PANCE Exam: Musculoskeletal Review Questions & Answers

GENERAL ORTHOPEDIC CONCEPTS

Question: By definition, a sprain involves injury to what types of connective tissue?
Those tissues that give support to joints: ligaments and joint capsules.

Question: How are sprains classified?
First degree: Minor stretching or partial tear of ligaments/capsule without instability when the joint is stressed
Second degree: Significant stretching and partial tear of ligaments/capsule allowing for partial opening of the joint when stressed
Third degree: Complete tear of ligaments/capsule with complete opening of joint when stressed

Question: By definition, a strain involves injury to what two types of connective tissue?
Muscle or tendon.

Question: What is a valgus deformity? Varus deformity?
- Valgus deformity is the angulation of an extremity at a joint with the more distal part angled away from the midline.
- Varus deformity is the angulation of an extremity at a joint with the more distal part angled toward the midline.

Question: Are dislocations and sprains more common in children or adults?
Dislocations and ligamentous injuries are uncommon in prepubertal children as the ligaments and joints are quite strong as compared to the adjoining growth plates. Excessive force applied to a child’s joint is more likely to cause a fracture through the growth plate than a dislocation or sprain.

Question: Which type of Salter-Harris fracture has the worst prognosis?
Type V (compression injury of the epiphyseal plate).
(See Figure 9-1.)

Question: Which type of Salter-Harris fracture is most common?
Type II (a triangular fracture involving the metaphysis and an epiphyseal separation).
(See Figure 9-1.)


Figure 9-1

Question: What is a stress fracture?
A stress or fatigue fracture is caused by small, repetitive forces that usually involve the metatarsal shafts, the distal tibia, and the femoral neck (though many other bones may be affected). These fractures may not be seen on initial radiographs.

Question: After a fracture, what are the three stages of healing?
1. Inflammatory
2. Reparative
3. Remodeling

Question: The end of the reparative phase is usually marked by clinical union of the fracture. How is clinical union defined?
- The fractured bones do not shift on clinical examination
- The fracture site is nontender
- The patient can use the limb without significant pain

Question: A pneumatic tourniquet can be inflated on an extremity to a level higher than a patient’s systolic blood pressure for how long without damaging underlying vessels or neurons?
2 hours.

Question: What basic disorder contributes to the pathophysiology of compartment syndrome?
Increased pressure within closed tissue spaces compromising blood flow to muscle and nerve tissue.

There are three prerequisites to the development of compartment syndrome:

1. Limiting space
2. Increased tissue pressure
3. Decreased tissue perfusion

What are the two basic mechanisms for elevated compartment pressure?

1. External compression—by circumferential casts, dressings, burn eschar, or pneumatic pressure garments
2. Volume increase within the compartment—hemorrhage into the compartment, IV infiltration, or edema secondary to injury or due to postischemic swelling

Question: What intracompartmental pressure level raises concern?
Normal pressure is less than 10 mm Hg. It is generally agreed that pressure greater than 30 mm Hg mandates emergency fasciotomy. The treatment for compartment pressures between 20 and 30 mm Hg is controversial and may require surgical consultation, especially if the patient is unreliable, i.e., with an altered level of consciousness.

Question: How do you clinically differentiate between acute compartment syndrome, neurapraxia, and arterial occlusion?
- The patient will have normal pulses in neuropraxia
- Decreased pulses in compartment syndrome (though this is a very rare and insensitive finding)
- No pulses in arterial occlusion
- Stretching the muscles will cause great pain in compartment syndrome but not in neuropraxia

Question: What fracture is most commonly associated with compartment syndrome?
The tibia, which often results in anterior compartment syndrome.

Question: What are the early signs and symptoms of compartment syndrome?
- Tenderness and pain out of proportion to the injury
- Pain with active and passive motion
- Hypesthesia and paresthesia

Question: What are the six Ps of compartment syndrome?
Pain
Pallor
Pulselessness
Paresthesia
Pressure
Paralysis

Question: What four Cs determine muscle viability?
Color
Consistency
Contraction
Circulation

Question: What are the late signs and symptoms of compartment syndrome?
- Tense, indurated, and erythematous compartment
- Slow capillary refill
- Pallor and pulselessness

What conditions are in the differential diagnosis of a limp or gait abnormality in a child?
- Legg-Calvé-Perthes disease (avascular necrosis of the femoral head)
- Osgood-Schlatter disease
- Avulsion of the tibial tubercle
- Infection
- Toxic transient tenosynovitis
- Patellofemoral subluxation
- Chondromalacia patella
- Slipped capital femoral epiphysis
- Septic arthritis
- Metatarsal fracture
- Proximal stress fracture
- Toddler fracture (spiral tibia fracture)


DISORDERS OF THE SHOULDER AND UPPER ARM

Question: What are the four muscles of the rotator cuff?
1. Supraspinatus
2. Infraspinatus
3. Teres minor
4. Subscapularis

Question: Which bone is most often fractured at birth?
The clavicle.

Question: What is the most common type of shoulder dislocation?
Anterior dislocation.

Question: A patient cannot actively abduct her shoulder due to pain and weakness. What injury does this suggest?
A rotator cuff tear.

Question: What is the most common joint dislocation?
Anterior shoulder dislocations account for half of all joint dislocations.

Question: What nerve is usually injured in glenohumeral dislocation?
Axillary nerve.

Question: What is the most reliable method of diagnosing a posterior shoulder dislocation?
Performing a physical examination and ordering a scapular Y-view X-ray. A posterior dislocation of the shoulder is often missed with a standard radiographic shoulder series.

Question: In a humeral shaft fracture, what nerve is most commonly injured?
The radial nerve.

Question: A patient presents with a complaint of pain at the site of the deltoid insertion with radiation into the back of the arm (C5 distribution). On examination, there is increased pain with active abduction from 70° to 120°. X-rays reveal calcification at the tendinous insertion of the greater tuberosity. What is the likely diagnosis?
Supraspinatus tendonitis.

What is the most common tendon affected in calcified tendonitis?
The supraspinatus.

Question: What humerus position puts the shoulder in greatest risk of dislocating anteriorly?
Abduction and external rotation.

Question: Shoulder separations happen at what joint?
The acromioclavicular joint.

Question: Shoulder dislocations happen at what joint?
The glenohumeral joint.

Question: What is the best way to position a patient’s arm to palpate the subacromial bursa?
With the humerus held in passive extension.

Question: What muscle forms the anterior wall of the axilla?
The pectoralis major.

