An 80 year old female presents to your office with a left ring finger deformity after a fall one week ago. She initially went to urgent care and xrays were unremarkable for a fracture (Figures 1 and 2). A photo of her left ring finger is shown in figure 3. On physical exam the left ring finger is in hyperextension at the PIP joint and flexion at the DIP joint. She able to flex her PIP joint with full motion. What is the best treatment option?

A 23 year old female presents to your office with right knee pain after her dog struck her knee from the side 2 days ago. Her dog is over 80 pounds and was running fast when he unexpectedly struck her knee. The knee buckled and she was unable to bear weight after. She has since had increased swelling and pain. On physical exam of the right knee, she has significant laxity with valgus stress at 30 degrees of flexion. She has a negative Lachman’s and a large joint effusion. She has significant tenderness along the medial tibial plateau at the insertion area of the MCL. MRI shows a lateral tibial plateau fracture with 2 mm of depression and laxity of the MCL fibers consistent with a complete rupture off the tibia attachment. What is the best treatment option?

A 16 year old male presents to the office with a history of right elbow pain for 6-8 months. His problem began several months ago while playing baseball. While pitching, he developed medial-sided elbow pain which increased with his pitch count. The pain improved after he ceased throwing. He has tried taking periods of 3-4 weeks off from throwing on a few occasions but the pain quickly returns when he pitches. He denies feeling a “pop” or a known injury why throwing. On physical exam of the right elbow there is a positive moving valgus stress test with pain over the medial elbow but no elbow instability. MRI was performed showing a low grade partial thickness tear of the ulnar collateral ligament (UCL) (Figure 1). Figure 2 is a fluoroscopic arthrography image of the right elbow with a negative “T” sign. What is the best treatment option at this time?

A 72 year old female presents to your office with a 6 week history of a bump in the back of her knee which seems to be associated with mild leg swelling below the knee. She denies any history of DVT or recent prolonged travel. She has had intermittent knee pain in the past which has been well controlled with ibuprofen. On physical exam she has a small joint effusion with pain to palpation over the medial joint line. AP and lateral xrays are shown in figures 1 and 2. A picture of the patient’s posterior knee is shown in figure 3. What is the best initial treatment option?

A 14 year old male presents to your office with right elbow pain after throwing a ball 2 days ago. He was pitching when he felt a pop in the right elbow followed by sharp pain on the inside of his elbow. He was unable to throw after and the pain and swelling has increased the last few days. On physical exam he has tenderness to palpation over the medial epicondyle. There is no gross deformity to the elbow or laxity. Side by side (ipsilateral and contralateral) AP xrays of the elbows are shown in figure 1. What is the best treatment option?

A 19 year old presents to your office with severe right knee pain after an injury at a trampoline park 2 hours earlier. When she landed from a jump she felt a pop in her knee and had immediate pain and inability to walk. On physical exam she has a large effusion and pain over the medial patella. AP, lateral, sunrise view xrays (figures 1,2 and 3) show an apparent avulsion fracture off the medial patella. Sagittal MRI (figure 4) shows a full thickness rupture of the medial patellofemoral ligament (MPFL). What is the best treatment option?

A 45 year old male presents to your office with right elbow pain after a fall 2 days ago. He fell on ice and landed with his arm extended. He had immediate elbow pain and has been unable to lift with that arm since. On physical exam he has moderate swelling and pain to palpation over the medial elbow. There is no apparent elbow instability with valgus stress to the elbow. AP and lateral xrays (figures 1 and 2) show a minimally displaced coronoid fracture at the anterior medial facet. What is the next best step in treatment?

A 62 year old male presents to your clinic with right shoulder pain after a fall 4 weeks ago. He was initially seen in the emergency department where x-rays showed a subtle anterior glenoid fracture (Figures 1, 2 and 3). His pain has improved but he has been unable to lift the arm well since the fall. On physical exam he is unable to elevate his arm in the scapula plane. What is the next best step in treatment.

A 76 year old male presents to your office with acute on chronic lower back pain, worse over the last month. He denies having a known injury but has had a lumbar decompression over 10 years ago and a few rounds of lumbar epidural steroid injections since then with minimal relief. He denies a known injury or precipitating event causing this most recent pain. Last month he was placed on Xarelto for atrial fibrillation which is now rate controlled. AP and lateral xrays are shown in figures 1 and 2. He has degenerative changes throughout the lumbar spine and an incidental finding of a 7.6 cm abdominal aortic aneurysm (AAA), to which he is unaware of. What is the next best step in treatment?

