NMS Q&A Family Medicine

162 NMS Q&A Family Medicinefractures, and bone scans may be necessary. There is noone blow that causes stress fracture; it is the results ofcyclic repetitive axial impact. Cortical thickening on x-raymay be seen in advanced stages of stress fractures. Runningand jumping are forbidden for at least 6 weeks, butswimming is allowed as early as tolerated.15. The answer is E, fifth metatarsal. Metatarsal stressfractures are the most common stress fracture amongmilitary personnel. Metaphyseal fifth metacarpal stressfractures carry a higher risk of conversion to a completefracture and nonunion. For that reason, unlike with othermetatarsal fractures, a fifth metatarsal fracture has to bemanaged more aggressively, including short-leg-castapplication, complete non-weight-bearing status, or openreduction and internal fixation.16. The answer is C, posterior process of the talus. Rapidplantar flexion of the ankle (the bounce test), reproducingthe original mechanism of injury, will produce pain inthe posterior talus.17. The answer is A. This is a story typical of lumbarspinal stenosis: lumbosacral and deep pelvic pain, moreoften than not symmetrical, coming on during walkingupright and relived by the sedentary position or otherwiseflexing at the hips for less than a minute. It occursmost often in a person’s seventh decade and later. Thecause tends to be a mixture of osteophytic spur formationand varying degrees of herniated discs (nuclei pulposi),effectively narrowing the spinal canal. Claudicationis often suspected but palpability of the pulses rules itout. Although a herniated disc can contribute to thesyndrome, it seldom occurs with this presentation; kneebuckling, as mentioned in the vignette, implies the L4to L5 root, not the L5 to S1. Prostatitis should be consideredin the differential diagnosis of deep pelvic pain,but back pain referral in that situation is sacral, and thepain of prostatitis has no relationship to posture oractivity. Lumbosacral strain does not radiate from thelow back.ReferencesAldridge T . Diagnosing heel pain in adults . Am Fam Physician .2004 ; 70 : 332 – 338 .Family Medicine Board Review 2009 . Kansas City, Missouri ; May3–10, 2009 .Sickles RT . Mechanical problems of the lower extremities . In:Rudy DR , Kurowski K , eds. Family Medicine: House OfficerSeries . Baltimore, MD : Williams & Wilkins ; 1997 : 399 – 412 .Terrell TR , Leski MJ . Sports medicine . In: Rakel RE , ed. Textbookof Family Practice , 6th ed . Philadelphia : WB Saunders ;2002 : 845 – 890 .Wexler RW . The injured ankle . Am Fam Physician 1998 ; 57 :474 – 480 .