Question: What muscle forms the posterior wall of the axilla?
The latissimus dorsi.

Question: What muscle is most frequently absent (either totally or partially) due to a congenital anomaly?
The pectoralis major.

Question: What portion of the bicep is most commonly torn from its bony attachment?
The long head of the biceps.

Question: Winging of the scapula indicates a weakness of what muscle?
The serratus anterior muscle.

Question: A positive drop arm test is suggestive of what condition?
A tear in the rotator cuff (especially the supraspinatus muscle).

Question: What is the likely diagnosis in a patient with significantly restricted range of motion at the shoulder joint 4 weeks after a painful shoulder injury?
Adhesive capsulitis (frozen shoulder).

Question: What other injuries may occur with an anterior dislocation of the shoulder?
- Axillary nerve injury
- Axillary artery injury (geriatric patients)
- Compression fracture of the humeral head (Hillsack deformity)
- Rotator cuff tear
- Fractures of the anterior glenoid lip
- Fractures of the greater tuberosity of the humerus

What type of shoulder dislocation is pictured in the radiograph Figure 9-2?


Figure 9-2 (Photo contributed by Kevin J. Knoop, MD MS, reproduced with permission from Knoop KJ, Stack LB, Storrow AB. Atlas of Emergency Medicine. 3rd ed. New York, NY: McGraw-Hill; 2010, Fig. 11.5)
This shows an anterior shoulder dislocation. Note the humeral head is anterior and inferior to the glenoid fossa


DISORDERS OF THE ELBOW AND FOREARM

Question: What is “nursemaid elbow”?
A subluxation of the radial head. During forceful retraction, fibers of the annular ligament that encircle the radial neck become trapped between the radial head and the capitellum. On presentation, children hold their arm in slight flexion and pronation.

Question: A patient has a fracture of the proximal third of the ulna. What additional injury should be ruled out?
A dislocation of the radial head. An anterior dislocation is most common. A proximal ulna fracture with a radial head dislocation is often called a Monteggia fracture.

Question: What is the significance of the fat pad sign seen on a lateral radiograph of the elbow following an injury?
This indicates the presence of an effusion or hemarthrosis of the elbow joint, suggestive of an occult fracture of the radial head, supracondylar fracture of the humerus, or proximal ulnar fracture.

Question: What is the order of appearance of the ossification centers in the elbow? At what approximate age do they appear?
Remember the acronym
CRITOE:
- Capitellum (3–5 months)
- Radial head (4–5 years)
- Internal (medial) epicondyle (5–7 years)
- Trochlea (8–9 years)
- Olecranon (9–10 years)
- External (lateral) epicondyle (11–12 years)

What is the most common site of bursitis?
The olecranon bursa of the elbow.

Question: What is the usual mechanism of injury in a supracondylar distal humeral fracture?
A fall on an outstretched arm.

Question: What artery is commonly injured with a supracondylar distal humeral fracture?
Brachial artery.

Question: What nerve is commonly injured with a supracondylar fracture?
The median nerve.

Question: Why is a displaced supracondylar fracture of the distal humerus in a child considered an emergency?
Because of the high potential for neurovascular compromise, which may lead to ischemic injury or nerve palsy.

Question: What nerve injury is associated with a medial epicondyle fracture?
Ulnar nerve.

Question: What is the most commonly missed fracture in the elbow region?
A radial head fracture. Like a scaphoid (navicular) fracture in the wrist, radiographic signs of a radial head fracture may not show up for days after the injury. A positive fat pad sign may be the only finding suggestive of this injury.

Question: Which epicondyle is involved in tennis elbow?
The lateral epicondyle.

Question: Which epicondyle is involved in golfer elbow?
The medial epicondyle.

Question: Does damage to the olecranon bursa tend to produce diffuse or localized swelling?
Localized as shown in Figure 9-3.


Figure 9-3 (Photo contributed by Selim Suner, MD MS, reproduced with permission from Knoop KJ, Stack LB, Storrow AB. Atlas of Emergency Medicine. 3rd ed. New York, NY: McGraw-Hill; 2010, Fig. 12.17.)

Which bone articulates with the humerus in the olecranon fossa?
The ulna.

Question: What are the three bony articulations of the elbow?

1. The humeroulnar joint

2. The humeroradial joint

3. The radioulnar joint

Question: Where can the ulnar nerve be best palpated at the elbow joint?
In the sulcus between the medial epicondyle and the olecranon fossa.

Question: What are the primary muscles that produce active elbow flexion?
The brachialis and biceps muscles.

Question: What are the primary muscles that produce active elbow extension?
The triceps muscles.

Question: Besides flexion and extension, what other motions happen at the elbow joint?
Supination and pronation.

Question: What motor neurons are being evaluated with biceps, brachioradialis, and triceps reflex testing?
- Biceps reflex—C5
- Brachioradialis reflex—C6
- Triceps reflex—C7


DISORDERS OF THE WRIST AND HAND

Question: What tendons are involved in de Quervain tenosynovitis?
The abductor pollicis longus and the extensor pollicis longus and brevis tendons.

Question: What is Finkelstein test?
A test used to determine whether a patient has de Quervain tenosynovitis. If pain is elicited when the patient grasps his thumb with the fingers of the same hand and deviates his wrist in the ulnar direction, then the test is positive.

Question: What is the most common type of peripheral nerve compression?
Carpal tunnel syndrome, which involves compression of the median nerve at the wrist. This syndrome is more often diagnosed in female patients than in male patients. Clinically, the patient will have pain and weakness, which worsen at night. Splinting the wrist in a neutral position or corticosteroid injections may provide relief. If conservative measures do not work, surgical decompression can be performed.

Question: Which fingers are potentially affected by carpal tunnel syndrome?
The first, second, third, and the radial side of the fourth finger.

Describe Tinel and Phalen tests:
Both test for carpal tunnel syndrome:

Tinel test: Tapping the volar aspect of the wrist over the median nerve with the hand hyperextended produces pain and/or paresthesias in the distribution of the median nerve

Phalen test: Full flexion at the wrist for 1 minute leads to paresthesia along distribution of median nerve

Question: What injury is often referred to as gamekeeper thumb?
Instability of the ulnar collateral ligament of the MCP joint of the thumb. This may be due to chronic valgus stresses on the joint or more commonly an acute injury (such as a fall during skiing) that results in a sudden valgus stress. Often, an acute injury of the ulnar collateral ligament of the thumb is referred to as “skier thumb.”

