Orthopedic Teaching Cases 2023, Jan, 17 | 12:00 am

FROM 10 TO 28 Sports Medicine CASES

CASE                               10                               

A 24-year-old, ultimate frisbee player reinjures his previously reconstructed left knee. He explains that 4 years ago he ruptured his ACL playing basketball. He had an allograft repair followed by an uneventful recovery. He returned to sports 8 months after surgery. X-rays are shown in Figure 9–5A and B.

 

 

 

Figure 9–5 A

 

 

 

 

 

Figure 9–5 B

 

Which element made the greatest contribution to his graft failure?

  1. Graft fixation

  2. Femoral tunnel position

  3. Graft type

  4. Meniscal pathology

  5. Tibial tunnel position

 

Discussion

The correct answer is (C). In younger people, allograft ACL reconstructions have been found to have a significantly higher failure rate than autograft reconstructions. Inadequate fixation can result in residual laxity following surgery. Tunnel position is important to restoring normal function of the knee. Meniscal pathology carries a worse prognosis over time but has not been associated with re-tears.

After careful consideration, he elects to proceed with a revision ACL reconstruction. In choosing between a single-stage ACL revision and a two-step, staged ACL revision (removal of hardware with bone grafting, followed by later revision ACL reconstruction), which finding most strongly favors a staged revision?

  1. Tunnel widening

  2. Vertical femoral tunnel

  3. Retained hardware

  4. Prior autograft reconstruction

  5. Meniscal tear

 

Discussion

The correct answer is (A). A staged revision is necessary when the existing tunnels are too wide to achieve reliable fixation or if their position compromises the accurate reconstruction of the ACL. Vertical femoral tunnel placement is usually easily avoided during a revision ACL. Retained hardware can be removed in one sitting. Prior autograft reconstruction and the presence of a meniscal tear should not affect the decision.

During the revision ACL reconstruction, the graft impinges in the notch as the knee is extended, making terminal extension 5 degrees short of straight. Which factor is responsible for the limitation in range of motion?

  1. Femoral tunnel too anterior

  2. Femoral tunnel too posterior

  3. Tibial tunnel too anterior

  4. Tibial tunnel too posterior

  5. Use of autograft

 

Discussion

The correct answer is (C). The tibial tunnel is too anterior and the graft is impinging as the knee extends. The femoral tunnel position will not affect knee extension. A tibial tunnel that is posterior will not impede extension. The graft type should not affect knee motion.

 

Objectives: Did you learn...?

 

 

The most common cause of graft failure? The indications of staged revision?

 

The causes of graft impingement?

 

CASE                               11                               

A 44-year-old waiter slips on a wet floor in the kitchen, hyperextending his right knee. He has an acute onset of swelling and pain with weight bearing. Three days later, radiographs reveal a minimally displaced fracture of the tibial spine.

What would you expect to find on his physical examination?

  1. Laxity on valgus stress at 30 degrees of knee flexion

  2. Increased external rotation of the tibia at 30 degrees of knee flexion

  3. Positive patellar apprehension sign

  4. Increase anterior translation of the tibia

 

Discussion

The correct answer is (D). Tibial spine avulsion injuries occur more frequently in children than adults. However, this injury can result in ACL laxity. Tibial spine fractures are not associated with valgus laxity (MCL sprain), a posterior lateral corner injury, or patellar instability.

The initial conservative treatment of this fracture may include all of the following EXCEPT:

  1. Activity modification

  2. Open chain strengthening

  3. Immobilization

  4. Aspiration

 

Discussion

The correct answer is (B). Activity modification and immobilization are essential steps to limit motion and prevent fracture displacement. Aspiration of the associated effusion may help to minimize pain due to capsular distention and help the patient achieve terminal extension. Open chain exercises will stress the knee with resistance and should not be performed early in the plan of care.

Six months following the injury, the patient reports his knee giving way when changing directions suddenly at work. His examination reveals increased anterior translation of the tibia, and the x-rays show a healed tibial spine without evidence of displacement.

