The patella is the largest sesamoid bone in the body which has the quadriceps tendon attached proximally and the patella ligament attached distally.  The quadriceps, patella, and patella ligament form the extensor mechanism of the knee. Disruption in any of these three structures may cause an inability to straight leg raise or bear weight on the knee. Patella fractures may be treated non-operatively if the extensor mechanism is intact, there is less than 2-3 mm of articular step off, and less than 4mm of fracture displacement. Non-operative acute treatment includes weight bearing as tolerated in a knee immobilizer or hinged knee brace locked in extension.  Weight bearing as tolerated is permitted in a knee immobilizer as the extensor mechanism is not activated with the knee in extension. Any type of flexion, especially with weight bearing, activates the extensor mechanism which creates forces through the patella that can displace the patella fracture. MRI is rarely indicated in displaced fractures unless the patient is unable to straight leg raise. CT is often ordered if the amount of fracture displacement is unclear.

References

1. Schuett DJ, Hake ME, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ. Current treatment strategies for patella fractures. Orthopedics. 2015 Jun 1;38(6):377-84.
2. Hargett, Damayea I. MD; Sanderson, Brent R. DO; Little, Milton T.M. MD Patella Fractures: Approach to Treatment, Journal of the American Academy of Orthopaedic Surgeons: March 15, 2021 – Volume 29 – Issue 6 – p 244-253

The location of the disc herniation will determine which nerve root is affected. Posterior lateral disc herniations generally affect the nerve root at the traversing level. The less-common lateral recess and foraminal disc herniations affect the exiting nerve root at the affected level. For instance, an L4–L5 posterior lateral disc herniation would affect the L5 nerve root. A foraminal herniation at that L4–L5 level would affect the L4 nerve root.  The L2 and L3 nerve roots control hip flexion. The L4 nerve root controls the tibialis anterior. The L5 nerve root controls the extensor hallucis longus and the S1 nerve root controls the gastrocnemius.

Reference
Hoppenfeld S. Physical Examination of the Spine Extremities. Prentice Hall. Upper Saddle River, NJ.

Calcific tendinitis is a painful infiltration of calcium into the rotator cuff tendon. The calcium forms within the tendon for reasons unknown, and causes painful symptoms often associated with subacromial impingement. The three main stages of calcific tendinitis include the precalcific, calcific, and postcalcific phases. The calcific phase is further divided into the formative, resting, and resorptive phases. Pain is the most intense during the resorptive phase when vascular infiltration promotes spontaneous resorption. Symptom duration and severity are highly variable and may be influenced by the size of the calcium deposit. The majority (over 70%) of symptomatic rotator cuff calcific tendinitis resolve with conservative treatment within 6 months. The majority of calcific deposits will get smaller or disappear on x-ray. Patients should be educated that the most painful period is actually during the resorptive phase and symptoms should resolve in 3-6 months. A subacromial steroid injection and physical therapy can offer pain relief as the resorptive phase progresses to pain free. 1,2
Answer C.
References
1. Suzuki K, Potts A, Anakwenze O, Singh A. Calcific Tendinitis of the Rotator Cuff: Management Options. J Am Acad Orthop Surg 2014;22:707-717
2. Carli AD, Ferdinando P, Giacomo D, Pitino D, Ferretti A. Calcific tendinitis of the shoulder. Joints. 2014 Jul-Sep; 2(3): 130–136.

The above x-rays show a bony mallet finger. Bony mallet fractures result from a forceful flexion to an extended distal phalanx causing the extensor tendon to pull off a piece of bone.  Patients with a mallet finger may also present with a swan neck deformity as disruption of the terminal extensor tendon causes increased extensor tone at the DIP.

Several types of splints and surgical techniques have been utilized to treat bony mallet fractures. The majority of injuries are treated with continuous splinting of the DIP alone for 6-8 weeks.  DIP splinting alone is also advised with an associated swan neck deformity as combined DIP and PIP splinting has not been shown to improve a swan neck deformity.  At no point should the DIP be flexed during the splinting period. If flexion occurs during the 6-8 weeks of splinting then the immobilization period is restarted. Dorsal and volar splints are used with no definitive benefit of one over the other.  Splinting in full extension or slight hyperextension of the DIP is recommended. However, overextension of the DIP should be avoided as this may result in dorsal skin compromise.

Bony mallet fractures do well with nonsurgical management when patients can be compliant with strict immobilization. This patient was treated in a volar splint at all times for 6 weeks. Although the fracture fragment is displaced in the above x-rays, studies have shown that the articular surface of the distal phalanx has significant remodeling potential.

Relative surgical indications include inability to tolerate splinting, volar subluxation of the distal phalanx, greater than 50% articular surface involvement, and open injury. Surgical techniques involve placing a k-wire to immobilize the DIP joint and may include reduction of the fracture fragment with a transarticular pin through the DIP.

References
Mallet Finger. http://www.orthobullets.com. Accessed on 11/1/14.

Bendre AA, Hartigan BJ, Kalainov DM. Mallet Finger. JAAOS 2005; 13: 336-344.

Acromioclavicular (AC) joint separation is a common injury resulting in a direct blow to the shoulder. Anterior-posterior AC joint stability is provided by the acromioclavicular (AC) ligaments and superior-inferior stability is provided by the coracoclavicular (CC) ligaments. Injury to the two coracoclavicular ligaments (the medial conoid and the lateral trapezoid) can cause superior migration of the clavicle. The Rockwood classification divides AC joint injuries into 6 types. Type I AC joint injuries are characterized by sprains of the AC ligaments without superior migration of the clavicle. Type II injuries cause tearing of the AC ligaments but not the CC ligaments. Grade III injuries tear both the AC ligaments and CC ligaments causing 25% to 100% superior displacement of the clavicle. Type IV, V, and VI injuries are rare. Type IV injuries result in posterior displacement of the clavicle into the trapezial fascia. Type V injuries are Type III injuries with >100% superior displacement of the clavicle. Type VI injuries displace inferiorly in a subcoracoid position. With type III-V injuries up to 18% of patients will have concomitant pathology such as SLAP lesions, rotator cuff injuries, and fractures. 1,2
This patient has a grade III/ borderline grade V AC joint separation indicating the acromioclavicular and corococlavicular ligaments have been injured.
Answer E.
References
1. Li X, Ma R, MD; Bedi A, Dines DM, Altchek DW, Dines J. Current Concepts Review: Management Of Acromioclavicular Joint Injuries. JBJS. January 2014 – Volume 96 – Issue 1 – p. 73-84
2. Spencer EE Jr. Treatment of grade III acromioclavicular joint injuries: a systematic review. Clin Orthop Relat Res, February 2007; 455(1); 38-44.

The pelvis provides attachment sites for many of the muscles that flex, extend, and rotate the hip. Musculotendinous attachments can pull bone off these sites, or cause avulsion fractures, with high energy injuries. The most common sites of avulsion fractures in the pelvis include the ischial tuberosity, the anterior inferior iliac spine (AIIS), and the anterior superior iliac spine (ASIS). The AIIS is the attachment site for the rectus femoris which flexes the hip. The ASIS is the attachment site for the Sartorius and tensor fasciae latae which flex and medially rotate the hip, respectively. The hamstrings (biceps femoris, semitendinosus, and semimembranosus) attach to the ischial tuberosity and extend the hip. 1,2

The AIIS is the most common site for all avulsion fractures of the pelvis. The AIIS apophysis fuses at age 16 years old on average and epiphyseal avulsion fractures typically occur between the ages of 14 and 17. As with this case of a 33 year-old patient, the AIIS can also avulse when the apophysis is fused. Avulsion injuries typically occur with sporting activities such as running, jumping, or kicking sports. Patients often recall a sudden “pop” or snapping sound followed by pain and weakness. The initial treatment is non-operative with a brief period of non-weight bearing and crutches. Physical therapy and weight bearing are initiated 1-2 weeks after the injury or when symptoms allow. Patients can often return to sport 2 months after avulsion fractures. 1,2

Answer D.

References

1. Schiller J, Defroda S, Blood T. Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete. JAAOS 2017; 25: 251-259.

2. AIIS Avulsion Fracture. http://www.orthobullets.com. Accessed on 5/13/2018.

The Ottawa ankle rules for foot and ankle radiographic series in acute ankle injury patients are a well-validated clinical decision aid that has reduced the ordering of foot and ankle radiography without compromising patient care.  Specifically, the rules indicate an ankle radiographic series if the patient has pain in the malleolar zone (the distal 6 cm of tibia, fibula and talus, and their overlying soft tissues) and any of the following: bone tenderness at the posterior edge (distal 6cm of the fibula) or tip of the lateral malleolus, bone tenderness at the posterior edge (distal 6cm of the tibia) or the tip of the medial malleolus, or inability to bear weight both immediately and in the emergency department.  A foot radiographic series is required if there is pain in the midfoot zone (the navicular, cuboid, cuneiforms, anterior process of calcaneus, and base of the fifth metatarsal, and their overlying soft tissues) and any of the following: bone tenderness at the base of the fifth metatarsal, bone tenderness at the navicular bone, or inability to bear weight both immediately and in the emergency department.