Question: What is a felon and how is it treated?
A felon is a subcutaneous infection in the pulp space of the fingertip, usually due to Staphylococcus aureus. Treat by incising the pulp space.

Question: What is the most commonly fractured carpal bone?
The scaphoid bone (navicular).

Question: How is a scaphoid (navicular) fracture diagnosed?
The initial radiograph frequently appears to be normal. If the patient has tenderness in the anatomical snuff box or pain with axial loading of the thumb, a scaphoid (navicular) fracture should be presumed and the hand splinted. A follow-up radiograph 10 to 14 days after the injury may then reveal the fracture.

Question: What is the most feared complication of a scaphoid (navicular) fracture?
Avascular necrosis. The more proximal the fracture, the more commonly avascular necrosis occurs.

Question: What is Kienbock disease?
Avascular necrosis of the lunate with collapse of the lunate secondary to fracture. As with a scaphoid (navicular) fracture, initial wrist X-rays may not demonstrate the fracture. Therefore, tenderness over the lunate warrants immobilization.

Question: What is a boutonnière deformity and how does the injured finger appear?
It is a rupture of the extensor apparatus of the PIP joint of a finger. The injured finger appears flexed at the PIP joint and extended at the DIP joint.

Question: How is a boutonnière deformity initially treated?
By splinting the PIP joint in full extension.

Question: Describe Dupuytren contracture:
A nodular thickening and contraction of the palmar fascia.

Question: Describe Galeazzi fracture/dislocation:
Displaced fracture of the distal radius with a dislocation of the distal ulna or a fracture of the distal ulnar physis.

What are Kanavel four cardinal signs of infectious digital flexor tenosynovitis?
1. Tenderness along the tendon sheath
2. Finger held in flexion
3. Pain on passive extension of the finger
4. Finger swelling

Question: What fracture has likely occurred to the individual in Figure 9-4?


Figure 9-4

A Colles fracture, which is a complete fracture of the distal radius in which the fragment is displaced dorsally as shown in the radiograph in Figure 9-5.


Figure 9-5

Question: Active adduction of the thumb tests which nerve?
Ulnar nerve.

Question: What is the best X-ray view for diagnosing lunate and perilunate dislocations?
Lateral X-ray views of the wrist.

A patient presents with an injury to his second (index) finger after forced flexion. He reports an inability to actively extend the tip of his finger (but he can extend it passively) (see Figure 9-6). What is the likely injury?


Figure 9-6 (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AB. Atlas of Emergency Medicine. 3rd ed. New York, NY: McGraw-Hill; 2010, Fig. 11.51.)
Mallet finger, which is a result of either a rupture of the distal extensor tendon or an avulsion fraction of the tendon insertion on the distal phalanx with a dorsal plate avulsion.

Question: What nerve provides sensations to both the dorsum and volar aspects of the hand?
Ulnar. Radial is primarily dorsum, and median is primarily volar.

Question: A patient presents with a small, soft bump on the dorsum of her wrist. The mass has a jelly-like consistency and is not significantly point tender. What is the likely diagnosis?
A ganglion cyst.

Question: In the wrist, what bone is dislocated most often?
Lunate. It is also the second most commonly fractured bone in the wrist.

Question: How is a perilunate dislocation diagnosed?
By AP and lateral X-rays. The lunate remains in alignment with the radial fossa, while the other carpal bones appear displaced.

Question: On an X-ray of the hand, the AP view shows a triangular shaped lunate. Diagnosis?
Lunate dislocation. Lateral films will reveal what resembles a cup spilling water.

Question: A patient presents with a snapping sensation in the wrist and a click. The X-ray of the patient’s hand reveals a 3 mm space between the scaphoid and the lunate. What is your diagnosis?
Scaphoid dislocation.

In a boxer fracture, how much angulation of the fifth metacarpal neck is acceptable?
Less than 40°.

Question: What ligament in the hand is commonly injured in a fall while skiing?
Thumb MCP joint ulnar collateral ligament rupture (gamekeeper thumb).

Question: Why is it important to get radiographic studies after an acute dislocation?
To rule out other injuries including ligament avulsion, articular fracture, or other signs that might indicate the presence of gross joint instability.

Question: Atrophy of the thenar eminence of the palm may indicate entrapment of what nerve?
The median nerve.

Question: Atrophy of the hypothenar eminence of the palm may indicate entrapment of what nerve?
The ulnar nerve.

Question: The median nerve passes through the carpal tunnel at the wrist. Where does the ulnar nerve pass through at the wrist?
The tunnel of Guyon.

Question: What other important structure passes through the tunnel of Guyon?
The ulnar artery.

Question: What do you call an infection that occurs on the posterior distal aspect of a finger, may wrap around the border of the finger nail, and often starts with a hangnail?
A paronychia.

Question: How should one treat a paronychia that has formed an abscess?
Incision and drainage of the abscess. Antibiotics may be used as well if an associated cellulitis has developed or in the rare situation where systemic signs and symptoms are present.

Question: Do most median nerve injuries occur as a result of acute macrotrauma or chronic microtrauma?
Most median nerve injuries are a result of repetitive movements over time producing chronic micro trauma.


DISORDERS OF THE BACK/SPINE

Question: What is the leading cause of disability for patients younger than 45 years?
Chronic lower back pain. Most patients with lower back pain do not need surgery and will recover from their injury within 6 weeks.

What must be checked in a patient with Down syndrome before medical clearance can be given for participation in sports?
Atlantoaxial instability must be ruled out by means of cervical radiographs and possibly CT scans with the head in various positions; 10% to 20% of children with Down syndrome have unstable atlantoaxial joints.

Question: What vertebrae most commonly sustains a thoracolumbar wedge fracture in the elderly?
L1.

Question: A patient in a motor vehicle accident sustains a hyperextension injury to the neck. Plain films reveal a C2 bilateral facet fracture through the pedicles. What is the common name for this type of fracture?
A hangman fracture.

Question: Injury to what cervical area results in Horner syndrome (ptosis, miosis, and anhidrosis)?
Disruption of the cervical sympathetic chain at C7 through T2.

Question: What spinal level corresponds to the dermatomal innervation of the perianal region? The nipple line? The index finger? The knee? The lateral foot?
- Perianal region: S2-S4
- Nipple line: T4
- Index finger: C6
- Knee: L4
- Lateral foot: S1

Question: A patient has difficulty squatting and standing due to weakness. What is the most likely spinal pathology?
L4 root compression with involvement of quadriceps muscles.