A 40 year old female presents to your office with a left thumb deformity for 8 weeks. She originally injured the thumb when she jammed it against the steering wheel during an MVA. She was seen the day of injury and her thumb xrays were negative for a fracture but she was unable to extend her interphalangeal joint (IP). She was diagnosed with a mallet thumb and placed in an extension splint, which she wore at all times for 6 weeks. When she removed the splint at 6 weeks her IP joint fell back into flexion and she still can’t extend her IP joint like her right thumb (figure 1). She would like to improve on IP extension as the deformity is unsettling for her. What is the next best step in treatment?

A 46 year old male presents to your office with a 6 week history of left hip pain. He notices the pain more with hip flexion including stepping up stairs and running. He denies a known injury or precipitating event. The pain has become worse over the last few weeks. On physical exam he has pain with hip flexion against resistance. There is no weakness and no pain with passive hip flexion and internal rotation. AP and lateral view xrays of the left hip are shown in figures 1 and 2. What is the most likely diagnosis?

A 60 year old male presents to your office with three months of right knee instability after a ski injury. He initially had a lot of pain and swelling but symptoms subsided over a month and he was walking relatively pain free. His biggest complaint now is the knee continues to give out on him when he is running and cutting. He is very active and still skis and plays men’s league soccer. Sagittal MRI image (figure 1) shows a proximal tear of the anterior cruciate ligament (ACL). The patient has heard of an ACL repair technique that may offer him a better result. Which statement is true regarding ACL repair?

A 43 year old male presents to your office with left upper back and left arm pain for the past month. He was lifting an object at work when it let go and his neck jerked back awkwardly. He had some neck discomfort for a week or so then the upper back and left arm pain began. He also gets occasional numbness and tingling int the small and ring finger on the left side. On physical exam his motor and sensation are intact in the left upper extremity. X-rays taken today show there to be no evidence of degenerative changes or fracture (figures 1 and 2). There is an incidental finding of a congenital C5-C6 fusion. This patient’s cervical fusion puts him at risk for which condition?

A 6-year-old male presents to your office with right small finger pain and deformity after jamming the finger in a fall a few hours ago. He had immediate onset of deformity and discomfort after the fall. On physical exam he has pain and swelling at the proximal phalanx of the small finger which looks ulnar deviated. AP, oblique, and lateral xrays (figures 1, 2, and 3, respectively) show a Salter Harris II fracture with approximately 15 degrees of angulation on the AP view. What is the best treatment option for this patient?

A 20 year old male presents to your office with a 3 month history of let wrist pain. The pain started after a hard check swing during a baseball game. Initial wrist xrays were read as negative for a fracture. He was treated for 4 weeks in a wrist splint but the pain returned when he started to swing a bat again. CT of the wrist done one week ago shows a displaced hook of hamate fracture (figure 1). He is an avid baseball player and would like to return as soon as possible. What would be the best treatment option?

A 22 year old male presents to your office with a self-inflicted gun shot wound to the left hand he sustained a few hours earlier. He was cleaning his gun when it accidentally went off sending a single BB, or a small round metallic object, into his hand. Ap and lateral xrays of the left hand are shown in figures 1 and 2. On physical exam there is a small entry wound to the palm of the hand between the 3rd and 4th metacarpals shafts. The entry site is clean and there is no site of the BB when cleaning the wound. There is no exit wound. Other than some mild pain with hand motion, he has full function of the hand. What is the best treatment option?

A 14 year old female presents to your clinic with a slow growing mass located on the dorsum of her right hand for the “several years”. The mass is asymptomatic and doesn’t affect her hand function. The patient and parents are concerned this lesion could be cancer but admit it doesn’t bother her at all. Figure 1 shows a picture of the 2-3 cm mass and figure 2 shows the mass is compressible and mobile to the touch. What is the best treatment option?

A 33 year old male presents to your office with right shoulder pain after falling off his dirt bike 2 days ago. He lost control of the bike and fell backwards landing directly on the right shoulder. He has immediate pain and has not been able to lift the right arm since the injury. He denies any numbness in right upper extremity. On physical exam he is tender to palpation over the posterior scapula and he has very limited forward elevation of the right arm. Three view trauma xrays of the right shoulder and scapular are shown in figures 1, 2, and 3. What is the fracture pattern commonly referred to as?