References

Seah RH, Mani-Babu S. Managing ankle sprains in primary care: What is best practice? A systematic review of the last 10 years of evidence. British Medical Bulletin 2011; 97:105-35.

Stiell IG, McDowell I, Nair RC, Aeta H, Greenberg G, McKnight RD, Ahuja J. Use of
radiography in acute ankle injuries: Physicians’ attitudes and practice. Can. Med. Assoc. J. 1992
Dec; 147(11):1671-78.

Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C,
Worthington JR. Implementation of the Ottawa ankle rules. JAMA 1994 Mar; 271(11):827-32.

The patient presents with a displaced lateral malleolar fracture with syndesmotic disruption evident by clear space widening of the medial malleolus. The patient should be treated with open reduction and internal fixation of the lateral malleolar fracture with syndesmotic fixation.

The ankle syndesmosis plays an important role in ankle joint stability and injuries can be difficult to recognize and treat. Making the diagnosis relies heavily on clinical exam and subtle radiograph findings. Degree of injury can range from mild sprain to displacement requiring operative management. Syndesmotic injuries are more complex than the typical lateral ankle sprains and usually require longer recovery. Without recognition and proper treatment they can be associated with long term disability. The distal syndesmosis resists separation forces between the distal tibia and fibula and if unstable can result in abnormal ankle joint loading. The four ligament complex includes the anterior inferior tibiofibular, interosseous ligament and membrane, posterior inferior tibiofibular and the inferior transverse ligaments.

Mechanism of Injury
Syndesmotic injuries are usually associated with an external rotation force. Injury can result from a fracture or be purely ligamentous.  Eversion ankle sprains or “high ankle sprains” represent just 1% of all ankle sprains and result from direct contact to the lateral leg with eversion of the ankle. Injury most always occurs with Weber C type fractures above the level of the mortise. Weber B fractures at the level of the mortise generally begin at the anterior tibiofibula ligament and proceed  posterior leaving the anterior and proximal syndesmosis intact.

Physical Exam
A clinician should always look for tenderness over the anterior syndesmosis, pain with syndesmotic squeeze, and tenderness over the proximal fibula. The syndesmotic squeeze is performed by compressing the fibula to the tibia at the mid calf. Pain over the distal syndesmosis when the ankle is externally rotated in a neutral position is also reliable. Pain, swelling and ecchymosis medially can indicate disruption to the medial deltoid and an unstable injury.  There may be an absence of ecchymosis and ankle swelling usually associated with a lateral ankle sprain.

Radiological Evaluation
Three views of the ankle including AP, mortise and lateral views should be obtained is a syndesmotic injury is suspected. Pain on palpation of the proximal fibula would require radiographs looking for a proximal fibula fracture and possible Maisonneauve injury. Medial clear space between the medial malleolus and talus, lateral clear space between the talus and fibula, and tibiofibular clear space are carefully examined for widening.  Injury may not be apparent on plain films and stress views with the ankle in external rotation may be necessary. Any clear space widening on plain films or stress views would indicated an unstable syndesmotic injury.  CT scan and MRI are rarely used as radiographs are diagnostic.

Association with Ankle Fractures
Fibula fractures proximal to the mortise are generally associated with a syndesmotic injury.  Incomplete disruptions can occur with some proximal fractures that spare the posterior syndesmosis and deltoid ligament. The deltoid ligament is a primary stabilizer of the ankle joint and prevents lateral shift of the talus. Studies have shown that with a syndesmotic injury, and intact deltoid, talar motion is stable. When the medial and lateral malleolus are rigidly fixed generally no syndesmotic screw is required. However, studies have shown even with rigid fixation of both operative stress views may still show medial clear space widening indicating an incompetent deltoid ligament and instability.  When a syndesmotic injury is suspected with an operative ankle fracture it is crucial to obtain stress views after the medial and lateral malleolus are rigidly fixed to determine instability.

Treatment
In the absence of clear space widening on plain and stress radiographs, treatment consists of rest, ice, compression and elevation. A period of 2-3 weeks of non-weight bearing is recommended with progressive weight bearing in a boot for an additional few weeks. Any new or latent diastasis evident on radiographs should be treated with a syndesmotic screw. Syndesmotic fixation is generally recommended with a fibula fracture 4-5 cm’s above the mortise in the presence of a deltoid ligament tear. Inadequate reduction can lead to late arthrosis and instability. Non-weight bearing in a protective boot or cast is initiated for the first 6-8 weeks post-op.  A protective boot or ankle brace can be used until screw removal at or after 12 weeks. Screw removal should be performed before normal weight bearing activities are resumed in order to prevent screw fatigue and break.

References
Zalavras C, Thordarson D: Ankle Syndesmotic Injury. Journal of the American Academy of Orthopedic  Surgeons. 2007;15:330-339.

Wuest, T.: Injuries to the Distal Lower Extremity Syndesmosis. Journal of the America Academy of Orthopedic Surgeons. 1997;5:172-181.

Bucholz, RW, Court-Brown C, Heckman JD. Rockwood and Green’s Fractures in Adults, 6th  edition. Philadelphia, PA: Lipppincott Williams and Wilkins; 2006. 2189-2197.

Fingertip amputations can be extremely painful and complicated injuries that are best treated by a hand specialist. The goal of treatment is to save as much of the finger as possible while maintaining a functional digit. Factors that determine treatment include how much soft tissue is left on the finger, orientation of amputation (guillotine vs oblique), bone exposure, and whether there is more dorsal or volar skin remaining. Partial fingertip amputations (<1.5 cm) without bone exposure and adequate skin volarly can often heal with primary closure or healing with secondary intention. Healing by secondary intention usually occurs by 4 weeks and is associated with less time out of work and few complications than flap procedures. Injuries with exposed bone and limited soft tissue coverage volarly often require removal of some or all of the distal phalanx to allow for skin closure. Partial remaining nail bed should be visualized and removed to prevent a hook nail deformity and digital nerves must be transected as far proximally as possible to prevent a painful neuroma. 1,2
Answer C.
References
1. DaCruz DJ, Slade RJ, Malone W. Fractures of the distal phalanges. The Journal of Hand Surgery: British & European Volume. 1988 Aug 1;13(3):350-2.
2. Neustein TM, Payne SH, Seiler JG. Treatment of Fingertip Injuries. JBJS Reviews - Review Articles: 21 April 2020 - Volume 8 - Issue 4 - p. e018

The lateral radiograph demonstrates an obvious patella alta or high riding patella. This finding is consistent with a patella tendon rupture. The patella tendon is able to withstand significant forces during knee motion considering 3.2 times body weight is generated through the knee while climbing stairs. Patella tendon ruptures most commonly occur in patients over 40 years old during a sudden quadriceps contraction. Patients on chronic oral corticosteroids and with a history of patella tendinitis are the most prone to tendon rupture.  The tendon typically tears off the inferior pole of the patella. Most patella tendon ruptures can be diagnosed with a careful physical exam and x-ray finding as above, and therefore MRI is only used if the diagnosis is in question. Patella tendon ruptures require timely surgical repair within two weeks of injury. Rehab after primary repair includes touch down weight bearing for 6 weeks with a gradual increase in weight bearing when quadriceps strength returns. The prognosis after a timely repair is excellent with most patients having a complete return of knee motion and strength. 1,2

Answer A.

References

1. Matava, Matthew J. MD Patellar Tendon Ruptures, Journal of the American Academy of Orthopaedic Surgeons: November 1996 – Volume 4 – Issue 6 – p 287-296
2. Patella tendon rupture. http://www.orthobullets.com. Accessed on 3/5/21.

Radial head fractures are the most common type of fracture of the elbow. The mechanism of injury is typically a fall on an outstretched hand where the radial head is compressed into the capitellum. Injury severity can range from a simple nondisplaced radial head fracture to a completely displaced, comminuted fracture with associated dislocation or collateral ligament injury. Minimally displaced fractures with less than 2mm of displacement can be treated non-operatively with excellent results. Early motion of the elbow should be initiated as soon as pain tolerates. The elbow can become permanently stiff with prolonged immobilization so early motion is crucial. A sling can be used for the first 1-2 weeks to allow for elbow rest but the patient should remove the sling for gentle range of motion 2-3 times a day. Patients should be instructed to avoid any lifting with the injured arm as any valgus stress placed on the elbow could cause fracture displacement. Follow-up radiographs are generally performed at one week, three weeks, and six weeks after injury to be certain the fracture doesn’t displace. Full range of motion of the elbow without pain is expected at 6 weeks. Patients may resume lifting with the injured arm when full painless range of motion is achieved and radiographs show full healing. 1,2

Answer B.

References

1. Tejwani, Nirmal C. MD; Mehta, Hemang MD Fractures of the Radial Head and Neck: Current Concepts in Management, Journal of the American Academy of Orthopaedic Surgeons: July 2007 – Volume 15 – Issue 7 – p 380-387
2. Rosenblatt Y, Athwal GS, Faber KJ. Current recommendations for the treatment of radial head fractures. Orthopedic Clinics of North America. 2008 Apr 1;39(2):173-85.

