daily question

[Scott Rand]

A collegiate swimmer develops medial winging of the scapula. If the EMG and nerve conduction studies are abnormal, the most likely nerve roots to be involved are? 

 

1. C7, C8, T1

2. C6, C7, C8

3. C5, C6, C7

4. C4, C5, C6

5. C3, C4, C5

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Scott E Rand, MD  FAAFP CAQSM

Director, Primary Care Sports Medicine Fellowship

Co Director of Sports Medicine, Houston Methodist Orthopedics and Sports Medicine Willowbrook

Assistant Professor of Clinical Family Medicine  Houston Methodist Academic Institute

Adjunct Assistant Professor of Family and Community Medicine, Texas A&M University

Assistant Professor of Family Medicine in Clinical Medicine  Weill Cornell Medical College.

13802 Centerfield Dr  Suite 300

Houston, TX  77070

[Scott Rand]

You are covering a weightlifting tournament and the competitor "misses the snatch" (the olympic lift in which the athlete attempts to move a loaded barbell from the floor to an overhead postion in one fluid motion).  You notice through your direct observation of the lift (and subsequent review of the video tape) that the loaded barbell (which weighed around 250 pounds) came down on the athlete's neck. The athlete was able to walk off the competition platform under their own power before you could reach the individual. Off the platform, the athlete complains of a sore neck and "nothing else." He denies radicular symptoms, limb weakness, headache, or parathesias. Your exam reveals normal peripheral neurological exam (DTR, sensation, strength) but some paracervical muscle sorenessand spinous process tenderness. Which of the following is most likely diagnosis?

A.     C3-C4 cervical subluxation

B.      Rupture of the Ligamentum Flava

C.      Clay Shoveler's fracture

D.     Paraspinal muscle strain

E.      Thoracic Outlet Syndrome

                         

 

[Scott Rand]

Which of the following cervical spine injuries are both considered stable non-emergent fractures?

A.     Flexion teardrop fracture and clay shoveler fracture

B.      Hangman fracture and posterior neural arch fracture

C.      Simple wedge fracture and flexion teardrop fracture

D.     Posterior neural arch fracture and simple wedge fracture

 

[Scott Rand]

A 16 year old male football player presents to your office with acute onset of mid-thoracic back pain which began immediately after being struck in the back during a football game the previous evening.  On exam, you note an area of point tenderness immediately lateral to the midline in the mid-thoracic region of the athlete’s back.  Other than some moderate paravertebral muscle spasm, he has no other physical findings.  Radiographic evaluation reveals a nondisplaced transverse process fracture.  Which of the following are appropriate management options for this athlete?

 

 

A.     Immediate immobilization on a back board and transfer to the hospital for neurosurgical evaluation

B.      Referral for fitting of a clam-shell type back brace

C.      Use of local ice, analgesics and anti-inflammatory medication, with return to activity as tolerated

D.     MRI evaluation to assess spinal cord compromise

E.      Disqualification from participation in collision sports for a minimum of six months

 

Correct: C

Transverse process fractures typically occur in sports as a result of a collision, usually involving rotation or extension.  Athletes can typically relate immediate onset of sharp pain associated with the collision.  Because of the relationship between the transverse process and other nearby structures such as ribs and paravertebral muscles, transverse process fractures are considered stable processes.  As such, they require no further surgical intervention.  Bracing is contraindicated in the management of these fractures, as it often adds to the patient’s discomfort.  The diagnosis of transverse process fracture is made through plain radiograph or CT, and additional imaging is not necessary.  Because of the stable nature of the fracture, treatment is designed to decrease discomfort, and athletes can return to play when they are comfortable, often using a flak jacket for additional protection.

 

 

1.       Fractures of the transverse process.  In Delee and Drez’s Orthopedic Sports Medicine, 2nd ed. 2003 (Online version).

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[Scott Rand]

Question:  What is the most common congenital coronary anomaly in sudden cardiac death?

 

 

[Scott Rand]

A 20-year-old female who is joining an intramural team at her college was noted to have an unusual murmur on her sports physical before the season began. The doctor thought he heard a continuous murmur at the left upper sternal border associated with a slightly widened pulse pressure and brisk to bounding pulses. Which of the following is the most likely diagnosis?

A. VSD

B. ASD

C. Coarctation of the  aorta

D. Patent ductus arteriosus (PDA)

 

[Scott Rand]

.  Look at the attached ECG.  What is the most likely diagnosis?  What findings are indicative of that diagnosis?