An 8 year old girl presents to your office with right elbow pain after falling off the monkey bars at the playground a few hours ago. She had immediate right elbow pain after the fall and has been unable to move the arm since. AP and lateral xrays show a displaced radial neck fracture (Figures 1 and 2). The fracture angulation appears to be just under 30 degrees. What is the best treatment option?

A 50 year old female presents to your office with complaints of right foot weakness for 2-3 weeks. She had previous mild lower back pain and radiating pain down the right leg about a month ago but that has since resolved. She denies any history of back surgery or peripheral nerve problems. On physical exam she is unable to dorsiflex her right foot and has weakness with her extensor hallucis longus and anterior tibialis muscles. Her gastrocnemius, posterior tibialis, and quadriceps muscles are intact. Sagittal MRI of the lumbar spine (figures 1 and 2) show severe bilateral foraminal stenosis at L4-L5 and L5-S1. Which statement below is true regarding the best treatment for her right foot drop?

A 60 male presents to your office with a progressive right middle finger deformity 4 weeks after jamming his finger after a fall. He was originally seen in urgent care where a lateral xray showed a small capsule avulsion fracture off the proximal phalanx (figure 1). He did not seek further treatment but his finger has become increasingly stiff and painful. Figures 2 and 3 show Boutonniere deformity. Injury to which structure is the cause of this deformity?

A 21 year old female presents to the office with a right small finger deformity and pain for the last 5 weeks. She was playing in a rugby game when she jammed her finger 4 weeks ago. She had immediate pain and swelling but did not seek treatment. Over the last 2-3 weeks the small finger has started to get stiff and she is now having trouble grasping objects. On lateral xray she has a capsule avulsion fracture of the middle phalanx that is sub-acute (Figure 1). Figure 2 and 3 show pictures of her right small finger proximal interphalangeal (PIP) joint contracture and how the small finger crosses over the ring finger when making a fist. What is the best treatment option?

A 26 year old male presents to the ED with neck pain following a motorcycle accident earlier in the day. He was helmeted when he was thrown from a bike after colliding with another vehicle. His head hit the ground and he had immediate neck pain after. CT of the neck shows an acute nondisplaced fracture through the right pedicle of C7 with extension into the right articular facet (figure 1). He is able to move the neck with moderate discomfort and his upper extremity motor and sensation are intact. What is the best treatment option for this cervical fracture?

A 62 year old women presents to your clinic with lower back pain for several months. The pain occasionally radiates to the right sided buttocks but doesn’t radiate below the knee. The pain seems to be made worse when she first starts to move after being in a stationary position for a prolonged period of time such as long car ride or sitting at her desk. The lower back pain is associated with back stiffness that causes increased pain with extending and twisting the back. AP and lateral xrays of the lumbar spine show joint space narrowing and subchondral sclerosis of the L4-5 and L5-S1 facet joints (figures 1 and 2). Which test is considered the “gold standard” to confirm the source of pain is from the facet joints?

A 67 year old male presents to the ED with right ankle pain after a fall from a ladder 2 hours earlier. He landed directly on his heel and can’t bear any weight on the foot. On physical exam the ankle shows moderate swelling but the skin is intact without any tenting. Lateral xray and sagittal CT are shown in figures 1 and 2, respectively. Which choice below describes the pattern of this calcaneus fracture?

A 21 year old presents to your office with left small finger pain and deformity after a fall a few hours ago. On physical exam the small finger is notably shortened but his skin and sensation to the finger are intact. AP and lateral xrays of the finger show a dorsal dislocation of the proximal interphalangeal (PIP) joint without fracture (figures 1 and 2). A digital block is performed and a bedside attempt at closed reduction is unsuccessful. What structure is likely causing this irreducible PIP joint dislocation?

A 10-year-old female is brought to your office by her parents with left elbow pain after an awkward fall during a gymnastics practice 2 days ago. She had immediate pain in the elbow and has developed significant swelling in the elbow over the last few days. On physical exam her left elbow has significant swelling and ecchymosis on the medial side with tenderness to palpation over the medial epicondyle. AP and lateral view xrays show a displaced (about 6 mm) medial epicondyle fracture (figures 1 and 2). Her motor and sensation are intact in her forearm and wrist. The family is wondering if surgery is recommended for this fracture. Surgical indications for displaced medial epicondyle fractures include all the following except which choice below?