The patient has a complete tear of the ulnar collateral ligament (UCL) of the thumb as noted by no discernable endpoint with radial stress to the MCP joint. An intact UCL is critical for hand function including grip strength. Tenderness to palpation over the MCP joint and instability with valgus stress (radial deviation) are key findings with a UCL injury. Radiographs are routinely ordered to assess for fractures and joint instability. MRI may be used if the diagnosis is in question or the degree of injury is unclear. MRI is not routinely ordered when patients have an obvious injury to the UCL.  Complete tears of the UCL should be treated surgically with repair of the UCL ligament. Almost 90% of complete UCL ruptures have a Stener lesion which will not allow healing without surgical repair. Small bony avulsion fractures of the UCL can be treated with a small screw or pin. If the avulsed fragment is too small for fixation the piece of bone can be removed and then ligament repaired down to bone. 1,2

Answer D.

References

1. Tang, Peter MD, MPH Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint, American Academy of Orthopaedic Surgeon: May 2011 – Volume 19 – Issue 5 – p 287-296
2. Pulos N, Alexander Y. Treatment of Ulnar Collateral Ligament Injuries of the Thumb. A Critical Analysis Review. JBJS Reviews – Review Article with Critical Analysis Component: 21 February 2017 – Volume 5 – Issue 2 – p. e3

The patient is presenting with a chronic slipped capital femoral epiphysis (SCFE). Chronic SCFE is defined as symptoms lasting >3 weeks and is by far the most common form, accounting for 85% of all patients who present with the condition. The stability of SCFE is based on the patient’s ability to bear weight. If patients can’t put any weight on the leg the SCFE is unstable whereas the ability to weight bear represents a stable pattern. Given the patient was able to walk in, although with pain, her SCFE would be classified as stable. The patient’s x-rays show a grade I mild slip which appears chronic. Given the duration of symptoms and the patients difficulty with bearing weight, the SCFE is still not healed. MRI has a role in diagnosing early pre-slip SCFE in the presence of normal radiographs, however this patient has growth plate changes noted. The treatment of choice for stable and unstable SCFE is single or double screw fixation to prevent further slippage of the growth plate. Unstable and severe slips may require open reduction of the growth plate with fixation. 1,2

Answer D.

References

1. Aronsson, David D. MD; Loder, Randall T. MD; Breur, Gert J. DVM, PhD; Weinstein, Stuart L. MD Slipped Capital Femoral Epiphysis: Current Concepts, Journal of the American Academy of Orthopaedic Surgeons: November 2006 – Volume 14 – Issue 12 – p 666-679
2. Wylie JD, Novais EN. Evolving Understanding of and Treatment Approaches to Slipped Capital Femoral Epiphysis. Curr Rev Musculoskelet Med. 2019;12(2):213-219. doi:10.1007/s12178-019-09547-5

Osgood-Schlatter disease (OSD) is a common knee condition seen in active adolescence which results from traction apophysitis at the tibial tubercle. Symptoms start during a period of rapid skeletal growth while patients participate in athletic activities. The diagnosis is straightforward with pain to palpation over the tibial tubercle and pain that is made worse with running and jumping activities. Radiographs are usually normal but may show irregularity and fragmentation of the tibial tubercle. Advanced imaging with MRI and/or CT is not indicated to confirm the diagnosis. Treatment involves NSAIDS, ice, activity modification and quadriceps stretching. Patients may have to pause athletic activities for a short period if pain is significant, however most patients can play through mild discomfort. OSD can be a nagging type of condition that lasts up to 12-18 months but generally resolves when patients reach skeletal maturity. Maintaining quadriceps flexibility through sport activities is critical to managing symptoms. 1,2

Answer A.

1. Bloom OJ, Mackler L. What is the best treatment for Osgood-Schlatter disease?. Clinical Inquiries, 2004 (MU). 2004.
2. Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood–Schlatter disease: review of the literature. Musculoskeletal surgery. 2017 Dec;101(3):195-200.

A Monteggia fracture is characterized by a proximal third ulnar fracture with a dislocation of the radial head. These fractures are rare in children and can be missed at the initial presentation in up to 50% of pediatric patients.  A missed diagnosis can cause disabling consequence as a persistent radial head dislocation can start to cause permanent loss of elbow motion and stability after just two weeks from injury. When establishing a diagnosis, the patients range of motion should be carefully scrutinized for full elbow flexion and extension and full forearm supination and pronation. It is crucial for providers to be able to recognize an intact radiocapitellar joint on radiographs. This can often be difficult with the numerous ossification centers of the elbow. If there is any confusion on radiographic interpretation an x-ray of the contralateral elbow should be obtained for a side to side comparison. The treatment of choice is an acute closed reduction and long arm cast with the forearm placed in supination. The radial head will often reduce spontaneously when ulna length is restored. Closed reduction should be performed as soon as possible as the reduction becomes more difficult as time from injury passes. Chronic Monteggia fractures, defined as a dislocation beyond 4 weeks, usually require an open reduction. Open reduction and internal fixation is only performed in patients with closed growth plates. 1, 2

Answer B.

References

1. Hubbard James, MD; Chauhan Aakash, MD, MBA; Fitzgerald Ryan, MD; Abrams Reid, MD; Mubarak Scott, MD; Sangimino Mark, MD;. Missed Pediatric Monteggia Fractures. JBJS Reviews – Review Article: 05 June 2018 – Volume 6 – Issue 6 – p. e2-e2
2. Monteggia fracture. http://www.orthobullets.com. Accessed 9/23/2020

The patient is presenting with a benign osteochondroma. This osteochondroma is uncommon in that it is located on the anterolateral femur causing mechanical impingement on the patella during knee motion. An osteochondroma is the most common benign tumor of childhood and young adults. Solitary osteochondromas may, although very rare (<1%), transform to a malignant chondrosarcoma over time. It is essential to identify tumor characteristics on radiographs and MRI to establish the correct diagnosis. Radiographic features of a benign lesion include tumor location at the metaphysis, the cortex of the lesion continuous with the cortex of the surrounding femur, and no metastases. Patterns of bone destruction signal a more malignant nature of a tumor. These patterns may include moth-eaten bone, a fast growing tumor, and an absent sclerotic boarder. MRI is the study of choice to assess the characteristics of the lesion to help determine if the lesion is benign or malignant. A cartilaginous cap greater than 1.5 cm is thickness is suspicious for malignant transformation. Surgical treatment of a solitary osteochondroma involves a marginal resection that includes the base of the stalk, the cartilage cap, and overlying periosteum. A wide resection is the treatment of choice for a chondrosarcoma. 1,2,3

Answer C.

References

1. August Image Quiz: Osteochondroma. Journal of Orthopaedics for Physician Assistants – Image Quiz: 01 August 2015 – Volume 3 – Issue 3 – p. 16
2. Aboulafia, Albert J. MD; Kennon, Robert E. MD; Jelinek, James S. MD Benign Bone Tumors of Childhood, Journal of the American Academy of Orthopaedic Surgeons: November 1999 – Volume 7 – Issue 6 – p 377-388.
3. Osteochondroma. http://www.radiopaedia.org. Accessed on 3/28/21.

The patient has clearly disrupted his extensor mechanism as he is unable to straight leg raise. Radiographs indicate he has ruptured his quadriceps tendon as a low riding patella (patella baja) is present. Quadriceps ruptures occur almost exclusively in men over 40 years of age. Quadriceps tendon ruptures are usually pretty obvious clinically with a palpable defect in the tendon near the patella insertion (suprapatellar gap), inability to straight leg raise, and patella baja on radiographs. MRI is only necessary if the diagnosis remains unclear. Acute ruptures are treated surgically with repair of the tendon back down to the patella. Patients should be treated surgically within 7 days as tendon retraction can occur beyond 72 hours. Retraction over time can make the repair more difficult and a graft may be necessary to fill the gap in cases of chronic tears. The most appropriate initial treatment in the emergency room setting is to place the injured extremity in a knee immobilizer with instructions to weight bear as tolerated with crutches. Instructions to follow-up with an orthopedic surgeon within 1-2 day is critical to ensure a timely repair. 1,2

Answer B.

References

1. Ilan, Doron I. MD; Tejwani, Nirmal MD; Keschner, Mitchell MD; Leibman, Matthew MD Quadriceps Tendon Rupture, Journal of the American Academy of Orthopaedic Surgeons: May 2003 – Volume 11 – Issue 3 – p 192-200
2. Quadriceps rupture. http://www.orthobullets.com. Accessed on 2/28/21.

Lateral ankle injuries are commonly seen in the pediatric population. In fact, ankle trauma is the most common pediatric injury. In skeletally immature patients it can be hard to conclude whether the injury is a lateral ankle sprain or a Salter-Harris I (non-displaced) fracture. A careful physical exam is critical in making the diagnosis, however kids often have difficulty pinpointing the exact location of the pain. Historically most lateral ankle injuries have been presumed to be growth plate injuries. The theory is that in growing kids, the physis is weaker than the surrounding ligaments and therefore injury to the growth plate is more likely. This theory has since been proven untrue. Boutis et al. performed an MRI on 135 pediatric patients who sustained a lateral ankle injury and found that almost all patients injured the lateral ligaments and not the physis. Only 4 of 135 (3%) patients had an MRI confirmed Salter-Harris I fracture. Salter-Harris I fractures and lateral ankle sprains have a similar treatment course which includes short-term immobilization or bracing (usually 3 weeks depending on symptoms) with a gradual return to activities as tolerated. Physical therapy is an important treatment for lateral ankle sprains to regain ankle motion, reduce swelling, and strengthening. Misdiagnosing lateral ankle sprains for physeal injuries often prevents physical therapy referral and leads to unnecessary immobilization and follow-up radiographs.