Question: What is the most common site of lumbar disk herniations?
Most clinically important lumbar disk herniations are at the L4-L5 or L5-S1 intervertebral levels. Evaluate these patients by checking for weakness of ankle and great toe dorsiflexors (L5). Also check pinprick sensation over the medial aspect of the foot (L5) and the lateral portion of the feet (S1).

Question: What is the eponym for a C1 burst fracture from vertical compression?
Jefferson fracture.

Question: Where is the most common site of cervical disk herniation?
Cervical disk herniations are most common at C6-C7, but also may occur at C5-C6 and other levels.

Question: Define spondylolysis:
A defect in the pars interarticularis.

Define spondylolisthesis:
The forward movement of one vertebral body on the vertebra below. Spondylolysis can lead to spondylolisthesis.

Question: A patient presents with back pain and complaints of incontinence. On examination, loss of anal reflex and decreased sphincter tone is noted. What is your diagnosis?
Cauda equina syndrome. The most consistent finding is urinary retention. On physical examination, you should expect saddle anesthesia (numbness over the posterior superior thighs as well as numbness of the buttocks and perineum).

Question: A patient has an avulsion fracture of the spinous process of C7 with a history of a hyperflexion mechanism. What is the diagnosis?
Clay shoveler fracture—a fracture involving the spinous process of C6, C7, or T1. The mechanism is usually flexion or a direct blow.

Question: A patient suffers a bilateral interfacetal dislocation as a result of excessive flexion. What is your concern?
Ligament disruption has occurred causing the C-spine to be unstable.

Question: Stable or unstable: clay shoveler fracture?
Stable.

Question: Stable or unstable: fracture of the posterior arch of C1?
Stable.

While providing medical coverage at a soccer game, a player goes down complaining of neck pain after a hard collision with another player and the ground. She does not lose consciousness, has full sensation and motor function in her extremities, but has significant point tenderness directly over her cervical vertebrae. How should you remove this player from the field?
Apply a stiff extrication collar, strap her to a backboard, and transport her to the hospital via ambulance for imaging studies. She may have a nondisplaced cervical fracture that could shift causing spinal cord damage if she is allowed to move freely.

Question: From what spinal nerve roots does the brachial plexus originate?
C5 through T1.

Question: Someone with a C5 disk herniation causing right-sided nerve root impingement will likely have pain in what part of his/her body besides the neck?
The right shoulder.

Question: At what level does spinal stenosis most commonly occur?
L3-4 and L4-5 interspaces.

Question: In patients with significant lumbar spinal stenosis, does walking lead to worsening or improving leg pain?
Worsening.

Question: In what gender does scoliosis most commonly occur?
Females.

Question: In males, when is kyphosis most common?
During adolescences.

Question: In women, when is kyphosis most common?
After menopause when osteoporosis and vertebral body fractures may lead to kyphosis.

Question: The C7 neurologic area is responsible for sensation in what part of the body?
The third finger.

Question: Of cervical, thoracic, and lumbar intervertebral disks, which has the lowest rate of herniation?
Thoracic.

Question: Fifty percent of cervical rotation takes place between what two cervical vertebrae?
C1 (atlas) and C2 (the axis). The remaining 50% is split up fairly evenly among the remaining five cervical vertebrae.

The 12th ribs articulate with what vertebrae?
The 12th thoracic vertebrae. Generally, the 12 sets of ribs articulate posteriorly with the thoracic vertebrae assigned the same number (i.e., 1st ribs articulate with T1, 2nd ribs with T2, etc.).

Question: What condition must be ruled out in a middle-aged man with profound limitation in spinal mobility?
Ankylosing spondylitis.


DISORDERS OF THE HIP AND PELVIS

Question: Describe the leg position of a patient with a femoral neck fracture:
Shortened, abducted, and slightly externally rotated.

Question: Describe the leg position of a patient with an anterior hip dislocation:
Mildly flexed, abducted, and externally rotated.

Question: Describe the leg position of a patient with a posterior hip dislocation:
Shortened, adducted, flexed, and internally rotated.

Question: What mechanism of injury typically leads to posterior hip dislocations and what are some common complications?
The mechanism of injury is force applied to a flexed knee directed posteriorly. This dislocation is associated with sciatic nerve injury and avascular necrosis of the femoral head.

Question: Describe the leg position of a patient with an intertrochanteric hip fracture:
Shortened, externally rotated, and abducted.

Question: Describe a typical patient with a slipped capital femoral epiphysis:
An obese boy, 10 to 16 years old, with groin or knee discomfort increasing with activity. He may also have a limp. The slip can occur bilaterally and best observed on a lateral view of the hip.

Question: What is the Young classification system for pelvic fractures?
The Young system divides pelvic fractures into four categories depending on the type and direction of force:
1. Lateral compression (LC)
2. Anterior–posterior compression (APC)
3. Vertical sheer (VS)
4. Combination mechanical mixed (CM)

Question: Describe a lateral compression pelvic fracture (LC):
This fracture is usually caused by a motor vehicle collision in which the car and patient are broadsided. The lateral force from the collision causes a sacral fracture, iliac wing fracture, or a sacroiliac ligamentous injury and a transverse fracture of the pubic rami. There is no ligamentous injury at the pubic symphysis.

Describe an anterior–posterior compression pelvic fracture (APC):
APCs are usually caused by a head-on motor vehicle collision. They always include a disruption of the pubis symphysis and usually involve a disruption (of different degrees) of the sacroiliac joint.

Question: Describe a vertical sheer pelvic fracture (VS):
VSs are usually caused by a fall. They involve an injury of the sacroiliac ligaments and either a disruption of the pubis symphysis or vertical fractures through the pubic rami. The iliac wing is vertically displaced.

Question: What life-threatening injury is associated with pelvic fractures?
Severe hemorrhage, usually retroperitoneal. Up to 6 L of blood can be accommodated in this space.

Question: What pelvic fracture is most likely to involve severe hemorrhage?
Vertical sheer fractures.

Question: Which pelvic fracture is most likely to involve bladder rupture?
Lateral compression fractures.

Question: Which pelvic fracture is most likely to involve urethral injury?
Anterior–posterior compression fracture.

Question: Which fracture is associated with avascular necrosis of the femoral head?
Femoral neck fractures.