 

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[Scott Rand]

At a college tennis tournament, you are caring for a 22 year old male tennis player from Italy who passed out in the middle of his match.  He denies chest pain.  You order an EKG which shows some T-wave inversions in leads V1 through V3 and an incomplete right bundle branch block.  When asked about family history, he recalls his grandfather died at a young age of some heart problem.  You are most worried about sudden cardiac death in this patient from which of the following?

A.      Coronary artery disease

B.      Hypertrophic cardiomyopathy

C.      Prolonged QT syndrome

D.      Arrhythmogenic right ventricular dysplasia

 

[Scott Rand]

A 33 year old male who is preparing for his third half-marathon is determined to improve his time at this year’s race so he decided to change several areas of his training that he thought would improve his performance, increasing: his overall mileage and hill running.  Unfortunately, he developed substantial lateral knee pain.  His physical exam demonstrates a positive Ober’s test.  He responded very well to stretching and strengthening exercises.  What else on the history and physical would you have expected to discover before beginning treatment:

A.     Normal lower extremity alignment

B.      Strong abductor muscles

C.      Less pain with hill running

D.     Positive Noble’s test

E.      Abnormal radiographs

 

 

[Scott Rand]

Which of the following is correct regarding the patellar fat pad?

A.     The infrapatellar fat pad is located anterior to the patellar tendon

B.      Fat pad irritation is exacerbated by flexion of the knee

C.      Fad pad impingement is painful because it is a highly innervated structure

D.     Surgical excision is often necessary for definitive treatment of an irritated fat pad

 

[Scott Rand]

A 17 year old female presents after injuring her right knee.  She was landing from a rebound and felt her knee “pop.”  She developed immediate swelling in the right knee and was unable to continue playing.  On exam, the knee has a large effusion with positive Lachman and anterior drawer tests.  Which is true regarding her diagnosis?

A.     ACL injuries are less common in female athletes

B.      Traditional surgical reconstruction of the ACL may be performed in children regardless of physeal status

C.      The ACL is the primary restraint to posterior translation of the tibia with respect to the femur

D.     A hemarthrosis would be expected with aspiration of the injured knee

E.      Findings on standard radiography are usually specific for ACL injury

 

[Scott Rand]

.  A 56 year old male patient with a history of hypertension, hyperlipidemia and a sedentary lifestyle has decided to sell his couch and begin a walking program.  He can climb 2 flights of stairs without significant dyspnea or angina symptoms.  Is an exercise stress test indicated for him prior to beginning this exercise program?

 

[Scott Rand]

.  List 5 absolute contraindications to aerobic exercise in pregnant athletes

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[Scott Rand]

.  List 5 benefits of exercise in pregnancy

[Scott Rand]

When discussing an appropriate exercise prescription with your patient, you include some of the general benefits that can be gained.  Which of the following statements would you include in that discussion?

A.      Resistance training does not help maintain fat-free mass

B.      Benefits are only achievable at maximal intensity levels in the elderly

C.      Resistance training is a primary means for increasing VO2max

D.      Strength gains cannot be maintained with once weekly exercise

E.       Age-related decline can be attenuated with regular exercise

 

[Scott Rand]

Which of the following acute headache medications is considered first-line prior to physical exertion in patients with primary exercise headache?

 

A.  Acetaminophen

B.  Ibuprofen

C.  Oxycodone

D.  Gabapentin

E.  Indomethacin

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[Scott Rand]

One of the new athletes to your college lists on his health history that he takes methylphenidate (Ritalin) for his attention deficit, hyperactivity disorder (ADHD). Regarding intercollegiate athletes taking stimulant medications, which of the following is a true statement (Select the best answer).

A.      The NCAA does not ban methylphenidate (Ritalin, Concerta) or amphetamine (Adderral) because their common use for the treatment of ADHD

B.      A medical exemption must be applied for and granted by the NCAA prior to athletic participation when stimulant medications are used for medical reasons

C.      The NCAA requires the institution maintain, in the student-athlete’s on-campus medical record, a copy of the physician’s signed prescription for dispensing the medication

D.      The NCAA requires the institution to maintain, in the student-athlete’s on-campus medical record, documentation from the prescribing physician detailing medical history, diagnosis, verification of that diagnosis through standard assessment, and dosing

E.       The NCAA tests for only anabolic substances and not stimulant medications

[Scott Rand]

A college athlete presents with fever, myalgias, rhinorrhea for 3 days. Which of the following treatments are banned by NCAA standards?

A.      Phenylephrine

B.      Pseudoephedrine

C.      Antipyretic agents

D.      Ephedrine

E.       Antihistamines

 

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[Scott Rand]

List three effects of hyaluronic acid in osteoarthritis viscosupplementation.