Answer D.

References

1. Boutis, Kathy, et al. “Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain?.” JAMA pediatrics 170.1 (2016): e154114-e154114.
2. Rougereau G, Noailles T, El Khoury G, Bauer T, Langlais T, Hardy A. Is lateral ankle sprain of the child and adolescent a myth or a reality? A systematic review of the literature. Foot and Ankle Surgery. 2021 May 1.

A toddler’s fracture is a low impact fracture of the distal one-third tibia with an intact fibula that usually occurs in children under the age of 2.5 years. A toddler’s fracture can occur as the tibia is rotated and the foot is fixed to the ground which causes the classic spiral fracture pattern. The injury can occur while running or falling from a height. The injury frequently goes unnoticed by parents or caregivers which may delay the presentation to clinic. Common physical exam findings include swelling and refusal to bear weight on the affected extremity. The fracture is generally non-displaced and may not be evident on initial radiographs. A toddler that presents to the office with a limp, pain along the affected tibia, and normal x-rays should be treated as a fracture. Treatment involves placing the child in a long leg cast with the knee flexed at 30 degrees to avoid weight bearing. Healing callus may be evident along the tibial periosteum as early as 2-3 weeks after the injury and may be the only evidence that a fracture occurred. The differential diagnosis in a limping toddler may include other subtle fractures that are caused by minor trauma including metatarsal buckle fractures, fractures of the midfoot, and fractures of the proximal tibia and distal tibia and fibula. 1,2

Answer C

References

1. John, Susan D., Chetan S. Moorthy, and Leonard E. Swischuk. “Expanding the concept of the toddler’s fracture.” Radiographics 17.2 (1997): 367-376.
2. Halsey, Matthew F., et al. “Toddler’s fracture: presumptive diagnosis and treatment.” Journal of Pediatric Orthopaedics 21.2 (2001): 152-156.

The hamstrings are made of 3 muscles including the semimembranosus, semitendinosus, and the biceps femoris which all attach to the pelvis at the ischial tuberosity. The biceps femoris has a long head, which attaches to the ischial tuberosity and a short head, which attaches to the mid-femur. The hamstring muscles can tear with a sudden extension of the knee in a flexed position, or a sudden contraction of the hamstrings. Most tears are muscular (better described as a strain) and occur near the midpoint of the hamstrings. Proximal avulsion injuries, where the hamstring tendons avulse off the ischial tuberosity, represent a more severe injury. Patients with proximal injuries have trouble sitting, ecchymosis in the buttocks a few days after the injury, and severe hamstring weakness. Radiographs should be taken in all patients with a suspected proximal rupture to rule out a bony avulsion fracture, which is common in the pediatric population. MRI is the study of choice to determine the extent of proximal avulsion injuries. Non-operative treatment is indicated with hamstring strains, one tendon proximal tears, and two tendon proximal tears with less than 2mm of retraction. Surgical repair is indicated when all three tendons are torn off the ischial tuberosity or if there is >2mm retraction from two tendons. Acute repair should be performed within 4 weeks of the injury or the tendon begins to retract and becomes difficult to repair. 1,2

Answer D.

References

1. Alzahrani M, Aldebeyan S, Abduljabbar F. Hamstring Injuries in Athletes: Diagnosis and Treatment. JBJS Reviews – Review Article: 30 June 2015 – Volume 3 – Issue 6 – p. e5
2. Cohen S, Bradley J. Acute Proximal Hamstring Rupture, Journal of the American Academy of Orthopaedic Surgeons: June 2007 – Volume 15 – Issue 6 – p 350-355

Dupuytren’s disease, or Dupuytren’s contracture, is an abnormal proliferation of the palmar fascia of the hand which leads to thickening of the palmar fascia. As the “cord” or thickening of the palmar fascia progresses, a flexion deformity of the MCP joint can start to develop. This patient is presenting early in the disease with a non-painful enlarging nodule and cords in the palm of her hand. Dupuytren’s disease is difficult to treat as there is no cure and the disease often progresses and reoccurs after surgical treatment. Observation is the best treatment option for patients who present early in the disease without pain and functional limitations. Physical therapy and bracing have not been shown to prevent or reverse Dupuytren’s contractures. Intralesional steroid injections may soften the nodule and potentially slow the progression of the disease. Injection of Clostridium histolyticum collagenase (Xiaflex) into the disease nodule can help break up and rupture cords to release flexion contractures. Surgical resection of the cords is indicated when there is decreased hand function caused by a flexion contracture at the MCP joint >30 degrees and the PIP joint >15 degrees. 1,2

Answer A.

References

1. Rayan G. Dupuytren Disease: Anatomy, Pathology, Presentation, and Treatment. The Journal of Bone & Joint Surgery – Selected Instructional Course Lecture: January 2007 – Volume 89 – Issue 1 – p. 189-199
2. Riester S, Van Wijnen A, Rizzo M, Kakar S. Pathogenesis and Treatment of Dupuytren Disease. JBJS Reviews – Review Article: 08 April 2014 – Volume 2 – Issue 4 – p. e2

The patient is presenting with vertebral osteomyelitis/ discitis which was caused by a postoperative infection. Other causes of discitis other than surgical inoculation include hematogenous dissemination (most common) which may be from intravenous drug use or a recent systemic infection. The most common pathogen is Staph aureus followed by Staph epidermidis and then gram-negative organisms associated with respiratory or genital urinary infections. The most common symptoms of discitis include diffuse lower back pain that is worse at night. The most common location for discitis includes the lumbar spine followed by thoracic, then cervical and lastly, the sacrum. Fever is present in one-third of patients and neurological symptoms occur in less than 20% of patients. Treatment involves identifying the causative organism before antibiotics are administered, either by blood culture or CT guided bone biopsy. If the blood cultures are positive than a CT biopsy can be avoided. Surgical management is recommended when there is evidence of neurological deficits, large abscess formation, or spinal instability. 1,2

Answer A.

References
1. Ahsan K, Hasan S, Khan SI, Zaman N, Almasri SS, Ahmed N, Chaurasia B. Conservative versus operative management of postoperative lumbar discitis. J Craniovertebr Junction Spine. 2020 Jul-Sep;11(3):198-209. doi: 10.4103/jcvjs.JCVJS_111_20. Epub 2020 Aug 14. PMID: 33100770; PMCID: PMC7546051.
2. Adult pyogenic vertebral osteomyelitis. http://www.orthobullets.com. Accessed on 9/10/22.

The patient has a classic bipartite patella on x-ray which was misdiagnosed as a patella fracture at the urgent care he went to. A bipartite patella is a congenital abnormality caused by failure of the patella growth plate to fuse. The abnormality is usually asymptomatic and found incidentally on x-ray. The x-ray of a bipartite patella classically shows a bony island at the superolateral pole of the patella. Most (75%) are located at the superolateral portion of the patella, 20% are lateral margin and 5% are inferior pole. A bipartite patella has smooth edges in between the bone island and main patella which helps differentiate from a fracture. A painful bipartite patella is rare and may be caused by a traumatic injury to the knee that disrupts the fibrocartilaginous connection between the main patella and accessory fragment. The presence of edema on MRI along the fibrocartilaginous connection can confirm an acute injury. Surgical excision of the accessary bone is only considered in patients with persistent pain beyond 6 months. Initially, patients should be treated with local ice, oral anti-inflammatories, and activities to tolerance. 1,2
Answer C.
References
1. Iossifidis A, Brueton RN. Painful bipartite patella following injury. Injury. 1995 Apr 1;26(3):175-6.
2. Bipartite patella. http://www.orthobullets.com. Accessed on 9/9/22.

The patient has a Salter Harris IV fracture of the medial malleolus as the fracture extends from the epiphysis through the physis and includes a small metaphyseal fragment. The fracture was found to be displaced 5 mm on CT which is well beyond the acceptable 2mm of displacement allowed for conservative treatment. Articular step off greater than 2mm is associated with an increased risk of post-traumatic arthritis. CT imaging is recommended for all patients suspected of having an articular step off. CT can often change the course of treatment as determining fracture pattern and displacement can be very difficult on plain x-ray. This patient is approaching skeletal majority as the distal tibial physis usually closes by age 16 in males. As such, screw fixation from the medial malleolus through the physis can be performed without fear of causing growth arrest. This patients surgery required an open reduction as his thick periosteum blocked attempts at closed reduction. 1,2

Answer C.

1. Su AW, Larson AN. Pediatric Ankle Fractures: Concepts and Treatment Principles. Foot Ankle Clin. 2015 Dec;20(4):705-19. doi: 10.1016/j.fcl.2015.07.004. Epub 2015 Oct 16. PMID: 26589088; PMCID: PMC4912125.
2. Pediatric ankle fractures. http://www.orthobullets.com. Accessed on 8/2/22.

