Emergency Medicine Examination & Board Review

Susan Promes

Chapter 14 Musculoskeletal Emergencies - all with Video Answers

Educators

Chapter Questions

Problem 1

A 35-year-old paint factory worker presents complaining of a wound to the volar aspect of his nondominant left hand which occurred 1 hour ago while using a high-pressure device. Upon exam the patient appears to have a small puncture wound approximately $0.5 \mathrm{~cm}$ wide with trace surrounding erythema and swelling $2 \mathrm{~cm}$ distal to the hypothenar eminence. He is neurovascularly intact on exam, and an $x$-ray reveals no fractures or obvious foreign body. What is the MOST appropriate next step in management?
(A) Irrigate the wound, update his tetanus, and suture.
(B) Irrigate, update tetanus, and do not suture but prescribe prophylactic antibiotics.
(C) Irrigate, update tetanus, and arrange outpatient follow-up with his primary care provider.
(D) Irrigate, update tetanus, and consult an orthopedist immediately.

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Problem 2

Which of the following statements is TRUE regarding compartment syndromes of the hand:
(A) Patients may complain of intense pain but have little if any physical findings.
(B) Paresthesias occur as a prominent feature.
(C) Pain is not a prominent feature.
(D) Patients prefer to maintain their hand in 45-degree flexion at the MCP and PIP joints, the "cupping position."

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Problem 3

Which of the following fractures may not be radiologically apparent on the first day of injury, necessitating repeat x-rays on a follow-up visit?
(A) Nondisplaced radial head fracture.
(B) Clavicular fracture.
(C) Calcaneus fracture.
(D) Scapula fracture.

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Problem 4

A 56-year-old man presents after an industrial accident where the patient's chest was pinned between heavy machinery. On exam you note an obese man; blood pressure is $150 / 80 \mathrm{mmHg}$, heart rate is 90 beats per minute, and respiration rate is 24 breaths per minute. He is complaining of left anterior neck and chest discomfort as well as dysphagia. On exam, the patient has swelling and tenderness along the left clavicular area and over the sternum, with pain exacerbated upon movement of the left shoulder. A chest x-ray (CXR) reveals no fractures or pneumothorax, but the patient continues to complain of pain and difficulty swallowing. What is the MOST appropriate next diagnostic step?
(A) Oral challenge and discharge with appropriate follow-up.
(B) Left shoulder radiographs.
(C) CT of the chest.
(D) End-expiratory CXR.

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01:01

Problem 5

What is normal two-point discrimination in the fingertips?
(A) $<2 \mathrm{~mm}$.
(B) $<4 \mathrm{~mm}$.
(C) $<6 \mathrm{~mm}$.
(D) $<12 \mathrm{~mm}$.

Narayan Hari

Numerade Educator

02:19

Problem 6

Which of the following is TRUE regarding gamekeeper's thumb?
(A) The mechanism of injury is usually forced adduction at the MCP joint.
(B) Delaying surgery as long as 1 month for an acutely ruptured ligament will help preserve future function.
(C) More than 40 degrees of radial angulation on stress testing indicates complete rupture.
(D) Injury to the dorsal capsule and volar plate are rare.

Qudsiya Anis

Numerade Educator

02:19

Problem 7

Which of the following is TRUE regarding perilunate and lunate dislocations?
(A) All require emergent orthopedic consultation.
(B) Associated carpal bone fractures are rare.
(C) Complications of these injuries include avascular necrosis and median nerve compression.
(D) Patients present with obvious hand deformity.

Qudsiya Anis

Numerade Educator

Problem 8

A 20-year-old female complains of right wrist pain after a fall onto an outstretched hand. Radiographs appear completely normal, but the patient has significant snuffbos
tenderness on exam. You suspect a scaphoid fracture. Which of the following is TRUE regarding this injury?
(A) A fat pad sign is insensitive for detecting fracture in obese patients.
(B) Avascular necrosis can occur if the blood supply to the distal portion of the scaphoid is compromised by the fracture.
(C) Clinically suspected scaphoid fractures should be splinted in a short arm thumb spica splint in a dorsiflexed and ulnar-deviated position.
(D) Unstable scaphoid fractures (rotated, comminuted, or displaced fractures) should be splinted in a long arm spica splint.