What study will provide the best insight into his condition?

  1. EMG

  2. 3-ft standing films

  3. MRI right knee

  4. MRI lumbar spine

  5. CT arthrogram right knee

 

Discussion

The correct answer is (C). An MRI will illustrate the integrity of the ACL and meniscal cartilage as a possible source of his instability and laxity. EMG will assess his nerve function, while 3-ft standing films can offer a perspective on the limb alignment. There is no evidence of lumbar disease contributing to his right knee disability. A CT arthrogram can be used to assess the ACL and menisci, but it does not offer the resolution or fidelity of an MRI.

 

Objectives: Did you learn...?

 

 

The physical examination findings of tibial spine avulsion in adult? The initial management of tibial spine avulsion in adults?

 

CASE                               12                               

A 19-year-old, college freshman has increased left anterior knee pain two weeks into her pre-season training with the team. She has tenderness proximal to the tibial tubercle that is worse with resisted knee extension. The pain is worse with activity and is occasionally associated with local swelling.

What sports is she most likely to be playing in college?

  1. Ice hockey

  2. Field hockey

  3. Archery

  4. Track & field

 

Discussion

The correct answer is (D). Patellar tendinitis occurs most commonly in athletes who engage in forceful, eccentric contractions of the knee as in jumping sports.

Her treatment may include all of the following except:

  1. Activity modification

  2. Immobilization

  3. Progressive flexibility

  4. Eccentric strengthening

  5. Corticosteroid injection

 

Discussion

The correct answer is (E). Corticosteroid injections are contraindicated because of the increased risk of tendon rupture. Activity modification and immobilization can help encourage symptoms to subside. Flexibility and eccentric strengthening are essential to the resolution of the condition.

 

Objectives: Did you learn...?

 

The causes and treatment of patellar tendinitis?

 

CASE                               13                               

A 56-year-old mason presents with acute swelling of his left knee. He explains that he has been laying a tile floor in a large bathroom and has continued to work 10-hour days since misplacing his knee pads at the end of last week. The left knee became large and swollen in the absence of any acute trauma. It is firm but not

tender. There is no surrounding erythema, and the overlying skin is intact.

 

What is the best next step in management of this problem?

  1. Aspiration

  2. Get new knee pads

  3. One week of oral antibiotics

  4. Immobilization

  5. Corticosteroid injection

 

Discussion

The correct answer is (B). The mason’s prepatellar bursa is swollen after the prolonged period of kneeling without his usual protection. Aspiration may provide temporary relief, but the fluid usually quickly re-accumulates. Because there is a significant risk of infection, aspiration is discouraged as a first step in treatment. In the absence of erythema or pain, antibiotics are not necessary. Immobilization can help reduce swelling if initial treatments are unsuccessful. Similarly, injecting the bursa with a corticosteroid can offer some benefit for recalcitrant bursitis.

In this case, which bursa is LEAST likely to be involved?

  1. Pes bursa

  2. Infrapatellar bursa

  3. Prepatellar bursa

  4. Deep patellar bursa

 

Discussion

The correct answer is (A). The bursa deep to the pes anserinus is rarely affected in housemaid’s knee. The prepatellar bursa is most commonly involved, followed by the infrapatellar and deep patellar bursa.

Which physical finding is LEAST suggestive of septic bursitis?

  1. Fever >37.8°C

  2. Pre-bursal temperature difference greater 2.2°C

  3. Pain with passive range of motion

  4. Skin lesions

 

Discussion

The correct answer is (C). A recent literature review found that fever >37.8°C, pre-

bursal temperature difference >2.2°C, and skin lesions were suggestive of septic bursitis. Pain with passive range of motion did not help differentiate septic from nonseptic bursae.

 

Objectives: Did you learn...?

 

The causes of prepatellar bursitis?

 

The physical examination findings of septic bursitis?