A 50 year old with male presents to your office with right knee pain for 8 months. He is an avid runner and the pain becomes significant at the quadriceps tendon insertion at the proximal patella after a short distance of running. Figure 1 shows a sagittal MRI image of the knee with evidence of insertional quadriceps tendinosis at the attachment site on the proximal patella. What is the next best step in treatment?

A 22 year old male present to your office with right shoulder pain after he was shooting his grandfathers shot gun 2 days earlier. The gun kicked back and he had immediate pain over the coracoid. On physical exam he has tenderness to palpation over the anterior coracoid and pain with forward elevation of the arm. AP and outlet views of the right shoulder (figures 1 and 2) show a nondisplaced coracoid fracture. What is the next best treatment option?

A 14 year old comes into your office with left shoulder pain after a fall from his bicycle two days earlier. He had immediate pain and has had difficulty lifting his arm over his head since. On physical exam he has tenderness over the AC joint and pain with forward elevation of the humerus. He also seems to have increased swelling to the distal deltoid of the shoulder but no tenderness to palpation over the area. AP and lateral xrays (figures 1 and 2) show no acute abnormalities. Incidentally a large bony mass protruding laterally on the proximal humerus is seen. MRI view of the proximal humerus is shown in figure 3. What is the next best step in treatment?

A 42 year old avid golfer presents to your office with 6 months of ulnar sided left wrist pain. He denies any known injury but when he swings a hammer or golf club the ulnar side of his wrist hurts. On physical exam his pain is reproduced when the wrist is forced in ulnar deviation and extension. AP and lateral xrays are shown in figures 1 and 2. Coronal MRI (figure 3) of the left wrist shows edema in the triquetrum and ulnar styloid. What is the most likely diagnosis?

A 66-year-old woman presents to your office with several months of right knee pain. She denies any specific injury or inciting event. The pain is most noticeable when initiating gait or starting activity after prolonged rest. On physical examination, there is a small joint effusion but no evidence of knee instability. Anteroposterior radiograph of the knee (Figure 1) demonstrates coronal tibiofemoral subluxation—the tibia is subluxed laterally relative to the femur. Coronal tibiofemoral subluxation in knee osteoarthritis most commonly results from which of the following pathological processes?

A 12-year-old football player presents to your office with lateral foot pain after twisting his ankle during play 3 weeks ago. He thought it was a mild sprain and played through the injury but the pain started to get worse. On physical exam he has tenderness to palpation over the proximal 5th metatarsal and minimal foot swelling. Oblique view radiograph of the right foot is shown in figure 1. Given his age, it is unclear whether figure 1 shows a proximal 5th apophyseal fracture, or a normal growth plate, so a contralateral comparison is ordered (Figure 2). What is the best treatment option for this patient?

A 35-year-old male presents to your office with right foot pain for 2 months. He had a subtle twisting injury at work that seemed to have aggravated the pain. He admits to off-and-on-mid-foot pain in his late teens and early twenties while playing sports but he has since stopped playing. On physical exam he has midfoot pain to palpation with a slight flat foot deformity. AP and lateral xrays are shown in figures 1 and 2. Sagittal MRI STIR image of the right foot shows a nonosseous calcaneonavicular coalition with bone marrow edema on the adjacent cortical margins (figure 3). What is the best treatment option for this patient?

A 47 year old female presents to your office with a several year history of left thumb pain. She has worked for years in landscaping and manufacturing and the pain has progressively worsened to the point she can no longer work. She has done periods of immobilization and multiple steroid injections with minimal relief. AP and lateral radiographs are shown in figures 1 and 2, respectively. Which of the following surgical options is most commonly performed for the treatment of thumb carpometacarpal (CMC) joint arthritis?