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02:04

Problem 9

Which of the following is TRUE regarding carpal fractures?
(A) Carpal bone fractures account for the majority of all hand injuries.
(B) Carpal bone fractures are usually readily apparent on the first set of radiographs obtained on the day of injury .
(C) Lunate fractures can result in avascular necrosis.
(D) Pisiform fractures should be splinted in an ulnar gutter splint and have a very poor prognosis due to ulnar nerve compromise.

Bryan Valdivia

Numerade Educator

Problem 10

A 35-year-old man presents with left wrist pain following a fall off a snowboard. A radiograph reveals a Colles' fracture of the distal radius. Which of the following is TRUE regarding Colles' fractures?
(A) Stable Colles' fractures can be treated with a wrist splint for 6 weeks.
(B) The goals of reduction are to restore the dorsal tilt, radial inclination, and proper length to the radius.
(C) Associated ulnar styloid fractures may indicate disruption of the cartilaginous structures stabilizing the wrist.
(D) The $x$-ray demonstrates volar angulation of the distal radius.

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Problem 11

A 22-year-old woman presents to the ED complaining of right elbow pain and swelling after falling off her motor scooter. On exam, she is holding the right arm in 45 degrees of flexion, and you palpate a prominent olecranon posteriorly. Radiographs reveal a posterior elbow dislocation. Which of the following statements is TRUE?
(A) The preferred method of reduction involves hyperflexion and internal rotation until a palpable reduction occurs.
(B) If full, smooth, passive range of motion (ROM) is not possible postreduction, the postreduction film should be examined for entrapment of the medial epicondyle.
(C) A long arm plaster splint should be applied in full extension and appropriate orthopedic follow-up arranged.
(D) An intact radial pulse postreduction rules out any possibility of vascular compromise.

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02:04

Problem 12

Which of the following is TRUE regarding supracondylar fractures?
(A) An anterior fat pad may be the only visible sign of a nondisplaced fracture on radiographs.
(B) Refusal to open the hand, pain with passive finger extension, and forearm tenderness are commonly found with this injury and should be treated with analgesics.
(C) Volkmann's ischemic contracture results from postischemic swelling in the forearm compartment, leading to compromised capillary perfusion and eventual fibrosis of the affected tissues.
(D) Most supracondylar fractures are displaced anteriorly.

Bryan Valdivia

Numerade Educator

00:48

Problem 13

Which of the following is suggestive of a radial head fracture?
(A) Abnormality of the capitellum.
(B) Anterior fat pad.
(C) Lack of pain on exam.
(D) Swelling on the medial aspect of the elbow.

Andrei Demkov

Numerade Educator

02:04

Problem 14

Which of the following is TRUE regarding the injury shown in Figure 14-1?
(A) Associated radial head dislocations are rare.
(B) These types of fractures are classified according to the location of the ulnar fracture and the direction of the radial head dislocation.
(C) Most of these fractures are treated with closed reduction and prolonged cast immobilization.
(D) All of the above.

Bryan Valdivia

Numerade Educator

02:19

Problem 15

Which of the following is TRUE regarding distal interphalangeal joint dislocations?
(A) They are often associated with neurologic deficits.
(B) They usually are displaced in a volar direction.
(C) Irreducible cases may indicate an entrapped volar plate.
(D) They all require surgical repair.

Qudsiya Anis

Numerade Educator

Problem 16

An 8-year-old football player is brought to your ED with an anxious set of parents and right shoulder pain. Radiographs reveal a minimally displaced midshaft fracture of the right clavicle. The parents ask you to tell them everything they need to know about the injury. Which of the following statements is TRUE?
(A) This is an uncommon place for a clavicular fracture to occur.
(B) A figure-of-eight harness is necessary for proper healing.
(C) The patient will likely have chronic shoulder pain as an adult.
(D) This fracture may be associated with intrathoracic injury.

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02:04

Problem 17

Which of the following is TRUE regarding scapular fractures?
(A) They are seldom associated with other injuries.
(B) Most require surgical fixation to ensure long-term shoulder function.
(C) They are usually the result of severe trauma.
(D) Fractures of the acromion and the scapular spine are the most common.

