NMS Q&A Family Medicine

160 NMS Q&A Family MedicineExamination Answers1. The answer is C. Patient hears and feels a “pop” as hepivots with a heavy box, that is, a non-impact injury, doesnot warrant a plain x-ray unless the criteria of the Ottawaknee rules: patient older than 55 years; tenderness of thepatella or of the fibula or inability to flex the knee morethan 90 degrees; TTP fibula (at the knee) or confined tothe patella; inability to flex knee ≥ 90 degrees. To the aboveindications should be added that plain x-rays in an urgentsetting should be taken if there was an impact injuryof any kind involved. Falls in which the patient landson straightened legs, especially in patients at risk forosteoporosis, must alert the physician to tibial plateaufracture.2. The answer is D. Posterior drawer test is the same asthe sag test if it is performed with the patient supine. Inthe sag test the knee is flexed 90 degrees while the examinerpushes the proximal tibia posteriorly and notes theposition of the anterior tibial plateau with respect to anteriorextent of the femoral condyles. That distance shouldbe 10 mm and should be compared to that of the otherside. If the clearance is significantly less, there appears asag that produces a concavity in the quadriceps tendonbelow the patella, signifying a posterior cruciate ligamentrupture. The anterior drawer test is more or less the oppositein performance and signifies an anterior cruciate tear.The valgus stress test employs application of a valgusstress while stabilizing the knee. A valgus deformity signifiesa medial collateral ligament tear; the varus stress testis the opposite. In an apologia for eponyms, they are thedaily verbal trade of orthopedic surgeons whom the primarycare physicians must consult. The McMurray test isfor meniscal injury, and the Lachman is a variant of theanterior drawer test.3. The answer is B. The “J sign” is observable lateraltracking of the patella as it moves superiorly during extensionof the knee. The pain is caused by the patella repetitivelyriding laterally over the ridge that is the lateralborder of the groove through which the patella rides,more commonly found in those with greater valgus carryingangles at the knee, mostly females. Causes are anatomical(excessive valgus angle at the knee, more likely infemales), dysfunctionally weak vastus medialis and excessivelytight vastus lateralis. Treatment is physical therapyin the vast majority of cases with surgery being a rarity.Pain and tenderness over the patella proper may occurwith patella stress fracture. Swelling over the patella withoutpalpable effusion in the joint is prepatellar bursitis.Tenderness over the quadriceps tendon occurs in quadricepstendinopathy. Knee pain without local findings (i.e.,referred) but with tenderness over the lateral epicondyleis iliotibial band syndrome or in the past called trochantericbursitis.4. The answer is D. On the basis of the moderate swellingand lack of evidence of grade III sprain, this patienthad a grade II inversion ankle sprain. This patient has noindications for a plain x-ray, not to mention an MRI. Thisis based on the patient’s ability to bear weight immediately,a negative anterior drawer test, and a negative inversiontest; both tests, if positive, would not allow weightbearing according to most experts. Weight bearing in thisscenario does not mean the ability to push off normallyon the toes in walking but to stand on the axis of the ankle.Indications for plain x-rays of the ankle, in the interest ofcost effectiveness, are based on the Ottawa rules: tendernessof the posterior edge of the lateral malleolus (in aninversion injury or medial malleolus in an eversion injury),or inability to bear weight immediately, or in the emergencycare situation. To send the patient out bearing fullweight would be foolhardy, risky (because of the possibilityof aggravating an unappreciated grade III sprain or afracture), and probably unenforceable. The use of supportivedressing or an air cast can never go wrong. GradeI or II sprains should be 90% well in 10 days and completelywell and ready for full athletic activity in 3 weeks.5. The answer is B. This patient has a grade III sprain,based on the positive anterior drawer test, and thus acomplete rupture of the talotibial ligament. Therefore, asa devoted athlete under the age of 40, he becomes a surgicalcandidate. Stat x-rays are indicated based on theOttawa criteria that include inability to bear weight, virtuallyalways present in the case of grade III sprains. Failureto appreciate the extent of this injury results in sendingthe patient forth with an unstable ankle. The latter maylead to further injury. That said, however, the outcomes ofrepair in the acute phase are very little different fromthose of repair of chronic ankle instability.6. The answer is D, plantar fasciitis. This patient, by herankle valgus deformity (eversion), shows that she has pesplanus. That condition is one of the causes of plantar fasciitisthrough the process of increasing tension on theplantar fascia. Others are pes cavus, decreased subtalarjoint mobility, and tight Achilles tendon. The other choicesare possible causes of heel pain as well. Retroachilles bursitisis caused by a loose-fitting shoe band at the heel thatallows repetitive motion of the skin overlying the bursa.(Quick relief is achieved by cutting a slit in the shoe atthe area of friction.) Achilles tendonitis is made worse by