 

CASE                               14                               

A 27-year-old soccer player injures himself in a fall onto a flexed knee, after colliding with an opponent. He describes a sense of his knee giving way when planting and pushing off to run. On examination, the knee demonstrates a slight sag, but the posterior translation of the tibia is less than one centimeter.

If the remainder of the knee examination is normal, which statement is most likely to be true?

  1. His foot was dorsiflexed when he hit the ground

  2. His foot was plantar flexed when he hit the ground

  3. His posterior translation will increase when the tibia is internally rotated

  4. He will be unable to complete a straight-leg raise

  5. His anterior drawer test will be positive

 

Discussion

The correct answer is (B). The plantar-flexed ankle decreases the tension on the gastrocnemius, allowing the PCL to absorb the full force applied to the tibia. Internal rotation will decrease the posterior translation. There is no evidence of an injury to the extensor mechanism or the ACL.

The initial management of this injury should emphasize:

  1. Quadriceps strengthening

  2. Hamstring strengthening

  3. Open chain rehabilitation

  4. Strict immobilization

 

Discussion

The correct answer is (A). Quadriceps strengthening provides a dynamic stabilizing

force for the knee to counteract the PCL laxity. Hamstring strengthening will not address the injury, and open chain exercises can increase patellar pain. Initial immobilization should only be relative. Patients should perform range of motion exercises daily to prevent arthrofibrosis and quadriceps atrophy.

Despite aggressive physical therapy, the patient has continued instability. With which movement would you expect the greatest disability?

  1. Side stepping

  2. Cross over drills

  3. Single-leg stance

  4. Descending stairs

 

Discussion

The correct answer is (D). Lateral movements like sidestepping and crossover drills are not typically a source of instability for patients with PCL injuries. Similarly, balance training on one-leg is often beneficial to knee function. Descending stairs and inclines often are problematic.

 

Objectives: Did you learn...?

 

The management of PCL laxity?

 

The disability associated with PCL laxity?

 

CASE                               15                               

A 39-year-old, catcher has an acutely locked knee. She was standing up quickly to throw to second base on an attempted steal when her right knee became stuck, and she was unable to straighten it. She has been unable to move the knee since the injury. On examination, the right knee has a limited range of motion, moving from 30 to 45 degrees of knee flexion. Beyond this arc, the endpoint is firm and painful. Anterior–posterior and lateral x-rays reveal an aligned knee without fracture or dislocation.

Your next step in her care is to:

  1. Administer a corticosteroid injection

  2. Obtain an MRI

  3. Provide her with oral anti-inflammatories and an appointment in 5 to 7 days

  4. Apply a long-leg splint

Discussion

The correct answer is (B). MRI has been shown to offer considerable guidance when evaluating patients with a traumatic knee extension deficit (locked knee). The normal radiographs offer assurance that there is no fracture or dislocation preventing knee motion. Injection with a corticosteroid alone will not offer a prompt analgesic benefit. Similarly, oral anti-inflammatories with prompt followup do not address the acuity of the patient’s problem. Immobilization in a long-leg splint may provide the patient with some comfort but does not advance her care.

She is found to have a loose body and a full-thickness cartilage defect on the medial femoral condyle. Which of the following reasons is the LEAST relevant indication for knee arthroscopy?

  1. Recurrent mechanical symptoms

  2. Risk of additional injury to articular cartilage

  3. Prevention of arthritis

  4. Treatment of cartilage defect

  5. Harvesting chondrocytes for autologous chondrocyte implantation (ACI)

 

Discussion

The correct answer is (C). Removal of the loose body will decrease the risk of repeat catching, locking, or giving way as well as lowering the risk of additional injury. If appropriate, the defect could be treated at the initial arthroscopy, or cells could be collected for subsequent treatment. Removal of the loose body with or without a cartilage procedure has not been shown to prevent arthritis.

 

Objectives: Did you learn...?