Bryan Valdivia

Numerade Educator

05:57

Problem 18

A 26-year-old man is brought to the trauma room after a high-speed motorcycle accident. He has suspected injuries to the abdomen and head as well as an obvious deformity of the left ankle. The left foot is dusky and cool, and pulses are difficult to palpate. What is the MOST appropriate next step in the management of this injury?
(A) Obtain ankle films immediately as other trauma radiographs are obtained.
(B) Call the orthopedist on call immediately to request assistance for the reduction.
(C) Perform immediate reduction prior to obtaining radiographs.
(D) Attempt reduction only after films and ankle-brachial indices have been obtained for both lower extremities.

Mariana Roldan

Numerade Educator

00:55

Problem 19

Which of the following is TRUE regarding acromioclavicular joint injuries?
(A) It is difficult to diagnose them clinically.
(B) Most injuries occur in the elderly.
(C) Shoulder radiographs are needed.
(D) Treatment of most injuries consists of analgesia, rest, and immobilization in a simple sling.

Andrei Demkov

Numerade Educator

Problem 20

For which of the following patients can the cervical spine be clinically "cleared" by NEXUS criteria?
(A) The 18-year-old woman complaining of severe left leg pain with an obvious deformity after a motor vehicle accident.
(B) The 65-year-old man with tenderness to palpation along the lateral cervical musculature but no midline tenderness along the bony prominences.
(C) The 48-year-old man with a Glasgow Coma Scale score of 14 and repetitive questioning after a motor vehicle accident who insists, "Nothing is wrong with me, let me go!"
(D) The 33-year-old football player with tingling in his left fingers but no neck pain after being tackled to the ground during practice.

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02:19

Problem 21

Which of the following is TRUE regarding cervical spine injuries?
(A) Fanning or widening of the spinous processes may indicate an injury to the anterior ligamentous structures.
(B) Injuries to the transverse ligament of the odontoid can occur without bony fracture and should be considered unstable injuries.
(C) The flexion-teardrop fracture is considered mechanically stable.
(D) A bilateral interfacetal dislocation ("locked facets") is considered mechanically stable.

Qudsiya Anis

Numerade Educator

Problem 22

A 76-year-old female with a history of a right hip replacement presents after a fall from standing with right hip pain. Initial radiographs reveal a dislocated prosthesis. Which of the following is the next MOST appropriate step in management?
(A) Perform immediate closed reduction under conscious sedation.
(B) Obtain immediate orthopedic consultation.
(C) Obtain additional radiographs of the hip to better delineate the dislocation.
(D) Obtain an AP pelvic film to detect associated occult pelvic injuries.

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Problem 23

Which of the following is TRUE regarding rhabdomyolysis?
(A) Symptoms relating to the musculoskeletal system are almost always present in clinically significant rhabdomyolysis.
(B) Complications of rhabdomyolysis include hyperkalemia, DIC, and renal failure.
(C) Patients who present with oliguric acute renal failure (ARF) secondary to rhabdomyolysis need IV mannitol therapy immediately to promote diuresis.
(D) The degree of creatine kinase (CK) elevation correlates with the severity of illness and the development of renal failure.

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Problem 24

A 30-year-old factory worker presents after a crush injury to the left leg. You suspect compartment syndrome and obtain compartment pressures immediately. The pressures consistently read as $35 \mathrm{mmHg}$. How do you interpret this reading?
(A) Normal.
(B) Mildly elevated but likely safe.
(C) Moderately elevated and should be repeatedly measured.
(D) Severely elevated and grounds for emergent fasciotomy.

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01:04

Problem 25

Which of the following is a common cause of compartment syndrome?
(A) Femur fracture.
(B) Metacarpal fracture.
(C) Radius fracture.
(D) Tibia fracture.

Joanna Quigley

Numerade Educator

Problem 26

A 35-year-old man presents after jumping from a 3-story building in a suicide attempt. He is unconscious on arrival and immediately intubated. His feet are swollen and appear deformed, and radiographs are obtained to rule out calcaneal fractures. Which of the following is TRUE regarding calcaneal injuries?
(A) Boehler's angle measured at 10 degrees rules out the possibility of occult fracture.
(B) Management is primarily supportive care, and surgery is rarely necessary.
(C) Associated vertebral fractures are classic but not commonly found.
(D) The patient is at risk for developing a compartment syndrome.