A mallet finger is caused by loss of extension at the distal interphalangeal (DIP) joint due to an extensor tendon disruption or bony avulsion off the dorsal aspect of the distal phalanx. Loss of extension at the DIP causes the flexor digitorum profundus tendon to pull the DIP joint into a flexion deformity. Bony avulsion fractures are stable if there is no subluxation of the distal phalanx, less than 50% of the joint surface is involved, and < 2-3 mm of displacement. Treatment of acute mallet injuries (<4 weeks old) involves keeping the DIP joint in an extension splint for 6-8 weeks. Dorsal or volar based splints can both be used as studies have shown no greater extension lag deformity with using one or the another. It is common for the DIP joint to have some permanent flexion of less than 10-20 degrees after treatment, however greater than 25 degrees is considered a poor outcome. 1,2

Answer B.
References
1. Alla SR, Deal ND, Dempsey IJ. Current concepts: mallet finger. Hand. 2014 Jun;9(2):138-44.
2. Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T. Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. The Journal of hand surgery. 2010 Apr 1;35(4):580-8.

Osteoporosis related lumbar compression fractures are a common injury in the aging population. Patients can often be treated conservatively with a corset brace, NSAIDs, and if necessary, narcotic pain medication. Pain associated with lumbar compression fractures can last much longer than other fracture types, in some cases lasting up to 4-6 months. Cement augmentation with kyphoplasty is another treatment option that can help relieve lower back pain and preserve vertebral height in patients who have failed at least 2-3 weeks of conservative treatment. MRI should be performed if a kyphoplasty is considered. MRI is critical in determining the age of fracture, with bony edema signaling an acute or subacute process. The absence of bony edema on MRI indicates a chronic fracture which is not amenable to kyphoplasty. Time to kyphoplasty is controversial with most agreeing non-operative treatment should be trialed for 2-3 weeks after onset of symptoms. The average time to kyphoplasty after onset of symptoms in one large meta-analysis was 10 weeks, with the same study showing improved outcomes with surgery over conservative care. Kyphoplasty has not been shown to increase the risk of adjacent, or secondary, vertebral fractures. Relative contraindications for kyphoplasty include bone retropulsion, the presence of radiculopathy, and greater than 70% vertebral height loss. 1,2

Answer A.

References

1. Halvachizadeh S, Stalder AL, Bellut D, Hoppe S. Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures. A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management. JBJS Rev, 9(10):e21.00045
2. Savage JW, Schroeder GD, Anderson PA. Vertebroplasty and kyphoplasty for the treatment of osteoporotic vertebral compression fractures. J Am Acad Orthop Surg. 2014 Oct;22(10):653-64.

Patients that present with a suspected scaphoid injury with negative x-rays create a treatment dilemma for providers. Treating the injury as a suspected occult fracture or obtaining immediate advanced imaging is the controversial next step. Up to 30% to 40% of scaphoid fractures are missed with clinical exam and initial x-rays and a missed diagnosis can lead to long term complications. Anatomical snuffbox tenderness is the most sensitive physical exam finding for identifying scaphoid fractures. Many providers treat patients with snuffbox tenderness with wrist immobilization due to a suspected fracture. However, treating all suspected scaphoid fractures as true fractures can result in unnecessary immobilization, lost time from sports and/or work, and potentially post-immobilization stiffness. Obtaining immediate advanced imagining is favored in most cost and outcome models as a negative MRI avoids the expense of further follow-up visits and repeat x-rays. If an immediate MRI is not available or unaffordable, a reasonable approach would be to repeat a physical exam and x-rays 2 weeks after the initial office visit. 1,2

Answer C

References

1. Karl JW, Swart E, Strauch RJ. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am, 97(22):1860-1868 | Scientific Articles | November 18, 2015
2. Stirling PH, Strelzow JA, Doornber JN, White TO, McQueen MM, Duckworth AD. Diagnosis of Suspected Scaphoid Fractures. JBJS Rev, 9(12):e20.00247 | Review Articles | December 08, 2021

Most posterior malleolar fractures occur in the setting of other fractures such as the trimalleolar fracture pattern (lateral, medial, and posterior malleolus fractures). Isolated posterior malleolar fractures (as with this case) are far less common and easy to miss. The importance of an intact posterior malleolus is to maintain a congruent joint line and provide stability to the ankle joint. AP, lateral and mortise view x-rays should be performed initially to determine the fracture pattern and to look for evidence of a syndesmotic injury. CT is recommended for all posterior malleolar fractures to check for joint space congruity and lateralization of the talus. For isolated, non-displaced posterior malleolar fractures, non-operative treatment with a non-weightbearing boot or cast is recommended. There is no clear consensus on indications for operative treatment but in general a fracture involving >33% of the articular surface and a >2mm articular step off are indications for open reduction and internal fixation. 1,2
Answer A.
References
1. Irwin, Todd A. MD; Lien, John MD; Kadakia, Anish R. MD. Posterior Malleolus Fracture. Journal of the American Academy of Orthopaedic Surgeons 21(1):p 32-40, January 2013. | DOI: dx.doi.org/10.5435/JAAOS-21-01-32
2. Smeeing DPJ, Houwert RM, Kruyt MC, Hietbrink F. The isolated posterior malleolar fracture and syndesmotic instability: A case report and review of the literature. Int J Surg Case Rep. 2017;41:360-365. doi: 10.1016/j.ijscr.2017.10.062. Epub 2017 Nov 13. PMID: 29149741; PMCID: PMC5695917.

The cauda equina consists of peripheral nerve roots (L1-S5) that continue from the spinal cord (picture a horse tail leaving the spinal cord) and is surrounded by a dural sac within the lumbar spinal canal. Lumbar disc herniations that compress peripheral roots can cause a number of symptoms including lower back pain, leg pain, and numbness and weakness in the lower extremities. A large disc herniation that occupies the central canal can compress the cauda equina causing severe motor and sensory impairment, or cauda equina syndrome (CES). Symptoms of CES may vary and include lower extremity pain and weakness, saddle anesthesia, and loss of bowel or bladder function. Loss of bladder function is a required element of CES and can vary from difficulty initiating a urinary stream to full incontinence. If symptoms of CES exist an urgent MRI must be performed to confirm the diagnosis and prepare for surgery. Neurological deficits can progress rapidly and become permanent with CES unless the disc herniation is removed and pressure is taking off the nerve roots. Emergent surgical decompression should be performed within 24-48 hours of symptom onset to improve neurological recovery. 1,2

Answer D.

References

1. Spector, Leo R. MD; Madigan, Luke MD; Rhyne, Alfred MD; Darden, Bruce II MD; Kim, David MD. Cauda Equina Syndrome. Journal of the American Academy of Orthopaedic Surgeons 16(8):p 471-479, August 2008.
2. Gitelman A, Hishmeh S, Morelli BN, Joseph Jr SA, Casden A, Kuflik P, Neuwirth M, Stephen M. Cauda equina syndrome: a comprehensive review. Am J Orthop (Belle Mead NJ). 2008 Nov 1;37(11):556-62.

Osgood-Schlatter disease (OSD) is a common knee condition seen in active adolescence which results from traction apophysitis at the tibial tubercle. Symptoms start during a period of rapid skeletal growth while patients participate in athletic activities. The diagnosis is straightforward with pain to palpation over the tibial tubercle and pain that is made worse with running and jumping activities. Radiographs are usually normal but may show irregularity and fragmentation of the tibial tubercle. Advanced imaging with MRI and/or CT is not indicated to confirm the diagnosis. Treatment involves NSAIDS, ice, activity modification and quadriceps stretching. Patients may have to pause athletic activities for a short period if pain is significant, however most patients can play through mild discomfort. OSD can be a nagging type of condition that lasts up to 12-18 months but generally resolves when patients reach skeletal maturity. Maintaining quadriceps flexibility through sport activities is critical to managing symptoms. 1,2

Answer A.

1. Bloom OJ, Mackler L. What is the best treatment for Osgood-Schlatter disease?. Clinical Inquiries, 2004 (MU). 2004.
2. Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood–Schlatter disease: review of the literature. Musculoskeletal surgery. 2017 Dec;101(3):195-200.

A ganglion cyst is the most common tumor of the hand and is 3 times more likely to occur in women compared to men. Ganglion cysts can occur on tendons by adhering to the outside of the tendon without affecting function. A flexor tendon sheath ganglion can be diagnosed by the presence of a small mass that moves with the tendon. Aspiration of clear gelatinous fluid helps confirm the diagnosis and rule out other causes in the differential such as a giant cell tumor and infection. MRI and x-ray are not indicated when a flexor tendon ganglion cyst is clinically diagnosed. Observation is first recommended in most cases as the cyst will likely resolve with time. This patient has trialed a period of immobilization however, and an aspiration is the most appropriate next step. Aspiration with or without steroid injection can be performed if the cyst fails to resolve. Patients should be warned that skin depigmentation and atrophy can occur with a steroid injection. A single aspiration has a high likelihood of recurrence, while surgical excision is often successful for complete resolution. Surgical excision comes with a higher risk of potential complications (infection, wound healing issues) so an aspiration is recommended before surgery is considered. 1,2
Answer B.
Resources
1. Thornburg, Lacy E. MD. Ganglions of the Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons: July 1999 – Volume 7 – Issue 4 – p 231-238
2. Jebson PJ, Spencer Jr EE. Flexor tendon sheath ganglions: results of surgical excision. Hand. 2007 Sep;2(3):94-100.