 

 

The imaging for a traumatic knee extension deficit (locked knee)? The indications for knee arthroscopy?

 

CASE                               16                               

A 17-year-old runner has increased leg pain in the last week of her pre-season training for cross-country. The pain began without trauma and is present every time she tries to run.

What is the most common site of a stress fracture?

  1. Calcaneus

  2. Distal femur

  3. Femoral neck

  4. Pubic ramus

  5. Tibia

 

Discussion

The correct answer is (E). In general, stress fractures occur more frequently in the lower extremities, with the tibia and metatarsals being the most common sites. They occur in the upper extremities although less frequently.

Which of the following is NOT part of the female athlete triad?

  1. Amenorrhea

  2. Disordered eating

  3. Osteoporosis

  4. Abulia

 

Discussion

The correct answer is (D). The female athlete triad consists of amenorrhea, disordered eating, and osteoporosis, and should be considered in all female athletes with a stress fracture. Evaluation of this condition and its underlying causes are essential to the athlete’s long-term health.

The benefits of an MRI in the diagnosis of a stress fracture is best described as:

  1. Very sensitive in identifying the presence and location of a stress fracture without visualization of a macroscopic fracture line

  2. Able to identify bony edema associated with an early stress fracture as well as the presence of a fracture

  3. Ideal for evaluating the location and extent of a fracture line

  4. Effective overview of anatomic alignment, but limited in early stress fractures

 

Discussion

The correct answer is (B). Bone scans are very sensitive in identifying the presence and location of a stress fracture without visualization of a macroscopic fracture line. MRI is able to identify bony edema in an early stress fractures. CT scans are ideal for evaluating the location and extent of a fracture line. Plain radiographs provide an effective overview of anatomic alignment but are limited in early stress

fractures and may not show the fracture.

 

When imaging is complete, her radiographs do not show a clear fracture line. However, there is edema on the MRI. Her pain is present with weight bearing. Which of the following locations presents the highest risk of fracture?

  1. Calcaneus

  2. Medial malleolus

  3. First metatarsal

  4. Anterior tibial diaphysis

  5. Inferior femoral neck

 

Discussion

The correct answer is (D). The lateral malleolus, calcaneus, and first through fourth metatarsals are at low risk for fracture propagation. The medial malleolus and inferior femoral neck represent an intermediate risk. High-risk locations include the superior femoral neck, the anterior tibial diaphysis, the navicular, the base of the fifth metatarsal, and the neck of the talus.

 

Objectives: Did you learn...?

 

 

The epidemiology of stress fractures? The three parts to the female athlete triad?

 

CASE                               17                               

During a football game, a 21-year-old, right-hand-dominant male experiences a numb and tingling sensation in his right arm after making a tackle. With his elbow at his side, his arm is weak in external rotation when compared to his left.

Which finding is LEAST likely to accompany this injury?

  1. Pain with lateral head turning toward the affected side

  2. Transient symptoms

  3. Positive Spurling test

  4. History of prior symptoms

  5. Bilateral symptoms

 

Discussion

The correct answer is (E). Stingers are transient and unilateral. Turning the head

toward the affected side may compress the nerve roots causing symptoms as would the Spurling maneuver. Patients who have a stinger are three times more likely to have another.

All of the following findings are concerning for a more serious injury EXCEPT:

  1. Circumferential distribution

  2. Neck pain

  3. Symptoms lasting more than 3 weeks

  4. Abnormal EMG

 

Discussion

The correct answer is (A). Burners often cause transient pain, burning or tingling in a circumferential, not dermatomal, distribution. Limited neck motion or pain requires additional evaluation. Players with persistent symptoms or EMG changes should not return to sports participation.

 

Objectives: Did you learn...?

 

 

The history and physical examination findings of stingers? The red flags associated with this injury?