Question: Describe the common features of a slipped femoral capital epiphysis:
The injury usually occurs in adolescence. The condition typically presents with anterior proximal thigh pain and a painful limp. Frequently, hip motion is limited, particularly internal rotation. Evaluation is aided by AP and frog-leg lateral radiographs of both hips.

Question: Which type of hip dislocation is most common: anterior, posterior, lateral, or medial?
Posterior hip dislocations are the most common, accounting for approximately 90% of all hip dislocations.

Question: A fracture of the acetabulum may be associated with damage to what nerve?
The sciatic nerve.

Question: Describe the signs and symptoms of pressure on the first sacral root (S1):
Symptoms of S1 injury include pain radiating to the midgluteal region, posterior thigh, posterior calf, and down to the heel and sole of the foot. Sensory signs are localized to the lateral toes. S1 root compression typically involves the plantar flexor muscles of the foot and toes. The ankle reflex is decreased or absent.

Question: What is the most commonly missed hip fracture?
Femoral neck fracture.

What is the most common site of aseptic necrosis?
The hip.

Question: What must be done to effectively palpate the coccyx and sacrococcygeal joint?
A rectal examination.

Question: What test can be done on newborn infants to check for a congenitally dislocating hip?
Ortolani click test. The child is positioned on his/her back and the hips are flexed, abducted, and externally rotated. The involved hip is unable to be abducted as far as the uninvolved side and there is a palpable click when the hip is reduced.

Question: What is the primary hip flexor muscle?
The iliopsoas muscle.

Question: What is the primary hip extensor muscle?
The gluteus maximus muscle.

Question: What is the primary hip abductor muscle?
The gluteus medius muscle.

Question: What is the primary hip adductor muscle?
The adductor longus muscle.

Question: Point tenderness and a boggy feeling over the greater trochanter may be indicative of what?
Trochanteric bursitis.

Question: What are the superior and inferior attachments of the inguinal ligament?
The superior attachment is at the anterior, superior iliac spines and the inferior attachment is at the pubic tubercles.

Question: What nerve lies midway between the ischial tuberosities and greater trochanters and can best be palpated with the hip in a flexed position?
The sciatic nerve.

Question: How are the femoral nerve, artery, and vein positioned in relationship to each other?
Moving from lateral to medial just inferior to the inguinal ligament, first comes the nerve, then the artery, and the most medial structure of the three is the vein.


DISORDERS OF THE KNEE AND LOWER LEG

Question: What long bone is most commonly fractured?
The tibia.

A 43-year-old female runner complains that she has diffuse, aching anterior knee pain that is worsened when she walks up or down stairs or when she squats down. There has been no acute trauma, but she has been increasing her running mileage. No effusion is present. What is the probable diagnosis?
Patellofemoral pain syndrome.

Question: What is the most significant complication of a proximal tibial metaphyseal fracture?
Arterial involvement, especially when there is a valgus deformity.

Question: Why “tap” a knee with an acute hemarthrosis?
Tapping the knee relieves pressure and pain for the patient and will allow you to ascertain whether fat globules are present, indicating a fracture.

Question: What are the four compartments of the leg?
1. Anterior
2. Lateral
3. Deep posterior
4. Superficial posterior

Question: What is the most common site of compartment syndrome?
The anterior compartment of the leg.

Question: What are the most common lower extremity fractures in children?
Tibial and fibular shaft fractures, usually secondary to twist forces.

Question: What radiograph would one order for a suspected patellar fracture in a child?
Standard radiographs including patellar or “sunrise views,” plus radiographs of the uninvolved knee for comparison.

Question: What are the differences between an avulsion fracture of the tibial tubercle and Osgood-Schlatter disease (which also involves the tibial tubercle)?
- Avulsion fractures present with an acute inability to walk. A lateral view of the knee is most diagnostic. Treatment is often surgical.
- Osgood-Schlatter disease is an overuse injury, which gradually develops in growing children. It is exacerbated by running, jumping, and kneeling activities. Treatment involves ice, padding, stretching, NSAIDS, rest, and occasionally immobilization.

Question: True/False: Osgood-Schlatter disease often requires surgical intervention:
False. It is usually a self-limiting condition with symptoms resolving by early adulthood. An enlarged, but painless tibial tuberosity often persists.

Question: What is a toddler fracture?
A spiral fracture of the tibia without fibular involvement. This type of fracture in toddlers is a common cause of limping or refusal to walk.

With a complete rupture of the medial collateral ligament, what would be felt by the examiner during a valgus stress of the knee?
Excessive laxity with no firm endpoint.

Question: A female basketball player plants her foot to make a quick change of direction while running down the court. She feels a popping sensation and falls to the ground in pain. Later that day she has a large effusion. Which knee ligament did she likely tear?
Anterior cruciate ligament.

Question: Which test is more sensitive when used to determine an anterior cruciate ligament tear in the knee: the anterior drawer test or the Lachman test?
The Lachman test is more sensitive because the stabilizing effect of the hamstrings is eliminated. While the knee is held at 20° flexion and the distal femur is stabilized, the lower leg is pulled forward. Significant anterior laxity compared to the other knee is evidence of an anterior cruciate ligament tear.

Question: What lower extremity joint is most commonly affected with pseudogout?
The knee. The causative agent is calcium pyrophosphate crystals.

Question: What nerve may be injured in a distal femoral fracture?
Peroneal nerve.

Question: Which is more common, a medial or a lateral tibial plateau fracture?
The lateral tibial plateau is most commonly fractured. If AP and lateral films are negative and you are suspicious of a tibial plateau fracture, follow-up with oblique views.

Question: What nerve may be injured with a knee dislocation?
The peroneal nerve.

Question: Does a torn meniscus or torn cruciate ligament produce a more dramatic appearing knee effusion?
A torn cruciate ligament due to its greater vascular supply.

Question: Are the anterior and posterior cruciate ligaments named based on the location of their attachments to the femur or tibia?
The tibia.

Question: Is the lateral or medial meniscus injured more frequently and why?
The medial meniscus is injured far more frequently due to its more firm fixation to the tibia and joint capsule as well as its attachment to the medial collateral ligament. Because the lateral meniscus is smaller, attached more loosely to the tibia, and not attached to the lateral collateral ligament, it has more ease of movement and is less prone to injury.

Question: A patient presents with a large area of swelling localized to the front of the knee, between the patella and the skin after a fall directly on her patella. The likely diagnosis is what?
Prepatellar bursitis.

Do patellar dislocations usually result in the patella going medially or laterally from its normal position?
Laterally.