[Scott Rand]

.  Please list 2 radiolucent and 2 radiodense benign bone tumors in pediatric patients.

 

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[Scott Rand]

You are seeing a 6 year old for a limp. It was initially intermittent but has been becoming more consistent. He does not complain of pain. There was no known injury and he does not play organized sports. He has no fever, no preceding illness, and is otherwise well. The most likely diagnosis is:

A. Slipped capital femoral epiphysis

B. Legg Calve Perthes disease

C. Neoplasm

D. Juvenile Idiopathic Arthritis

E. Toxic synovitis

 

[Scott Rand]

A 6-year-old boy presents to your office with foot pain that is increasing in severity. His parents state he has recently been limping. There is no history of trauma and he is otherwise healthy. Radiographs are shown in the attached files. Which of the following is the most appropriate treatment for this child?

1.  Observation
2.  Open biopsy and curettage
3.  Long leg non-walking cast
4.  Amputation
5.  Short leg walking cast

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[Scott Rand]

Describe the salter harris classification of physeal fractures .

[Scott Rand]

This 17 year old football player presented with a firm lump in the right biceps approximately 3 weeks after a football game where he took multiple hits to the right upper arm.  

[Scott Rand]

.  This 12 year old male presented to the clinic with complaints of pain over the ulnar aspect of the right hand after hitting a tree when angry.

 

 

 

 

[Scott Rand]

.  This 36 year old male fell from a ladder and landed on his feet 2 days prior to presentation to the clinic.  He complains of pain in the medial ankle area and is unable to bear weight without significant discomfort. 

 

 

 

[Scott Rand]

.  This 40 year old female triathlete presented with several months of worsening low back pain without radiation, noted mostly during flip turns in the pool.  Some pain with running.  Feels best biking. 

 

 

 

 

 

[Scott Rand]

A baseball player was hit in the upper thigh by a line drive and he complains of swelling and pain immediately. You note a large hematoma present in the location of the injury. You begin your evaluation by palpating the borders of the femoral triangle. Which of the following structures does  not form a border of the triangle?

A.      Medial border of the adductor brevis

B.      Inguinal ligament

C.      Medial border of the adductor longus

D.      Medial  border of the sartorius

 

[Scott Rand]

What component of the deep posterior compartment of the lower leg assists with plantar flexion?

A.      Tibialis Posterior

B.      Flexor Digitorum Longus

C.      Soleus

D.      Tibialis Anterior

 

[Scott Rand]

What is the main arterial blood supply to the ACL in the knee?

A.      Posterior tibial artery

B.      Superior medial genicular artery

C.      Anterior tibial artery

D.      Middle genicular artery

[Scott Rand]

A day after being struck with a pitched ball on the ulnar aspect of the left wrist and hand, a professional baseball player develops “pins and needles” in the small and ulnar half of his ring fingers. He finds it extremely difficult to grab the bat to participate in batting practice. After x-rays demonstrate no acute abnormalities of the left wrist and hand, he is diagnosed with Guyon’s canal syndrome. What two bones form Guyon’s canal?

A.      Pisiform and Triquetrum

B.      Pisiform and Hamate

C.      Hamate and Lunate

D.      Triquetrum and Lunate

 

[Scott Rand]

On average,VO2 max is lower in postpubertal females when compared to postpubertal males.  Which of the following statements is true concerning reasons for this difference?

A.     Females, on average, experience a relative decrease in body fat after puberty

B.      Females, on average, have increased cardiac output compared to males

C.      Females, on average, have larger muscle fiber area compared to males

D.     Females, on average, have lower blood hemoglobin content

  

[Scott Rand]

Which of the following does not cause delayed onset muscle soreness (DOMS)?

 

 

 

A.     Lactic acid accumulation in muscle tissues

B.      Structural damage to muscle fibers

C.      Eccentric exercise

D.     Swelling on a cellular level which may activate and sensitize afferent nerve endings around damaged muscle fibers

E.      Training at an intensity greater than customary

 

 

[Scott Rand]

A high school football player presents to your clinic with his parents. They seek information about nutrition and supplements for athletes. Which of the following statements is true regarding nutrition and high intensity exercise?

A.     Fat is broken down to glycogen during exercise

B.      In regards to training in a hot, humid environment, thirst is a sensitive and reliable indicator of dehydration and estimating fluid loss

C.      Due to the increased demand on an athlete's body, protein supplements are necessary in addition to a healthy diet

D.     An athlete's diet should consist of about 60 % carbohydrates

 

[Scott Rand]

 

In response to intense exercise, catecholamine release will occur. These hormones can lead to several effects in the athlete. Which of the following is due to alpha receptor effect?