 

CASE                               18                               

A 17-year-old, right-hand-dominant, volleyball player presents for worsening right shoulder pain. Over the summer, she played more than usual having joined a travel team. Her pain is worse after playing, and she has noticed that her power has decreased when she strikes the ball. There has been no numbness or tingling in her arm, and she denies any trauma. Strength testing reveals no weakness when her arm is at her side. When outstretched, her right arm is weaker than the left. When completing wall push-up, her back is asymmetric.

The prominence in her back is best described as:

  1. Postural kyphosis

  2. Scapular winging

  3. Congenital scoliosis

  4. Hemihypertrophy

 

Discussion

The correct answer is (B). Long-thoracic nerve palsy can present in overhead athletes in the absence of trauma. The repetitive motion may result in nerve traction and resulting dysfunction in the serratus anterior leading to medial scapular winging. Postural kyphosis will result in a symmetric prominence of the upper back. Congenital scoliosis presents early in life. Hemihypertrophy is a congenital syndrome resulting in one side of the body or one limb larger than the other.

Which nerve root is LEAST likely involved in her injury?

  1. C5

  2. C6

  3. C7

  4. C8

  5. T1

 

Discussion

The correct answer is (D). The long thoracic nerve arises predominantly from C5 to C7. In 8% of people, C8 contributes.

The best test to confirm the diagnosis and grade the severity is:

  1. MRI

  2. Metabolic panel

  3. Muscle biopsy

  4. EMG

  5. Serial examinations

 

Discussion

The correct answer is (D). EMG with nerve conduction velocity will evaluate the function of the long-thoracic nerve and can offer an assessment of the severity of the injury. In long-thoracic nerve palsy, blood work and muscle function are normal. Repeat examination can be used to monitor recovery over 12 to 24 months but offer little confirmation or assessment of severity.

 

Objectives: Did you learn...?

 

 

The pathophysiology of medial scapular winging? The diagnostic findings of medial scapular winging?

CASE                               19                               

The mother of twin, 12-year-old girls contacts your office because her daughters are interested in playing soccer in the fall. The league requires a preparticipation physical examination.

All of the following are addressed by a preparticipation physical EXCEPT:

  1. Assessment of life-threatening conditions that may be revealed by sports participation

  2. Evaluation of current injuries to be treated before returning to play

  3. Impartial documentation of skill and fitness

  4. Create an opportunity to address injury prevention

  5. Address legal and insurance requirements for the sponsoring organization/institution

Discussion

The correct answer is (C). The goal of preparticipation physical examinations is to diagnosis medical conditions that place an athlete at risk during sports participation. It also provides an opportunity to ensure the appropriate treatment of existing problems while also planning for prevention and safety. Legal concerns and insurance policies often require certification of the athlete’s health prior to competition. In amateur athletes, the preparticipation physical is not a resource for player assessment.

When taking a history for the preparticipation examination, which of the following is LEAST worrisome?

  1. Long QT syndrome

  2. Healed long-bone fracture

  3. Shortness of breath

  4. Missed or absent menses

  5. Prior heat stroke

 

Discussion

The correct answer is (B). The history should be examined for cardiac disease (hypertrophic cardiomyopathy, sudden death, long QT, or Marfan syndromes), exertional symptoms (shortness of breath, heart palpitations, chest pain, orthopnea), neurologic disorders (seizures, concussions, stingers), prior heat-related illnesses, as well as signs of female athlete triad (amenorrhea, disordered eating, and

osteoporosis). Prior fracture history is important and should be carefully reviewed.

 

Cardiac auscultation is recommended with the patient standing, sitting and supine. Which of the following murmurs does NOT require further evaluation before participation?

  1. Systolic murmur, squatting, 2/6 intensity

  2. Murmur that worsens with Valsalva

  3. Diastolic murmur

  4. Systolic murmur, supine, 4/6 intensity

  5. Murmur that worsens with standing

 

Discussion

The correct answer is (A). Mild systolic murmurs that do not worsen with Valsalva or change in position do not require additional workup. All diastolic murmurs, any systolic murmur that changes with provocation, and any systolic murmur with 3/6 intensity or higher needs to be evaluated.

