly after the injection, typically within the first 24 to 48 hours. This reaction is usually self-limited and resolves without intervention.
54 year old male w/PMH of HTN, HLD, DM2 (HbA1c 9.8) and alcohol use disorder presents to your clinic for worsening back pain x 3 weeks. He reports he had normal spine XRs at chiropractor's office last week. He has tried ibuprofen which was not helpful. He notes a new tingling sensation in both legs and feet. Temp 100.6F, VS otherwise normal. On exam he has moderate spinal tenderness over L3-4. He has decreased patellar and achilles reflexes. Straight-leg raise is positive bilaterally. Labs are notable for glucose of 284, WBC 13.3, ESR 79, CRP 19.7.
Spontaneous spondylodiscitis
- Diabetes is a risk factor
- Focal back pain is the most common presenting symptom, with or without fever
- Serum acute phase response is usually present
- Treatment: IV antibiotics (4-6+ weeks)
- Ddx: osteomyelitis, tuberculosis, meningitis, malignancy, fracture, gout, ankylosing spondylitis
Who currently holds the world for the most broken bones?
Evel Knievel
433 fractures by the end of 1975
A 30-year-old male presents to his primary care physician with right wrist pain following a fall onto an outstretched hand (FOOSH) while playing basketball two days ago. He reports persistent pain localized to the radial side of the wrist, which is exacerbated by movement and gripping activities.
On physical examination, there is tenderness in the anatomical snuffbox and pain with axial loading of the thumb.
Initial plain radiographs of the wrist are normal.
A) ACE-wrap and RICE-measures for 2 weeks
B) Thumb-spica splint and repeat x-rays in 2 weeks
C) ACE-wrap and repeat x-rays in 2 weeks
D) Thumb-spica splint and RICE-measures for 2 weeks
Scaphoid fracture
Commonly misdiagnosed in primary care setting
B) Thumb-spica splint, repeat radiography in 2 weeks, MRI if negative
A 75-year-old male patient with no known medical history presents to the primary care clinic with his wife for progressively worsening bilateral leg weakness over the past six months. He reports increasing difficulty with ambulation due to the weakness. He notes new-onset urinary urgency in this timeframe. His wife expresses alarm that in the past 6 months he has become significantly more forgetful, and has exhibited difficulty concentrating on even basic tasks.
On physical examination, the patient exhibits a wide-based gait with short steps and reduced arm swing. Neurological examination reveals mild lower extremity weakness, particularly in the proximal muscles, and impaired balance. There is no significant spasticity or sensory loss. Cognitive assessment shows mild deficits in attention and executive function.
What is the most likely diagnosis?
Normal pressure hydrocephalus (NPH) is a condition characterized by the triad of gait disturbance, cognitive impairment, and urinary incontinence, with normal cerebrospinal fluid (CSF) pressure on lumbar puncture and ventriculomegaly on imaging.[1-2]
In the context of a 75-year-old male patient presenting with progressive leg weakness, shuffling gait, urinary urgency, and mild cognitive difficulties, these symptoms are highly suggestive of NPH. Gait disturbances, often described as a shuffling or broad-based gait, are typically the earliest and most prominent symptom. Cognitive impairment in NPH usually manifests as difficulties with attention, executive function, and memory. Urinary symptoms, such as urgency, frequency, and incontinence, are also common and can significantly impact the patient's quality of life.