A.     Vasoconstriction

B.      Cardiac acceleration

C.      Lipolysis

D.     Bronchodilatation

E.      Increased myocardial contractility

 

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[Scott Rand]

During the second football practice of the day on day three of the college preseason football camp, an offensive lineman is found sitting on the ground unwilling to stand up.  He states his left calf is cramping and that he feels lightheaded and exhausted.  You suspect possible exertional heat stroke.  Which of the following statements about this condition is true?

A.      Axillary, oral, or a rectal temperature greater than 104 F (40C) establishes the diagnosis of exertional heat stroke

B.      This condition occurs randomly without warning and can not be predicted

C.      Cold/ice water immersion is an effective way to treat exertional heat stroke

D.      There are two patterns of presentation:  sodium depletion and water depletion

[Scott Rand]

A 16 year old female soccer player receives a direct blow to the mouth from an opposing player’s elbow.  She immediately comes to the sideline and is noted to have bleeding from her mouth.  In her hand, she is holding an intact, avulsed tooth.  Which of the following management options will help to ensure the best outcome?

 

 

 

 

A.      Gently wipe away blood and tissue remnants from the tooth with sterile saline-moistened gauze, preserve in saline and refer to dentist immediately

B.      Clean the tooth with sterile saline, protect it in dry sterile gauze, and follow-up with dentist within eight hours

C.      Reimplantation of the avulsed tooth and immediate referral

D.      Preserve the tooth in milk and ensure follow-up with her dentist within eight hours

E.       Discard the tooth and salvage and stabilize the underlying tissue with a protective mouth guard

[Scott Rand]

A 26 year old African American female presents to the medical treatment tent you are staffing at a large cross country ski race in upper Wisconsin.  She is complaining of painful edematous purple lesions on her face.  She is in excellent health, an avid cross country runner from southern Illinois.  She denies pregnancy or any medical problems.  She does not seem to be in any acute distress.  She and her friends have been taking “nips” out of a pocket flask containing Blackberry brandy.  Which of the following is true?

A.      She has classic Pernio or chilblain

B.      She should immediately stop the race and be transported to the main medical tent 10 kilometers away via ambulance

C.      She can go back out after applying protective UV cold barrier ointment on her face

D.      She should quickly rewarm her face by sitting next to the propane gas warmer in the tent

E.       It is best to warm her face slowly using cool water then to slowly apply heated water to prevent further tissue damage

 

[Scott Rand]

A 21 year old type 1 diabetic athlete begins training for a 50 mile bike ride with a partner. She uses an insulin pump and is experienced with running cross country in high school. During her first 30 mile ride she experiences symptoms of hypoglycemia at 25 miles and almost falls before stopping. She is confused and her BS is 40.

What is the most appropriate immediate action?

A.      Eat a banana or sports bar

B.      Administration of glucagon by her partner

C.      Drink a carbohydrate sports drink then quickly resume riding to reach a safe destination

D.      Drink 8 ounces of water to improve volume status

 

[Scott Rand]

When treating patients with osteoarthritis, what therapy program has been shown to be most effective in improving Western Ontario MacMaster (WOMAC) scores?

A.      A Home Exercise Program to improve compliance

B.      Water therapy in a group setting

C.      Formal Physical Therapy for at least 4 weeks

D.      Supervised Physical Therapy followed by a Home Exercise Program

 

 

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[Scott Rand]

 

45 year old tennis player presents with 6 weeks of low back pain with radiation to the left big toe made worse with bending over to tie his shoes.  He wants to do physical therapy and you write for which back program to reduce his current symptoms of pain?

 

A.      McKenzie exercises

B.      Williams exercises

C.      Back school

D.      Lumbar traction

[Scott Rand]

There are several different types of  muscle stretching techniques.  Using a partner to stretch the hamstring passively then pushing against the partner by contracting the muscle isometrically then stretching further in the same range of motion is an example of:

A.      Static stretching

B.      Dynamic stretching

C.      Ballistic stretching

D.      Proprioceptive neuromuscular facilitation

 

 

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[Scott Rand]

Which of the following statements about open and closed kinetic chain exercises is correct?

 

 

A.      Open kinetic chain exercises occur when the distal aspect of the extremity is fixed and cannot move

B.      Closed kinetic chain exercises typically involve functional weight-bearing and sport-specific activities

C.      Knee extensions and straight leg raises are examples of closed kinetic chain exercises

D.      During open kinetic chain exercises, motion occurs simultaneously at all joints comprising the kinetic chain

E.       Closed kinetic chain exercises produce shearing forces, while open kinetic chain exercises produce compressive forces

 

[Scott Rand]

Your high school's stud point guard suffers a dislocation of the third finger PIP joint. X-rays define a nondisplaced fracture involving 20% of the articular surface. Would you recommend surgery? Why or why not?