 

Objectives: Did you learn...?

 

 

The purpose of a preparticipation physical? The murmurs that require further workup?

 

CASE                               20                               

 

Which of the following is NOT a cause of sudden cardiac death in athletes?

  1. Hypertrophic cardiomyopathy

  2. Coronary artery abnormalities

  3. Situs inversus

  4. Long QT syndrome

  5. Commotio cordis

 

Discussion

The correct answer is (C). Situs inversus is not a cause of sudden cardiac death in athletes. While it is associated with a number of anatomic variations, it is not a contraindication for participation.

The most common cause of sudden cardiac death in athletes is:

  1. Hypertrophic cardiomyopathy

  2. Coronary artery abnormalities

  3. Long QT syndrome

  4. Commotio cordis

 

Discussion

The correct answer is (A). Hypertrophic cardiomyopathy is characterized by left ventricular hypertrophy that causes an obstruction to ventricular outflow. It is best diagnosed by echocardiography.

 

Objectives: Did you learn...?

 

The causes of cardiac sudden death?

 

The most common cause of cardiac sudden death?

 

CASE                               21                               

A 15-year-old wrestler presents with a scaly rash on his chest halfway through the season. Several of his teammates have the same round, scaly patches, and applying skin lotion has not made any improvement. Because of the cold winter, he has not been outdoors.

What is the most likely diagnosis?

  1. Tinea corporis

  2. Tinea capitis

  3. Lyme disease

  4. Eczema

  5. Psoriasis

 

Discussion

The correct answer is (A). Ring worm is common in wrestlers because of their many close contacts. All participants should be screened prior to the season. Tinea capitis is localized to the head. Lyme disease is unlikely without prior tick exposure. Eczema can have scaly plaques, but is not contagious.

Upon microscopic examination, the scaly edges of the wound should be scraped and examined after treatment with what compound?

  1. Prussian blue

  2. Silver nitrate

  3. Potassium hydroxide

  4. Methylene blue

  5. Ziehl–Neelsen stain

 

Discussion

The correct answer is (C). Potassium hydroxide. This treatment will reveal the characteristic hyphae found in fungal infections. In tinea corporis, dermatophytes can be recognized under the microscope by their long branch-like tubular structures called hyphae. Fungi causing ringworm have a distinct appearance.

 

Objectives: Did you learn...?

 

The clinical and microscopic findings of tinea corporis?

 

CASE                               22                               

A 14-year-old, soccer player presents for his preseason physical. He describes having difficulty breathing during sport participation and occasionally after he exerts himself.

Which of the following symptoms is NOT consistent with exercise-induced bronchospasm?

  1. Dry cough

  2. Dizziness

  3. Wheezing

  4. Shortness of breath

  5. Chest tightness

 

Discussion

The correct answer is (B). Dizziness following exertion is not a common symptom of exercise-induced bronchospasm (EIB), nor is a productive cough or persistent chest pressure. A dry, unproductive cough is commonly present along with wheezing, shortness of breath and chest tightness.

Which environmental factor is LEAST likely to exacerbate exercise-induced bronchospasm (EIB)?

  1. Intense exercise

  2. Cold weather

  3. Air pollution

  4. Endurance sports

  5. Viral respiratory illness

 

Discussion

The correct answer is (D). Endurance sports have not been associated with increase rates of exercise-induced bronchospasm. Conversely, intense exercise, cold weather, air pollution, viral respiratory illnesses, and seasonal allergens frequently result in bronchospasm.

When appropriate, in-office spirometry testing can help diagnose underlying asthma in patients with EIB. What value of forced expiratory volume (FEV1) would confirm the diagnosis?

  1. 100%

  2. 99%

  3. <95%

  4. <90%

  5. <50%

 

Discussion

The correct answer is (D). FEV1 <90% of predicted value can confirm the diagnosis of asthma, even when patients are believed to have EIB.