Question: Do patellar dislocations occur more commonly in males or females?
Females.

Question: What four muscles make up the quadriceps?
1. Vastus lateralis
2. Vastus intermedius
3. Vastus medialis
4. Rectus femoris

Question: What three muscles make up the hamstrings?
1. Semimembranosus
2. Semitendinosus
3. Biceps femoris

Question: What condition is often a result of avascular necrosis of a segment of subchondral bone, typically involving the lateral surface of the medial femoral condyle?
Osteochondritis dissecans. This condition may also give rise to loose bodies within the joint.


DISORDERS OF THE ANKLE AND FOOT

Question: What is the most common type of ankle injury?
Sprains account for the majority of all ankle injuries. Of these, most involve the lateral complex. The anterior talofibular ligament is the most commonly injured of the lateral ankle ligaments.

Question: Where are the most common sites of stress fractures in the foot?
Second and third metatarsals.

Question: A 21-year-old female patient complains of pain and a clicking sound located at the posterior lateral malleolus. A fullness beneath the lateral malleolus is found. What is the probable diagnosis?
Peroneal tendon subluxation with associated tenosynovitis.

Question: What is the most helpful physical examination test for determining if an anterior talofibular ligament injury has occurred?
An anterior drawer test will reveal pain and/or laxity if an anterior talofibular ligament injury has occurred.

Question: What are the signs and symptoms for compartment syndrome involving the anterior compartment of the leg?
Pain on active and passive dorsiflexion and plantar flexion of the foot, and hypesthesia/paresthesia of the first web space of the foot.

What metatarsal fracture is often associated with a disrupted tarsal–metatarsal joint?
Fracture of the base of the second metatarsal. Treatment may require open reduction and internal fixation.

Question: What fracture is frequently missed when a patient complains of an ankle injury?
Fracture at the base of the fifth metatarsal, caused by plantar flexion and inversion. Radiographs of the ankle may not include the fifth metatarsal.

Question: Achilles tendon ruptures occur most commonly in what gender and age group?
Middle-aged men. It occurs most commonly on the left side.

Question: A stress fracture of the second or third metatarsal is suspected but not detected on initial X-rays. How many days after the initial examination should a second X-ray be ordered?
14 to 21 days.

Question: What tarsal bone is most commonly fractured?
The calcaneus (60%).

Question: What is the most common injury mechanism that results in a calcaneus fracture?
A fall from a significant height.

Question: What guidelines are often used to determine if a patient who has suffered an ankle injury needs X-rays?
The Ottawa ankle rules.

Question: What is the tarsal–metatarsal joint also called?
Lisfranc joint.

Question: The second metatarsal is the locking mechanism for the midpart of the foot. A fracture at the base of the second metatarsal should raise suspicion of what?
A disrupted joint. Treatment may require open reduction and internal fixation (ORIF).

Question: What is a Jones fracture?
An avulsion fracture at the base of the fifth metatarsal, usually secondary to plantar flexion and inversion. Also called a ballet fracture, it is the most common metatarsal fracture.

Question: The mortise view of the ankle is important in the diagnosis of:
Medial (deltoid) ligament disruption of the ankle.

Question: What potential complication is of concern in distal tibial (medial malleolus) fractures that are treated without surgery?
Nonunion at the fracture site.

Question: What is the most common presentation of a Charcot joint?
A swollen ankle and a “bag of bones” appearance on X-ray.

What is the most common cause of a Charcot joint?
Diabetic peripheral neuropathy.

Question: What nerve is located in the tarsal tunnel?
The tibial nerve.

Question: What ligament is commonly injured after an inversion ankle sprain?
The anterior talofibular ligament.

Question: What joint is most commonly affected with gout?
The great toe MCP joint.

Question: Describe the signs and symptoms of tarsal tunnel syndrome:
Insidious onset of paresthesia as well as burning pain and numbness on the plantar surface of the foot. Pain radiates superiorly along the medial side of the calf. Rest decreases pain.

Question: The strong ligaments on the medial side of the ankle are collectively known by what name?
The deltoid ligament.

Question: What ankle motion can lead to injury to the deltoid ligaments?
Excessive eversion.

Question: Extreme pain on the undersurface of the foot from the calcaneus anteriorly that is often worse with the first few steps of the day or after a prolonged period of standing is likely due to what condition?
Plantar fasciitis.

Question: What are the characteristics of a Morton foot?
The second toe is longer than the first, which can lead to an increased risk of overuse injuries.

Question: What group of muscles on the lateral part of the lower leg must be strong to prevent excessive ankle inversion?
The peroneal muscles.

Question: What are the characteristics of a cavus foot (pes cavus)?
A high medial longitudinal arch, limited tarsal mobility, poor shock absorption qualities, excessive callus build up on the ball, and/or heel area caused by increased stresses in these areas.

Question: What two plantar flexing muscles attach into the Achilles tendon?
The gastrocnemius and soleus muscles.

Question: What is the common name for a laterally deviated first toe or hallucis valgus?
Bunion.

What are the characteristics of a pes planus foot?
Flat foot, lowered medial longitudinal arch, often associated with excessive foot pronation.

Question: What type of serious ankle injury is seen in the radiograph in Figure 9-8?


Figure 9-8 (Reproduced, with permission, from Brunicardi FC, Andersen DK, et al. Schwartz’s Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2007, Fig. 42-49.)
A bimalleolar ankle fracture involving the distal tibia and fibula.


INFECTIOUS DISEASE

Question: Where is the most common site of infectious arthritis in adults?
The knee (although it can occur in other joints such as the hip, ankle, and wrist).

Question: What is the most common bacteria implicated in infectious arthritis in adults?
Staphylococcus aureus.

Question: Where is the most common site of osteomyelitis of the vertebral column?
The lumbar spine.

What are the different types of osteomyelitis?
- Acute hematogenous osteomyelitis
- Salmonella osteomyelitis
- Chronic hematogenous osteomyelitis
- Exogenous osteomyelitis

Question: What bacterial organism is most commonly the cause of osteomyelitis?
Staphylococcus aureus.

Question: What is the most common mechanism that infectious organisms use to reach the bone leading to osteomyelitis?
By hematogenous spread.

Question: What other mechanisms of pathogen transmission can result in osteomyelitis?
- Spread of organisms from contiguous soft tissue infection
- Direct inoculation of the pathogen into the bone from trauma or surgery

Question: What is the best way to determine the organism(s) that may be causing osteomyelitis?
Bone biopsy of the suspected infection site with sample sent for culture and sensitivity.