Each finger has a digital nerve that runs on both the radial and ulnar boarders, supplying sensation to their respective sides. Digital nerves provide discriminatory sensation which is critical for hand function and dexterity. Digital nerve injuries are often missed as clinicians often fail to perform simple tests required to make the diagnosis. Nerve injuries treated with surgical repair do better if treated early so making the diagnosis is critical. Two point discrimination of the finger is often used to determine if a digital nerve has been injured and requires repair. The American Society for Surgery of the Hand (ASSH) recommended values for two point discrimination (2PD) includes <6 mm is counted as normal, 6–10 mm as fair, 11–15 mm as poor, and >15 mm as protective. Digital 2PD >6mm is highly predictive of a digital nerve injury. Microsurgical repair is performed within the first several days of injury to provide for optimal nerve regeneration. 1,2
The patient has 2PD over 6 mm on both sides of his ring finger indicating a likely laceration through both digital nerves. He is also unable to flex his DIP indicating a likely FDP tendon laceration but can flex his IP joint indicating an intact FDS tendon. 1,2
Answer A.
References
1. Boesch CE, Medved F, Held M, Bender D, Schaller HE, Fuchsberger T. Analysis of the two-point discrimination test in daily routine practice. European Journal of Plastic Surgery. 2017 Aug;40(4):333-6.
2. Mermans JF, Franssen BB, Serroyen J, Van der Hulst RR. Digital nerve injuries: a review of predictors of sensory recovery after microsurgical digital nerve repair. Hand (N Y). 2012 Sep;7(3):233-41.

The ulnar styloid is a bony projection of the distal ulnar that serves as an attachment site for distal radial and ulnar joint ligaments (DRUJ) and triangular fibrocartilage complex (TFCC). Isolated ulnar styloid fractures are rare as they usually occur in association with distal radius fractures. Although the non-union rate for ulnar styloid fractures can be as high as 77%, rarely due they cause any DRUJ instability or require surgical fixation. Treatment of minimally displaced fractures includes a short arm cast for 6 weeks. The size and amount of displacement of the ulnar styloid fracture is the best predictor of resulting DRUJ instability. Fractures can occur (from smallest to largest) at the tip, base, or the larger fovea. Fractures at the tip are the most common and least likely to cause instability. Fractures with >2mm of displacement are more likely to cause DRUJ instability. Displaced ulnar styloid fractures can increase the likelihood of symptomatic abutment to the carpus. Evidence of DRUJ instability include a positive Ballottement test, widening of the DRUJ on AP x-ray, and radioulnar distance of more than 6mm on lateral view x-ray. 1,2,3
Answer B.
References
1. Maniglio M, Park IJ, Zumstein M, Kuenzler M, McGarry MH, Lee TQ. The critical size of ulnar Styloid Fragment for the DRUJ Stability. Journal of wrist surgery. 2021 Oct;10(05):385-91.
2. Mirghasemi AR, Lee DJ, Rahimi N, Rashidinia S, Elfar JC. Distal Radioulnar Joint Instability. Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):225-9.
3. Logan AJ, Lindau TR. The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment. Strategies Trauma Limb Reconstr. 2008 Sep;3(2):49-56.

A careful physical exam and knowledge of finger anatomy is essential to prevent missing finger injuries. The main flexor tendons of the finger include the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. The FDS tendon inserts at the volar aspect of the middle phalanx and acts to flex the proximal interphalangeal (PIP) joint. The FDP tendon inserts at the volar base of the distal phalanx and acts to flex the DIP joint. A Jersey Finger is an avulsion of the FDP tendon off its insertion at the at the base of the distal phalanx. The mechanism of injury is a forced extension on a flexed finger such as when a football player grabs a jersey while the player runs away. The middle finger is involved in 75% of cases as the increased length results in a more forceful DIP flexion when grasping. On physical exam patients will have an inability to make a full fist and to flex the DIP joint. X-rays of the finger are critical for identifying a bony avulsion vs. a pure tendon avulsion. FDP avulsion injuries require surgical repair which includes reattaching the tendon back down to the distal phalanx. This should be performed within 3 weeks of injury or the tendon can retract and become irreparable. Avulsion fractures often require open reduction and internal fixation of the fracture fragment. Hand therapy is used postoperatively and return to sports is expected around 3 months post-op. 1,2
Answer D.
References
1. Ruchelsman, David E. MD; Christoforou, Dimitrios MD; Wasserman, Bradley MD; Lee, Steve K. MD; Rettig, Michael E. MD. Avulsion Injuries of the Flexor Digitorum Profundus Tendon. American Academy of Orthopaedic Surgeon: March 2011 – Volume 19 – Issue 3 – p 152-162
2. Bachoura A, Ferikes AJ, Lubahn JD. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017 Mar;10(1):1-9.

The olecranon is an attachment site for the triceps muscle and a critical component of the elbow extensor mechanism. The most common mechanism of injury causing an olecranon fracture is a direct blow to the elbow. Non operative treatment is recommended for non-displaced fractures whereas surgery is recommended in most cases of displaced fractures. The most common surgical options include both plate fixation and tension band wiring. Fracture fixation is not without potential complications however, which can occur more often in elderly patients with poor skin and osteoporotic bone. Duckworth et al found that in low demand elderly patients, non-operative treatment of displaced olecranon fractures had similar short and long term outcomes compared to operative treatment. Non operative treatment of displaced fractures is the same as for nondisplaced fractures; the elbow is immobilized in 60-90 degrees of flexion for 2-3 weeks, followed by gentle motion, and lifting restrictions until healing is present on x-ray. Weekly x-rays should be taken for the first 2-3 weeks to make sure further displacement doesn’t occur. The mean displacement in the aforementioned Duckworth study was 10 mm and greater displacement was associated with worse outcomes. 1,2
Answer A.
References
1. Duckworth AD, Bugler KE, Clement ND, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. JBJS. 2014 Jan 1;96(1):67-72.
2. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. Journal of orthopaedic trauma. 2001 Nov 1;15(8):542-8.

This patient sustained a low impact vertebral fracture in the setting of normal bone density which raises suspicion of a pathological fracture. The patient has a normal intact PTH, calcium, and vitamin D levels which rules out primary and secondary hyperparathyroidism. The most common primary bone malignancy and cause of a pathological vertebral fracture is multiple myeloma. Multiple myeloma is an incurable B lymphocyte malignancy characterized by proliferation and expansion of plasma cells in bone marrow. Symptoms can include fatigue and bone pain but many patients are completely asymptomatic and a pathological fracture is the first sign. Multiple myeloma is diagnosed when monoclonal proteins are found in the blood or urine. A serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) detect these proteins and should be ordered in patients with a suspected pathological fracture of the vertebral spine in the absence of a known cause of metastatic disease. If the SPEP and UPEP are positive then a bone marrow biopsy is performed to confirm plasma cells in the bone marrow. 1,2
Answer A.
References
1. Giorgi PD, Schirò GR, Capitani D, D’Aliberti G, Gallazzi E. Vertebral compression fractures in multiple myeloma: redefining the priorities during the COVID-19 pandemic. Aging Clinical and Experimental Research. 2020 Jul;32(7):1203-6.
2. Angtuaco EJ, Fassas AB, Walker R, Sethi R, Barlogie B. Multiple myeloma: clinical review and diagnostic imaging. Radiology. 2004 Apr;231(1):11-23.

Pediatric elbow injuries are one of the most common reasons for emergency room or urgent care visits. There are 6 growth centers around the elbow which can make interpreting x-rays difficult in pediatric age groups. Comparison x-rays of the un-injured elbow are often necessary to distinguish normal and abnormal findings. Supracondylar fractures are the most common fracture around the elbow (60%), followed by lateral and medial condylar fractures, and less common, radial head and olecranon fractures. Non-displaced fractures are treated non-operatively with a 3-4 week period of immobilization. Immobilizing options generally include a long arm cast, removable long arm splint, or a sling. The use of a long arm cast or posterior splint provides improved pain relief over a sling in the first two weeks from injury. Elbow immobilization should not be continued beyond 4 weeks as arthrofibrosis of the elbow can start to set in and could lead to a permanent loss of motion. Silva et al found that the use of a removable long arm soft cast (removable under parent supervision) for non-displaced elbow fractures provides a convenient option for patients while safely maintaining fracture alignment. 1,2
Answer C.
References
1. Lins RE, Simovitch RW, Waters PM. Pediatric elbow trauma. Orthopedic Clinics of North America. 1999 Jan 1;30(1):119-32.
2. Silva M, Sadlik G, Avoian T, Ebramzadeh E. A removable long-arm soft cast to treat nondisplaced pediatric elbow fractures: a randomized, controlled trial. Journal of Pediatric Orthopaedics. 2018 Apr 1;38(4):223-9.