Which of the following options is NOT beneficial in the treatment of EIB?

  1. Activity modification

  2. Warm-up programs

  3. Inhaled albuterol

  4. Leukotriene modifiers

  5. Allergen desensitization

 

Discussion

The correct answer is (E). Avoidance of environmental allergens or strenuous exercise and implementing warm-up exercises may reduce a patient’s symptoms. Pharmacologic treatment with inhaled albuterol, leukotriene modifiers, or inhaled corticosteroids can be beneficial. Allergen desensitization has not been helpful.

Objectives: Did you learn...?

 

The symptoms of EIB?

 

 

The exacerbating factors of EIB? The treatment of EIB?

 

CASE                               23                               

 

At a 10-km fun run, a 42-year-old woman collapses near the finish line. She is responsive but confused. Her blood pressure is 80/40. Which of the following findings are most concerning?

  1. Core temperature >40.5°C

  2. Headache

  3. Tachycardia

  4. Profuse sweating

  5. Nausea/vomiting

 

Discussion

The correct answer is (A). Heat stroke is the most severe form of heat-induced illness. A core temperature >40.5°C combined with mental status changes and/or the lack of sweating are sign of a medical emergency.

Which of the following treatments is essential for patients with heat stroke?

  1. Rest

  2. Intravenous fluids

  3. Whole-body immersion

  4. Oral salt replacement

 

Discussion

The correct answer is (C). Whole-body immersion in an ice bath is the most efficient method for achieving rapid cooling in patients with heat stroke. Rest, IV fluids and salt replacement are helpful, but less urgent when trying to prevent end-organ failure and death.

 

Objectives: Did you learn...?

 

 

The alarming signs and symptoms of heat stroke? The treatment of heat stroke?

CASE                               24                               

A 32-year-old, competitive cross-country skier presents to the ski clinic with a painful right hand one hour after completing a 20-km race. The conditions were colder than he had expected, but he is pleased with his decision to wear less because he set a personal record for the distance. His right thumb and ring finger are numb despite his efforts to warm them up in the shower.

Which of the following is the LEAST likely diagnosis?

  1. Superficial frostbite

  2. Deep frostbite

  3. Acute carpal tunnel syndrome

  4. Acute rhabdomyolysis

  5. Hypothermia

 

Discussion

The correct answer is (D). Prolonged exposure to cold temperatures can lead to temperature-related illnesses like hypothermia, superficial frostbite, and deep frostbite. Periods of intense exertion in sports requiring prolonged use of the hands for gripping have been associated with carpal tunnel syndrome. Rhabdomyolysis can be seen in athletes following periods of intense or prolonged exertion. Localized numbness and pain in the hand are an unlikely presentation.

All of the following treatments are helpful in the management of hypothermia EXCEPT:

  1. Transition to a warmer environment

  2. Removal of wet clothing

  3. Consuming warm liquids

  4. Warming bath immersion

 

Discussion

The correct answer is (D). Changing to a warmer environment (removal from the cold), removing wet clothing, and consumption of warm liquids are helpful in treating mild hypothermia. Warm water immersion may be dangerous in more severe cases if the process is too rapid.

Objectives: Did you learn...?

 

 

The causes of acute rhabdomyolysis? The treatment of cold exposure?

 

CASE                               25                               

A 15-year-old football player is interested in gaining weight in order to be more competitive next season. He has been eating more, lifting weights, and taking supplements. His mother has concerns about his decision.

Which of the following substances are banned in competition?

  1. Methionine

  2. Creatine phosphate

  3. Caffeine

  4. Arginine

  5. Testosterone

 

Discussion

The correct answer is (E). Anabolic steroids are illegal at all levels of competition. Amino acids, like methionine and arginine are not regulated nor is the use of creatine. Caffeine intake is regulated, but its use is permitted below a designated blood plasma concentration.

Use of exogenous testosterone has a number of effects when consumed. Which of the following is NOT true?