Question: What are the most common findings of osteomyelitis on X-ray?
Periosteal elevation and demineralization.

Question: Where does acute hematogenous osteomyelitis most commonly affect children?
The long bones.

Question: Where does acute hematogenous osteomyelitis most commonly affect adults?
The vertebrae.

Question: What must be done if the patient with osteomyelitis does not respond to antibiotic therapy?
A surgical decompression of the infected area.

Question: What patients are at risk for developing
Salmonella osteomyelitis?
Patients with sickle cell anemia.


NEOPLASTIC DISEASE

Question: What five primary carcinomas most commonly metastasize to the bone?

1. Prostate
2. Breast
3. Lung
4. Kidney
5. Thyroid

What part of the body is most commonly the site of metastatic tumors?
The spine.

Question: In what age group are cancerous bone lesions generally metastatic and not primary tumors?
In patients older than 60 years, most bone lesions are metastatic.

Question: What is more common: benign or malignant tumors of the bone and soft tissue?
Benign tumors are more common.

Question: What are lipomas?
Benign, soft, freely movable, nontender masses in the soft tissue.

Question: What are chondrosarcomas?
Malignant tumors of the cartilage.

Question: What are osteosarcomas?
Malignant tumors of the bone.

Question: With what is nocturnal bone pain often associated?
Malignancy, but some benign bone lesions can produce nocturnal pain as well.

Question: What part of the skeletal system is affected by Ewing sarcoma, multiple myeloma, and lymphoma of the bone?
The marrow elements.

Question: What is osteoid osteoma?
A fairly common benign bone tumor that often occurs in the proximal femur and can present as hip pain that is often worse at night and responds well to NSAIDS.

Question: What population is most likely to develop osteoid osteoma?
Teenagers.

Question: What has likely occurred if a patient has had dull achy pain for some time associated with a malignant bony lesion and then suddenly has intense pain at the same location after some moderate stress on that bone?
The patient may have experienced a pathologic fracture.

Question: What is the most common malignant bony lesion of the foot and where is it usually found?
Ewing sarcoma is the most common malignant bony lesion of the foot, often affecting the tarsal bones or the diaphysis of the metatarsals when it occurs. Despite this, Ewing sarcoma is seen much more frequently in the proximal femur, tibia, fibula, humerus, and pelvis than it is in the foot.

What is the best way to confirm the diagnosis when a suspicious bony lesion is seen in an imaging study (X-ray, CT, MRI, bone scan, etc.)?
A bone biopsy must be done (often as an open procedure).

Question: What is the most common primary malignant bone tumor that proliferates through the bone marrow and often results in extensive skeletal destruction, osteopenia, and pathologic fractures?
Multiple myeloma.


OSTEOARTHRITIS

Question: Which is more common osteoarthritis or rheumatoid arthritis?
Osteoarthritis is the most common type of arthritis.

Question: What structure is progressively damaged and eroded over time leading to osteoarthritis?
Articular cartilage.

Question: Which joints of the hands are most commonly affected by osteoarthritis?
The distal interphalangeal (DIP) joints of the fingers are most commonly affected by osteoarthritis.

Question: What are the bony prominences (caused by osteophytes) at the DIP joints in patients with osteoarthritis called?
Heberden nodes.

Question: What are some of the common risk factors for developing osteoarthritis?
- Advancing age
- Obesity
- Repetitive micro joint trauma
- Acute major joint trauma

Question: What are the most common symptoms and signs of osteoarthritis?
- Joint stiffness
- Joint pain
- Joint deformity

Question: What effect on function can osteophytes have in advanced osteoarthritis?
The osteophytes can cause a physical obstruction resulting in significantly decreased range of motion in the affected joints.

Question: Does osteoarthritis typically produce a mild or major joint effusion?
The effusions that occur with osteoarthritis are typically mild.

What findings would commonly be seen on the weightbearing X-rays of a patient with severe osteoarthritis of the knees?
- Decreased joint space between the femur and tibia (may be bone-on-bone), especially in the medial compartment
- Osteophytes or spurs at the joint margins
- Sclerosis of the bone

Question: What lifestyle changes can help patients with osteoarthritis decrease their symptoms and slow the progression of the condition?
- Weight loss if the patient is overweight so as to decrease the stress on the joints
- Avoidance of activities that place heavy impact, torsion, or other stresses on the joints
- Gentle exercise that encourages motion of the joints (gentle yoga, water exercises, exercise bikes, etc.)
- Shock absorbing footwear or shoe inserts to minimize the stress transferred to the weight-bearing joints

Question: What types of medication may provide some relief for patients suffering with osteoarthritis?
- Acetaminophen
- Salicylates
- NSAIDS
- Topical analgesic liquids, creams, balms, and patches
- Glucosamine and chondroitin*
- Intra-articular corticosteroid injections
- Intra-articular hyaluronan injections (for knee joints)

Question: What surgical treatment options exist for those with severe joint pain and dysfunction that have failed conservative management of their osteoarthritis?
- Joint replacement surgery (arthroplasty) can provide significant pain reduction and increased function for many patients. There have been especially good outcomes for those undergoing arthroplasty of the hips, knees, and shoulders.
- Joint fusion surgery (arthrodesis) may be a good option to reduce joint pain in some patients, especially those suffering from severe ankle or wrist osteoarthritis. Joint motion will be lost.


OSTEOPOROSIS

Question: What leads to increased fracture rates among those with osteoporosis?
Decreased bone volume. The bone that remains is generally normal.

Question: How many general types of osteoporosis are there?
There are two types. Type 1 occurs only in postmenopausal women due to loss of estrogen levels while type 2 can occur in either gender and is associated with advancing age.

Question: What bones are most commonly fractured in patients with type 1 osteoporosis?
The vertebrae and distal radius.

Question: What type of bone is primarily affected by type 1 osteoporosis?
Trabecular bone.
*At the time of publication of this book, these substances were still being investigated in several studies to determine true efficacy.

What bones are most commonly fractured in patients with type 2 osteoporosis?
The hip and pelvis.

Question: What type of bone is affected by type 2 osteoporosis?
Both trabecular and cortical bone.

Question: What test is generally used to diagnose osteoporosis?
A DEXA scan (dual energy X-ray absorptiometry).

Question: What percentage of bone loss must occur before decreased bone density is visible with traditional X-rays?
More than 30%.