The peroneal tendons include the peroneal brevis and peroneal longus tendons which primary function for foot eversion and pronation. Both tendons run along the lateral fibular and the peroneal brevis attaches to the base of the 5th metatarsal and the peroneal longus inserts on the plantar aspect of the first metatarsal and medial cuneiform. Physical exam signs of peroneal tendonitis include pain to palpation running along the lateral fibular and pain with resisted eversion of the foot. Injury to the peroneal tendons can range from tenosynovitis, tendinosis, and tearing. These injuries can occur from a number of causes such as an ankle sprain, hindfoot varus deformity, and ankle sprains, to name a few. MRI is the best study of choice to distinguish between these injuries and to look for tendon subluxation and tearing. Treatment of peroneal tendon pain starts with immobilization, ice, and anti-inflammatories. A walking boot for 3-4 weeks generally helps reduce inflammation, followed by a slow progression to normal activities. A lateral heel wedge can reduce hindfoot varus taking pressure off the peroneal tendons. 1,2
Answer A.
References
1. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot & ankle international. 2006 Mar;27(3):221-8.
2. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2009 May 1;17(5):306-17.

The patient has a displaced intra-articular dorsal base fracture of the distal phalanx. Distal phalanx fractures are the most common type of phalanx fractures. The vast majority of phalangeal fractures can be treated non-operatively, even with some displacement. For dorsal base fractures, if the joint is congruent then the fracture pattern is stable and can be treated with distal interphalangeal joint (DIP) immobilization. If the distal phalanx is subluxed from the middle phalanx and the fracture involves >30% to 40% of the articular surface, then open or closed reduction with percutaneous fixation is generally required. The terminal extensor tendon attaches to the dorsal base of the distal phalanx and acts to extend the DIP joint. Fractures of the dorsal base can cause an extension lag if there is disruption in the terminal extensor mechanism. This patient has full extension at the DIP joint with an intact terminal extensor mechanism. The patient was treated with an alumafoam splint to the DIP joint to keep the joint congruent and in extension. 1,2
Answer B.
1. Henry, Mark. Fractures and Dislocations of the Hand. Rockwood, C. A., Green, D. P., & Bucholz, R. W. (2006). Pg 782-785. Rockwood and Green’s fractures in adults (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
2. Phalanx fractures. http://www.orthobullets.com. Accessed on 5/28/2022.

Pediatric elbow fractures can be a challenge to diagnosis as the ossification centers of the elbow appear and close at varying ages. The capitellum is the first ossification center to appear at 1-2 years of age followed by the radial heat at 3-4, medial epicondyle at 5-6, the trochlea at 7-8, the olecranon at 9-10, and finally the lateral condyle at 11-12. The mnemonic CRITOE can be used to remember this sequence, capitellum, radial head, internal (medial) condyle, trochlea, olecranon, and external (lateral) epicondyle. Knowing this chronological sequence of ossification can help identify fractures and displacement. For instance, this patient’s olecranon ossification center has appeared so the medial epicondyle should be present. If there is any question of fracture, an x-ray of the contralateral elbow is useful for comparison. The medial epicondyle apophysis is the last growth plate to fuse in the elbow, generally between the ages of 15 and 20. The medial epicondyle is an attachment site for the forearm flexor-pronator mass and the ulnar collateral ligament. 1,2

Answer D.

References

1. Gottschalk, Hilton P. MD; Eisner, Eric MD; Hosalkar, Harish S. MD. Medial Epicondyle Fractures in the Pediatric Population. Journal of the American Academy of Orthopaedic Surgeons 20(4):p 223-232, April 2012. | DOI: 10.5435/JAAOS-20-04-223
2. Bolander S, Post G. Prompt Recognition. 5 Pediatric Elbow Fractures not to Miss. JBJS JOPA 2023; 11(2):

The differential diagnosis for hip pain in an athletic adolescent can be broad. Coxa saltans, otherwise known as “snapping hip syndrome”, can include a tight IT band snapping over the greater trochanter and catching of the iopsoas tendon at the iliopectineal eminence or on the femoral head. Other common diagnoses may include tight hip flexors, hip dysplasia, acetabular labral tear, and femoroacetabular impingement. Hip dysplasia generally produces symptoms of hip instability (popping sensation, pain with activities) and is associated with chronic symptoms for years. Radiographs of the hip will show decreased femoral head coverage with a lateral center-edge angle (LCEA) <20 degrees. Femoroacetabular impingement (FAI) causes pain with hip flexion and rotation and patients may describe their pain using a C sign by cupping the anterior lateral aspect of the hip with the thumb and forefingers. FAI is opposite to hip dysplasia as the condition is caused by over coverage of the femoral head by the acetabulum. FAI usually has an increased LCEA >40 degrees. Conservative treatment is initially recommended for all adolescent patients presenting with athletic related hip pain. A period of rest and NSAIDS can usually settle down an inflammatory condition like tendinitis or hip joint synovitis. Physical therapy is also important to stretch tight muscles and tendons and to strengthen the hip joint for athletic performance. 1,2

Answer A.

References

1. Schmitz, Matthew R. MD; Murtha, Andrew S. MD;  The ANCHOR Study Group; Clohisy, John C. MD. Developmental Dysplasia of the Hip in Adolescents and Young Adults. Journal of the American Academy of Orthopaedic Surgeons 28(3):p 91-101, February 1, 2020.
2. Allen, William C. MD; Cope, Ray MD. Coxa Saltans: The Snapping Hip Revisited. Journal of the American Academy of Orthopaedic Surgeons 3(5):p 303-308, September 1995.

The patient has an avulsion fracture of the less trochanter. Avulsion fractures are commonly seen in the pediatric population at secondary ossification centers including the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine, and less often in the tibial tubercle, calcaneus, and greater and lesser trochanters. Secondary ossification centers act as attachment sites for tendons and ligaments and don’t contribute to the length of bone. Secondary ossification centers generally fuse by 17 years of age so the most common age group for avulsion fractures are adolescent athletes. In adolescents the tendon attachment is stronger than the growth plate so sudden contraction of the attached tendon/muscle can result in an avulsion injury. Avulsion injuries are diagnosed radiographically in most cases and advanced imaging is not necessary unless the diagnosis is in question. Isolated lesser trochanter avulsion fractures occur with a sudden contraction of the iliopsoas muscle (hip flexor). Patients present with groin pain, difficulty ambulating, and inability to flex the hip. Lesser trochanter avulsion fractures are treated non-operatively with a 3-4 week period of rest and crutches for support, followed by a gradual rehab back into athletic activities. Sports should be resumed when the patient is asymptomatic and there are radiographic signs of healing, which may take 2-3 months. The prognosis for lesser trochanter avulsion injuries is excellent and surgery is only considered if patients develop a symptomatic nonunion and/or a painful exostosis. Surgery involves removal of the painful nonunion with reattachment of the iliopsoas to the proximal femur. 1,2

Answer C.

References

1. Tahir T, Manzoor QW, Gul IA, Bhat SA, Kangoo KA. Isolated Avulsion Fractures of Lesser Trochanter in Adolescents – A Case Series and Brief Literature Review. J Orthop Case Rep. 2019 Jan-Feb;9(1):11-14.
2. Schiller, Jonathan MD; DeFroda, Steven MD, ME; Blood, Travis MD. Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete. Journal of the American Academy of Orthopaedic Surgeons 25(4):p 251-259, April 2017.

The ulnar collateral and radial collateral ligaments provide stability to the MCP joint of the thumb and are critical structures for thumb function. The ulnar collateral ligament on the ulnar side of the thumb is particularly important for grasping objects and is 10 times more likely to be injured than the radial collateral ligament. UCL injuries represent 86% of all athletic thumb injuries. Treatment of bony avulsion injuries is controversial but general guidelines include conservative treatment if the fracture is displaced <2mm. Larger fragments (involving >30% of the joint space) and >2mm of displacement tend to have more thumb instability with conservative treatment. Fracture rotation can also lead to a nonunion so x-rays should be critically reviewed for alignment of the fracture fragment.  Treatment of nondisplaced, and <2mm displaced, bony UCL injuries involves immobilization with a thumb spica cast for 6 weeks. 1,2

Answer A

References

1. Thumb collateral ligament injuries. http://www.orthobullets.com. Accessed on 4/30/23
2. Chang, Andy L. MD; Merkow, David B. MD; Bookman, Jared S. MD; Glickel, Steven Z. MD. Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation. Journal of the American Academy of Orthopaedic Surgeons 31(1):p 7-16, January 1, 2023. | DOI: 10.5435/JAAOS-D-22-00112

The scapholunate (SL) ligament is an interosseous structure that stabilizes and connects the scaphoid and lunate bones during wrist motion. The SL ligament has three parts: the dorsal (strongest part of ligament, intermediary, and volar. Injury to the SL ligament is commonly caused by a fall on an outstretched hand which may cause dorsal wrist pain and swelling. SL ligament tears are often missed as AP radiographs are commonly for the injury. A clench fist view x-ray is a dynamic study to help diagnose an SL injury and will show widening of the SL interval. Bilateral clenched fist views are recommended as they consistently pick up SL gaps (if present) and subtle changes. An SL gap >3mm is considered abnormal and unstable. MRI is the best study to diagnose SL ligament tears, and determine the extent of injury, which can range from partial, complete repairable, and complete irreparable tears. Missed SL ligament injuries can progress from a partial tear to complete tear without timely treatment, leading to wrist instability and progressive arthritis. Non-operative treatment for nondisplaced SL injuries is recommended and may include casting or splinting the wrist. Complete tears on MRI and SL widening seen on dynamic x-ray should be treated operatively. 1,2
Answer A.
References
1. Schmitz MW, Morrell NT, Jacobs RC. Diagnosis and Surgical Treatment of Acute Scapholunate Ligament Injuries. JBJS JOPA, 9(2):e20.00039
2. Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: a review of current concepts. Hand. 2013 Jun;8(2):146-56.