  1. Can be used orally or via intramuscular injection

  2. Side effects are believed to be reversible following cessation

  3. Resistance may occur following prolonged use

  4. Aggression and mood disturbances occur commonly

  5. A ratio of testosterone to epitestosterone greater than 6 to 1 is abnormal

 

Discussion

The correct answer is (C). Repeated use of human growth hormone (HGH) has been shown to result in the development of resistance. This finding has not been seen with the repeated use of testosterone or other anabolic steroids. These compounds can be administered orally, transcutaneously or via intramuscular injection. While their side effects include aggression and mood disturbances, these changes are believed

to be reversible following cessation. Drug tests focus on the ratio of testosterone to its precursor, epitestosterone.

 

Objectives: Did you learn...?

 

The exogenous effects of testosterone?

 

CASE                               26                               

A 14-year-old wrestler has been experiencing left leg pain during practice and competition. He explains that the pain comes on quickly and is proportional to how hard he is pushing himself. There have been occasions when his leg felt clumsy and weak late in a match. He has no pain when riding a stationary bicycle.

Which test offers the best insight into his diagnosis?

  1. MRI

  2. MRI spectroscopy

  3. Nuclear medicine blood flow studies

  4. Compartment pressure measurements

  5. EMG

 

Discussion

The correct answer is (D). The relationship of his symptoms to activity suggests exertional compartment syndrome. To assess any potential changes, compartment pressures should be measured.

When the symptoms are present, he has difficulty landing on his left foot and lifting it off of the ground due to pain. What other finding is most likely present on his examination during an episode?

  1. Weak ankle plantar flexion

  2. Diminished Achilles reflex

  3. Decreased posterior tibial pulse

  4. Down going Babinski reflex

  5. Weak great toe extension

 

Discussion

The correct answer is (E). The increased pressure affects the anterior compartment of the lower leg resulting in diminished strength in the anterior tibialis and extensor

hallucis longus. The posterior compartment does not appear to be involved, and there is no suggestion of upper motor neuron dysfunction.

A positive test for exertional compartment syndrome will reveal:

  1. Resting pressure greater than 15 mm Hg

  2. Exertional pressure greater than 30 mm Hg

  3. Failure of pressure to return to baseline after 15 minutes

  4. Pressure greater than 15 mm Hg at 15 minutes after exercise

  5. All of the above

 

Discussion

The correct answer is (E). All of the above answers are consistent with acute exertional compartment syndrome.

 

Objectives: Did you learn...?

 

Diagnosis exertional compartment syndrome?

 

CASE                               27                               

 

In comparing the medial and lateral femoral condyles, the lateral femoral condyle:

  1. Is larger than the medial

  2. Projects farther posteriorly

  3. Is more distal than the medial

  4. Has greater width than the medial

 

Discussion

The correct answer is (D). The medial femoral condyle is larger than the lateral. It projects farther posteriorly and is more distal. The lateral femoral condyle projects more anteriorly and is wider medial to lateral than the medial femoral condyle.

Which of the following provides the greatest innervation to the intra-articular knee?

  1. Posterior tibial nerve

  2. Femoral nerve

  3. Obturator nerve

  4. Sciatic nerve

 

Discussion

The correct answer is (A). The posterior articular branch of the posterior tibial nerve is the largest nerve that innervates the intra-articular knee.

 

Objectives: Did you learn...?

 

The anatomy of the knee?

 

CASE                               28                               

 

The best clinical test(s) for determining the presence of a meniscal injury is (are):

  1. Posterior sag test

  2. Apley test

  3. McMurray test

  4. Pivot shift test

  5. B and C

 

Discussion

The correct answer is (C). The McMurray test is the best test for determining meniscal injury. This is done by flexing the knee and then extending the knee while performing internal and external rotation of the tibia/fibula.

 

Objectives: Did you learn...?

 

The test for diagnosing meniscal injury?