Question: What nutritional supplements when combined with resistance exercises and a physically active lifestyle might help prevent the development of osteoporosis?
Calcium and vitamin D.

Question: What class of medication is commonly used to treat patients with confirmed osteoporosis?
Bisphosphonates.

Question: When patients have decreased bone mineral density, but not decreased enough to be diagnosed with osteoporosis, what other condition might they be diagnosed with?
Osteopenia.


RHEUMATOLOGIC CONDITIONS

Question: Describe the classic bony changes that occur in the hands of someone suffering from rheumatoid arthritis:
Ulnar deviation and subluxation at the MCP joints.

Question: Describe the classic bony changes that occur in the feet of someone suffering from rheumatoid arthritis:
Claw toes and hallux valgus.

Question: Describe the systemic manifestations that can occur with rheumatoid arthritis:
- Vasculitis
- Pericarditis
- Pulmonary disease

Question: Besides a positive rheumatoid factor, what other laboratory values are commonly seen in patients with rheumatoid arthritis?
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein (CRP)

Needle-shaped crystals found within the synovial fluid of a painful joint are associated with what condition?
Gout.

Question: What is the chemical composition of the crystals found in the joint of a patient suffering from gout?
Uric acid.

Question: What is the treatment for acute gout?
Indomethacin or other NSAIDs. For those intolerant of NSAIDS, colchicines is effective as well, but many patients experience nausea, vomiting, and/or diarrhea.

Question: What medications have been most commonly used to prevent future gout attacks by decreasing uric acid levels?
Probenecid and allopurinol.

Question: What joint is most commonly the site of an initial gout attack?
The first metatarsal phalangeal joint.

Question: Examination using polarized microscopy of synovial fluid aspirated from a painful, swollen joint showing positively birefringent rhomboid-shaped crystals is associated with what condition?
Pseudogout.

Question: What is the chemical composition of the crystals found in the joint of someone suffering from pseudogout?
Calcium pyrophosphate dihydrate.

Question: What joints are most commonly affected by pseudogout?
- Knee
- Wrist
- Elbow

Question: What is the recommended treatment for pseudogout that is affecting one or two joints?
Joint aspiration followed by intra-articular glucocorticoid injection. Adjuvant treatment with NSAIDS or colchicine may also be used.

Question: What autoimmune disorder commonly affects women of childbearing age, may affect multiple organs, and commonly presents with a facial rash, photosensitivity, arthralgias, and antinuclear antibodies?
Systemic lupus erythematous (SLE).

Question: The joints of what body parts are most effected by SLE?
Hands, wrists, and knees.

What is Felty syndrome?
Rheumatoid arthritis with splenomegaly and neutropenia. It is a late complication of rheumatoid arthritis.

Question: If a patient presents with multiple joint arthralgias as well as excessive dryness of the mouth and eyes, what condition must be ruled out?
Sjögren syndrome.

Question: A middle-aged female patient presents with swelling, stiffness, and pain in her fingers, wrists, and knee joints as well as taut, shiny skin. What is her likely diagnosis?
Scleroderma.

Question: A 65-year-old female patient presents to an urgent care center with complaints of fatigue, fever, a 10 lb weight loss, as well as pain and stiffness in her neck, shoulders, and pelvic area. What condition do you suspect?
Polymyalgia rheumatica.

Question: What condition is characterized by inflammation of striated muscles in the proximal limbs, neck, and pharynx and elevated enzymes including CPK, AST, ALT, and LDH?
Polymyositis.

Question: What condition is far more common in women and is characterized by diffuse muscle tenderness, heightened sensitivity to touch in many different areas of the body, fatigue, and often depression?
Fibromyalgia.

Question: Describe the three general subcategories of juvenile rheumatoid arthritis (JRA):

1. Pauciarticular-onset JRA is diagnosed in those patients with involvement of less than five joints after 6 months of illness. This is the most common type of JRA and actually has several subgroups.

2. Polyarticular-onset JRA is diagnosed in patients with involvement of more than four joints after 6 months of illness. This is the second most common type of JRA and also has several subgroups.

3. Systemic-onset JRA (formerly called Still disease) is associated with arthritis in any number of joints, rash, and intermittent fever. This is the least common form of JRA.

Question: What condition is characterized by inflammation of the medium- (and sometimes small) sized arteries, occurs most commonly in middle-aged men, presents with fever, fatigue, weakness, weight loss, abdominal pain, arthralgias, arthritis, skin lesions, renal insufficiency, hypertension, edema, and oliguria?
Polyarteritis nodosa (PAN).

Question: What condition is a seronegative arthritis that is often seen in combination with urethritis and conjunctivitis? This condition is often precipitated by a sexually transmitted disease (often linked to Chlamydia trachomatis) or gastroenteritis and may present with lesions in multiple locations (mouth, penis, extremities), swollen toes, and heel pain.
Reactive arthritis (formerly known as Reiter syndrome).


REFERENCES
Becker MA. Prevention of recurrent gout. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Becker MA. Treatment of acute gout. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Becker MA. Treatment of calcium pyrophosphate crystal deposition disease. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Beutler A, Stephens MB. General principles of fracture management: bone healing and fracture management. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Bloom J, Burroughs KE. Metacarpal neck fractures. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Booher JM, Thibodeau GA. Athletic Injury Assessment. 3rd ed. St. Louis, MO: Mosby; 1994.
Chorley J. Elbow injuries in the young athlete. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
DeLaney TF, et al. Clinical presentation, staging, and prognosis of the Ewing’s sarcoma family of tumors. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Goldenberg DL. Clinical manifestations and diagnosis of fibromyalgia in adults. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Griffen L. Essentials of Musculoskeletal Care. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005.
Hoppenfeld S. Physical Examination of the Spine and Extremities. East Norwalk, CT: Appleton-Century-Croft/Prentice-Hall; 1976.
Hunder GG, Stone JH. Clinical manifestations of and diagnosis of polyarteritis nodosa. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Lehman TJ. Classification of juvenile rheumatoid arthritis. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Nigrovic PA. Overview of hip pain in childhood. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
O’Connell CB, Zarbock SF. A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants. Baltimore, MD: Lippincott William & Wilkins; 2004.
Sexton DJ. Overview of osteomyelitis. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.
Thomas CL. (Editor). Taber’s Cyclopedic Medical Dictionary. Philadelphia, PA: F.A. Davis; 1993.
Yu DT. Reactive arthritis (formerly Reiter syndrome). In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2009.