Patients that present with a suspected scaphoid injury with negative x-rays create a treatment dilemma for providers. Treating the injury as a suspected occult fracture or obtaining immediate advanced imaging is the controversial next step. Up to 30% to 40% of scaphoid fractures are missed with clinical exam and initial x-rays and a missed diagnosis can lead to long term complications. Anatomical snuffbox tenderness is the most sensitive physical exam finding for identifying scaphoid fractures. Many providers treat patients with snuffbox tenderness with wrist immobilization due to a suspected fracture. However, treating all suspected scaphoid fractures as true fractures can result in unnecessary immobilization, lost time from sports and/or work, and potentially post-immobilization stiffness. Obtaining immediate advanced imagining is favored in most cost and outcome models as a negative MRI avoids the expense of further follow-up visits and repeat x-rays. If an immediate MRI is not available or unaffordable, a reasonable approach would be to repeat a physical exam and x-rays 2 weeks after the initial office visit. 1,2

Answer C

References

1. Karl JW, Swart E, Strauch RJ. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am, 97(22):1860-1868 | Scientific Articles | November 18, 2015
2. Stirling PH, Strelzow JA, Doornber JN, White TO, McQueen MM, Duckworth AD. Diagnosis of Suspected Scaphoid Fractures. JBJS Rev, 9(12):e20.00247 | Review Articles | December 08, 2021

Knowing how to differentiate stable and unstable ankles fractures is critical in determining which injuries would do better with surgical treatment. Ankle stability is provided by the bones of the ankle and the surrounding ligament structures. The lateral ligaments include the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL).  The medial side of the ankle is stabilized by the deltoid ligament and the syndesmosis between the fibula and tibia is stabilized by the anterior and posterior inferior tibiofibular ligaments (AITFL and PITFL) and the interosseus ligament. Fracture patterns help dictate if a fracture is stable and if ligament structures have been injured. For instance, the more proximal that a fibular fracture occurs the more likely it is unstable. Medial sided deltoid tenderness on physical exam was once thought to indicate an unstable injury, however tenderness may indicate a superficial deltoid injury only and the stronger deep fibers may remain intact. A complete deltoid rupture will show medial clear space widening and lateral talar shift on mortise view x-ray indicating a unstable injury. If a complete deltoid injury is suspected (high fibular fracture, syndesmosis tenderness, normal initial x-rays) a weight bearing x-ray can be obtained 7-10 days after the injury to the stress the joint. MRI has not been shown to reliably, or accurately, determine a partial vs. complete deltoid rupture and is not recommended for ankle fractures.

Answer A.

References

1. Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: diagnosis and treatment. EFORT open reviews. 2018 May;3(5):294.
2. Nortunen S, Lepojärvi S, Savola O, Niinimäki J, Ohtonen P, Flinkkilä T, Lantto I, Kortekangas T, Pakarinen H. Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. JBJS. 2014 Nov 19;96(22):1855-62.

Acute carpel tunnel syndrome (ACTS) can occur after a distal radius fracture due to elevated compartment pressures in the wrist from swelling and compression from a displaced fracture. A carpel tunnel contusion can be differentiated from ACTS by worsening symptoms over time in ACTS. Generally symptoms are watched over a few days to follow symptom progression and wait for swelling to subside prior to surgery. Failing to recognize ACTS can lead to permanent injury to the medial nerve. ACTS is diagnosed clinically with pain and paresthesia in the medial nerve distribution or thumb, index, and middle fingers. Fracture translation >35% and female patients less than 48 years of age are at higher risk of developing persistent carpel tunnel syndrome. Patients with persistent or worsening ACTS symptoms should have a prophylactic carpel tunnel release at the time of open reduction and internal fixation (ORIF). A closed reduction of a displaced fracture and splinting may also help ACTS symptoms before definitive surgery. The incidence of ACTS after a distal radius fracture is around 9% and the symptoms are severe enough in 5% of patients to require a carpel tunnel release. A carpel tunnel release can be performed with a separate incision at the time of ORIF of a distal radius fracture. 1,2

Answer D.

References

1. Leow, J.M., Clement, N.D., McQueen, M.M. et al. The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius. Eur J Orthop Surg Traumatol 31, 981–987
2. Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. The Journal of hand surgery. 2008 Oct 1;33(8):1309-13.

Quervain (stenosing tenosynovitis) is a condition where the tendons become inflamed and swollen which causes friction and pain at the first dorsal compartment during thumb motion. The Finkelstein test is a reliable test to make the diagnosis and includes tucking the thumb in a clenched fist and ulnar deviating the wrist. X-rays of the thumb can help rule out carpometacarpal (base of the thumb) arthritis. A period of rest and immobilization with a thumb spica splint is recommended initially to help reduce the friction of the tendons gliding under the fibrous tissue of the first dorsal compartment. Corticosteroid injections offer a very successful treatment option should more conservative treatments fail. Many patients get complete relief after one injection. Nearly all patients will have relief of symptoms with a combination of an injection and intermittent immobilization at 6 months. If patients fail two injections and continue to have pain surgical treatment with an open release of the first dorsal compartment is a successful option. 1,2

Answer C.

References

1. Ilyas, Asif M. MD; Ast, Michael MD; Schaffer, Alyssa A. MD; Thoder, Joseph MD. de Quervain Tenosynovitis of the Wrist. Journal of the American Academy of Orthopaedic Surgeons 15(12):p 757-764, December 2007.
2. Larsen C, Fitzgerald M, Nellans K, Lane L. Management of de Quervain Tenosynovitis: A Critical Analysis Review. JBJS Rev, 9(9):e21.00069

Adhesive capsulitis is characterized by functional loss of both passive and active shoulder range of motion due to a fibroplastic proliferation of the joint capsule. Adhesive capsulitis most commonly occurs in middle-aged women and has a high association with hypothyroidism and diabetes. Most cases will resolve with conservative treatment within 6 months. The key to treatment is continued shoulder motion with physical therapy and a home stretching program. The focus should be a gentle and progressive stretching program. An intra-articular corticosteroid injection has been shown to improve passive motion and shorten the overall duration of symptoms.  Functional deficits after >6 months of physical therapy warrant discussion about surgical options which may include a manipulation under anesthesia or an arthroscopic capsular release. Sling immobilization is contraindicated because it likely will promote further joint contracture and prolonged recovery. 1,2

Answer B.

References

1. Redler, Lauren H. MD; Dennis, Elizabeth R. MS, MD. Treatment of Adhesive Capsulitis of the Shoulder. Journal of the American Academy of Orthopaedic Surgeons 27(12):p e544-e554, June 15, 2019. | DOI: 10.5435/JAAOS-D-17-00606
2. Wang W, Shi M, Zhou C, Shi Z, Cai X, Lin T, Yan S. Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder: a meta-analysis. Medicine. 2017 Jul;96(28).

A trimalleolar ankle fracture involves 3 critical components of the ankle joint: the lateral, medial and posterior malleolus. Trimalleolar fractures represent just 7% of all ankle fractures and are unstable injuries and prone to displacement. Nonoperative treatment may be attempted in low demand patients with non-displaced fractures. However, in healthy active patients the risk of ankle instability and post traumatic arthritis is too high with non-operative treatment and surgery is recommended. Surgical treatment typically involves open reduction and internal fixation of the lateral malleolus with a plate and screws and percutaneous screw fixation of the medial malleolus fracture. If the posterior malleolus fragment involves >25% of the joint space, open reduction and internal fixation is recommended. This usually involves a posterior surgical approach to the ankle with plate and screw fixation. This patient’s posterior malleolus fragment is small, or involving approximately 5% of the joint space, so it doesn’t need to be fixed. The medial and lateral malleolus are displaced and should be fixed. 1,2

Answer C.

References

1. Stead TS, Pomerantz LH, Ganti L, Leon L, Elbadri S. Acute Management of Trimalleolar Fracture. Cureus. 2021 Jan 6;13(1):e12536. doi: 10.7759/cureus.12536.
2. Hong CC, Nashi N, Roy SP, Tan KJ. Impact of trimalleolar ankle fractures: how do patients fare post-operatively?. Foot and Ankle Surgery. 2014 Mar 1;20(1):48-51.