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[Scott Rand]

What is the boutonniere deformity of the finger and how is it different from the pseudoboutonniere deformity?

 

 

[Scott Rand]

A 25 year old male presents with thumb pain after a fall while skiing. On exam, his MCP joint is grossly unstable and MRI reveals a Stener lesion. Optimal management of this injury requires

A.      Thumb splinted in extension for 4 weeks

B.      Thumb spica splint x 6 weeks

C.      Short arm cast for 6 weeks

D.      Surgical repair

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[Scott Rand]

DeQuervain”s tenosynovitis involves which tendon

sheaths?

 

A.      extensor digitorum profundus and extensor pollicis

B.      flexor pollicis longus and abductor pollicis longus

C.      flexor pollicis longus and abductor pollicis brevis

D.      extensor pollicis brevis and abductor pollicis longus

 

[Scott Rand]

:  Wrestlers with herpes gladitorum must have no lesions and have been treated with antiviral medications for ___  days before being allowed to participate

 

 

[Scott Rand]

Which of the following statements is true regarding skin infection in athletes?

A.      Rifampin is the first line treatment for MRSA infections

B.      Any skin wound that is suspicious for Staphylococcus infection should be cultured

C.      The gold standard treatment of MRSA is appropriate oral antibiotics

D.      First line treatment of MRSA should be topical antibiotics

E.       Special cleaning of locker room, equipment and playing area is needed if MRSA is diagnosed in

[Scott Rand]

How do you advise your patient to avoid being this guy in the marathon

 

 

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[Scott Rand]

What are Pieozogenic papules?

 

 

 

[Scott Rand]

1.        What nerve(s) supply the rotator cuff muscles?

Supraspinatus and infraspinatus are innervated by the suprascapular nerve.  Teres minor is innervated by the axillary nerve.  Subscapularis is innervated by the upper and lower subscapular nerves.  

[Scott Rand]

1.        Give the origin and insertion, action and innervation of the serratus anterior muscle

[Scott Rand]

1.       Weakness of what muscle results in lateral winging of the scapula?

[Scott Rand]

SLAP type II tears can be associated with increased

A. anterioinferior translation
B. multidirectional subluxation
C. posterior recurrent subluxation
D. all of the above

[Scott Rand]

1.       Weakness of what muscle results in lateral winging of the scapula?

Trapezius.  Innervated by cranial nerve XI

[Scott Rand]

A 22 year old male wrestler presents to your clinic after falling awkwardly in a match approximately 4 hours earlier in the day injuring his left wrist.  The patient appears uncomfortable and states the pain has been getting worse since the time of the injury despite ice and immobilization.  On exam, he has swelling and is tender over the distal radius.  His neurovascular exam is intact but he is unwilling to allow extension of his wrist or fingers because of pain.  An x-ray is done and shows a minimally displaced extraarticular fracture of the distal radius.  Which of the following complications of this injury is most likely at this time?

A.      Stretch injury of the median nerve

B.      Compartment syndrome

C.      Malunion

D.      Complex regional pain syndrome

 

[Scott Rand]

A 22 year old male American football player suffers a hyperpronation injury of the right forearm and this results in a first-time dorsal-ulnar dislocation of the distal radioulnar joint (DRUJ).  Fracture is ruled out by radiographs and adequate closed reduction is achieved.  How should this injury be managed?

A.      Thumb spica splint for 2 weeks

B.      Short arm cast for 4 weeks

C.      Long arm cast for 6 weeks

D.      Orthopedic referral for arthrodesis

 

 

[Scott Rand]

What bones articulate with the Capitate?

 

[Scott Rand]

Your patient presents to you for follow up of a FOOSH mechanism and radial sided wrist pain.  He was seen in an urgent care at the time of the injury, had negative x-rays of the wrist, and diagnosed with a sprain.  He is now 10 days out from the injury and is no better.  Your exam suggests a scaphoid fracture.  

 

Proper methods of diagnosis and treatment include all of the following EXCEPT:

 

1. repeat plain films, including scaphoid view, of the wrist
2. CT scan of the wrist if the plain films are normal/negative
3. for a nondisplaced waist fracture can heal well, but will require 8-12 weeks of immobilization
4. short arm thumb spica casting for distal or waist fractures
5. operative fixation for proximal pole or displaced fractures of any zone