A 44-year-old female presents to your office with right elbow stiffness for 6 months after sustaining a nondisplaced radial head fracture. AP and lateral xrays of the right elbow (figures 1 and 2) from the original injury show a non displaced fracture of the radial head. The fracture healed well in 6 weeks and her elbow pain has subsided but she continues to have trouble with elbow extension and full flexion. She reports difficulty performing activities of daily living such as personal hygiene and typing. On examination, her elbow range of motion is -40 degrees of extension and 110 degrees of flexion. She has completed 2 months of supervised physical therapy with minimal improvement. Which of the following is the most appropriate next step in management?

A 14-year-old right-hand–dominant girl presents with recurrent episodes of right shoulder “slipping out” over the past six months. The instability seemed to have started after a shoulder dislocation in a basketball game that was closed reduced in the emergency department. Recently she was playing basketball and had sharp pain while grabbing and rebound and was unable to continue playing. On examination, she has full but guarded range of motion of the right shoulder, increased external rotation compared with the contralateral side, and positive apprehension and relocation tests. A sulcus sign is absent. Plain radiographs are normal. Axial MRI arthrogram (figure 1) demonstrates an anteroinferior labral tear without significant glenoid bone loss or a large Hill-Sachs defect. Which of the following is the most appropriate management recommendation to discuss with the patient and her family?

A 23-year-old man presents with right knee pain for “several years”. He remembers having some discomfort as a teenager that was associated with a slowly enlarging, firm mass along the anteromedial distal thigh. He recently started a construction job where he does a lot of bending and squatting which has made the pain worse. He denies trauma, constitutional symptoms, or family history of skeletal disorders. Physical examination reveals a hard, immobile bony prominence over the distal femur with discomfort at terminal knee flexion. AP and lateral xrays (figures 1 and 2) show a pedunculated osseous lesion arising from the metaphysis of the distal femur with continuity of the cortical and medullary bone. Which of the following is the most appropriate management for this patient?

A 56-year-old male presents with 2 months of progressive right shoulder pain that worsens with overhead activity. He denies any injury or known precipitating event. On physical exam he has positive impingement signs and mild weakness with forward elevation of the arm in the scapular plane. Xrays of the right shoulder show no acute abnormalities and sagittal view MRI (figure 1) demonstrates a partial-thickness articular-sided supraspinatus tear involving approximately 40% of tendon thickness. Which of the following is the most appropriate initial management?

A 15-year-old male varsity hockey player presents to your office with significant chest pain after being checked by an opponent yesterday. The opponent struck his chest with a lowered shoulder and he had immediate pain and was unable to continue play. He now has sharp midline chest pain that worsens with deep inspiration, coughing, and trunk movement. He denies loss of consciousness or dyspnea. On exam, he is hemodynamically stable with normal oxygen saturation. There is focal tenderness over the mid-sternum without deformity, crepitus, or ecchymosis. Breath sounds are equal bilaterally. ECG is normal. A lateral chest radiograph shows a nondisplaced fracture of the sternal body (figure1). No rib fractures, pneumothorax, or mediastinal widening are seen. Which of the following is the next best step in treatment for this patient’s injury?

A 26-year-old male mechanic presents to your office with right forearm pain after tripping on a wet bathroom floor and striking his forearm directly against a granite countertop 2 days ago. He reports immediate pain and swelling localized to the mid-forearm. He denies wrist or elbow pain. On physical examination, there is focal swelling and tenderness over the midshaft of the ulna without skin compromise. Forearm compartments are soft, and neurovascular examination is intact, including normal ulnar nerve sensation. There is no tenderness at the distal radioulnar joint (DRUJ) or proximal radioulnar joint (PRUJ), and no evidence of instability at the elbow or wrist. Anteroposterior and lateral radiographs of the forearm demonstrate a subtle, nondisplaced midshaft fracture of the ulna (figures 1 and 2). Which of the following is the most appropriate initial management for this patient?

A 62-year-old female presents to the emergency department with right hip pain after a fall on the ice earlier in the day. She reports immediate pain and inability to bear weight on the right lower extremity. On examination, she has significant tenderness to palpation over the right greater trochanter and severe pain with hip flexion and internal rotation. An AP pelvis radiograph demonstrates a non-displaced right intertrochanteric fracture (Figure 1). Coronal CT reveals fracture extension into the lesser trochanter, indicating involvement of the posteromedial cortex (figure 2). She is otherwise healthy, lives independently, and was ambulating without assistive devices prior to the injury. Which of the following is the most appropriate treatment for this patient’s fracture?