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Problem 27

A 50-year-old woman presents after a bicycle accident complaining of right midfoot tenderness. You are concerned about an injury to the Lisfranc's joint. Which of the following is TRUE regarding this injury?
(A) A fracture noted at the base of the first metatarsal is pathognomonic.
(B) Plantar ecchymosis may be an occult sign of injury.
(C) A gap of $<3 \mathrm{~mm}$ between the bases of the first and second metatarsals is considered normal.
(D) Most injuries require prolonged casting for up to 12 weeks.

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Problem 28

A 42-year-old man presents complaining of severe, sudden left leg pain and weakness that occurred while playing tennis earlier that day. You suspect an Achilles tendon rupture. Which of the following is the next MOST appropriate step in management?
(A) Immediate orthopedic consultation.
(B) Splinting in neutral position and orthopedic follow-up within 1 week.
(C) Immediate MRI to confirm the diagnosis.
(D) Splinting in plantar flexion and orthopedic follow-up within 3-4 weeks.

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Problem 29

A 55-year-old woman presents after a high-speed motor vehicle accident. She complains of right hip pain, and on exam you appreciate a shortened, rotated right leg. Which of the following statements is TRUE regarding this patient?
(A) If her leg is internally rotated and adducted, she most likely has an anterior hip dislocation.
(B) If her leg is externally rotated and abducted, she most likely has a posterior hip dislocation.
(C) Closed reduction can wait until radiographs are obtained.
(D) Closed reduction should not be attempted unless an orthopedic specialist is available to perform the reduction.

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Problem 30

A 29-year-old man is brought in by ambulance after a high-speed motorcycle accident. The paramedics state that when they arrived on the scene, the patient's left knee appeared severely deformed, and a splint was immediately applied. Upon removal of the splint in the ED, you do not appreciate any obvious deformity but do note severe swelling of the joint. The patient is in severe pain at the knee, and you appreciate severe instability of the knee in multiple directions. Which of the following is TRUE regarding this patient?
(A) He most likely has a quadriceps tendon rupture and should be splinted in a knee immobilizer.
(B) Any effusion present should be immediately aspirated.
(C) This patient is at high risk for neurovascular injuries and should be admitted regardless of the neurovascular exam.
(D) Radiographs should be ordered to rule out a fracture, and the patient should receive prompt outpatient follow-up to evaluate potential ligamentous injuries.

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00:17

Problem 31

In what region are the majority of epidural cord compressions found?
(A) Cervical spine.
(B) Thoracic spine.
(C) Lumbar spine.
(D) Sacral nerve roots.

Alexander Burbelo

Numerade Educator

Problem 32

What is the MOST appropriate imaging modality in a patient with neck and arm pain worsening over the last week who has triceps weakness with no history of trauma?
(A) No imaging is necessary; attempt conservative therapy.
(B) Obtain plain films of the neck.
(C) Perform MRI
(D) Perform CT myelography.

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00:57

Problem 33

What is the MOST common systemic disease affecting the spine?
(A) Multiple sclerosis.
(B) Rheumatoid arthritis.
(C) Amyotrophic lateral sclerosis.
(D) Malignancy.

Joanna Quigley

Numerade Educator

Problem 34

A 35-year-old male with a 1-week history of progressive pain radiating from the lumbar spine down the back of the leg presents to the ED. His physical examination is normal except for complaints of back pain with movement. What is the MOST appropriate imaging test?
(A) No imaging is necessary; attempt conservative therapy.
(B) Obtain plain films of the lumbar spine.
(C) Perform MRI.
(D) Perform CT.

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Problem 35

What is the MOST common finding in cauda equina syndrome?
(A) Urinary retention.
(B) Decreased anal sphincter tone.
(C) Weakness or numbness in the lower extremities.
(D) Saddle anesthesia.

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Problem 36

What is the MOST specific radiologic sign of a rotator cuff tear?
(A) Sclerosis of the humeral head.
(B) Obliteration of the peribursal fat plane.
(C) Narrowing of the acromiohumeral space.
(D) Osteophytic changes of the acromion and/or clavicle.

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02:03

Problem 37

In Figure 14-2, the examiner is attempting to examine which muscle?
(A) Teres minor.
(B) Teres major.
(C) Infraspinatus.
(D) Supraspinatus.

Lillian Asherman

Numerade Educator