A 26-year-old female presents to your office with right hand pain after twisting her hand while unwrapping a heavy box. She reports feeling a sharp pain over the dorsum of the hand with minimal trauma. She denies any known prior injury. On examination, there is focal tenderness and swelling over the third metacarpal shaft. There is no rotational deformity, and neurovascular examination is normal. AP, oblique, and lateral radiographs (figures 1, 2, and 3) demonstrate a nondisplaced transverse fracture through a lytic, expansile intramedullary lesion of the third metacarpal with mild cortical thinning and internal chondroid calcifications. What is the most appropriate initial management of this patient’s injury?

A 36 year old female presents to your office with severe right sided arm pain and numbness for the last month. She had a posterior decompression with laminoforaminotomy and discectomy 6 months ago and was doing well. Pre-operative sagittal MRI is shown in figure 1. She denies a known injury or precipitating event which caused the right arm pain to return. On physical exam she has significant weakness to her triceps (elbow extension) and numbness over the right middle finger. Sagittal MRI done one week ago shows a large recurrent C6-C7 disc herniation (figure 2). Which statement is true regarding surgical options for cervical radiculopathy due to cervical disc herniation?

A 74-year-old woman presents to the orthopedic clinic with progressive pain and stiffness in her right great toe for several years. She reports worsening pain with walking, particularly during push-off, and difficulty wearing shoes due to dorsal toe pain. Conservative measures including NSAIDs, shoe modifications, and a carbon footplate have provided minimal relief. She denies any recent trauma. On physical examination, there is a prominent dorsal osteophyte over the first metatarsophalangeal (MTP) joint with tenderness to palpation. Active and passive dorsiflexion of the first MTP joint is markedly limited to approximately 10°, and pain is elicited throughout the midrange of motion with a positive grind test. AP and lateral weight-bearing radiographs (figures 1 and 2) demonstrate near-complete joint space loss, subchondral sclerosis, and large dorsal osteophytes consistent with advanced degenerative changes of the first MTP joint. Based on this patient’s presentation, which of the following treatment options is most appropriate to provide reliable long-term pain relief and functional improvement?

A 65-year-old female presents to your office with a 2-month history of right shoulder pain that she believes began after a weekend of kayaking. She received a corticosteroid injection two weeks ago with a small amount of relief. She continues to experience pain with reaching, grasping objects, and overhead activities. Sagittal MRI of the right shoulder demonstrates a small full-thickness tear of the anterior supraspinatus tendon. She has full passive range of motion and no weakness with forward elevation of the arm. After discussion, she asks whether she should proceed with surgical repair or attempt nonoperative management first. Based on the current evidence comparing operative and nonoperative treatment of full-thickness rotator cuff tears, which of the following statements is most accurate?

A 74-year-old woman presents with at least 6 months of chronic low back pain without a history of trauma. She denies radicular symptoms and reports pain localized predominantly to the right lower lumbar region. Her pain is exacerbated by prolonged inactivity, including long car rides and standing in one position, and is associated with significant stiffness, particularly during lumbar bending and rotation. She has undergone physical therapy, NSAID treatment, and activity modification with minimal improvement. A diagnostic lumbar medial branch block resulted in greater than 80% pain relief for the expected duration of the anesthetic. Lumbar spine radiographs (Figure 1) demonstrate severe facet joint arthrosis, most pronounced at L4–L5. Axial MRI (Figure 2) shows facet joint hypertrophy with inflammatory changes. There is no significant disc herniation or central canal stenosis.Based on the clinical presentation, imaging findings, and response to diagnostic injection, the patient is diagnosed with facet-mediated axial low back pain. Which of the following interventions is best supported by current evidence for providing long-term pain relief (>6 months) in this patient?

A 42-year-old right-hand–dominant female presents with a 3-month history of progressive pain along the radial aspect of her right wrist. She reports worsening discomfort with lifting her infant, gripping objects, and repetitive thumb movements at work. She localizes the pain to the area just proximal to the radial styloid and notes tenderness with palpation over this region. On examination, there is marked tenderness over the first dorsal extensor compartment. Pain is reproduced with resisted thumb abduction and extension. A Finkelstein test elicits sharp pain along the radial wrist. There are no neurologic deficits and xrays are unremarkable for arthritic changes. Which of the following statements is true regarding the best initial step in treatment?