Regarding clinical diagnosis of a cruciate ligament injury, which ONE of the following statements is TRUE?
Answer: A: The clinical diagnosis of ACL injury has the following characteristics:
PCL tears less frequently present as isolated injuries than anterior cruciate tears.
References:
Regarding the diagnostic accuracy of a physical examination in detecting a meniscal injury, which ONE of the following examinations is likely to be MOST accurate?
Answer: A: Although presentations with meniscal injuries are relatively frequent, studies describing the accuracy of physical examination findings are limited. A combination of examination findings gathered from various examinations of the knee has a reasonably high sensitivity and specificity in the diagnosis of meniscal, ACL and PCL injuries. This is described as ‘composite examination of the knee’ in the literature without elaborating what specific examinations were included. No single examination or test has high sensitivity and specificity, although some of these tests are performed routinely. Therefore, findings from a number of examinations will be more useful in the ED diagnosis.
Mean sensitivity for composite examination is 77% and specificity is 91%. In contrast, joint line tenderness has a mean sensitivity of 79% but its specificity is very low at 15%. With a 95% confidence interval it has a positive likelihood ration (LR) of 0.9 and negative LR of 1.1. The mean sensitivity of the commonly performed McMurray test is 53% and specificity is 59%, with a positive LR of 1.3 and negative LR of 0.8. Other tests and examination findings (knee effusion, Apley compression test, medial-lateral grind test) have not been formally evaluated in more than one study.
Regarding ankle sprains, which ONE of the following statements is TRUE?
Answer: D: Sprains to the lateral ankle are more common than that to the medial ankle and occur secondary to significant inversion and plantar flexion. Isolated sprains to the anterior talofibular ligament occur in two-thirds of cases. Medial ankle sprains, especially deltoid ligament sprains, are less likely to occur in isolation. With medial collateral ligamental sprains a fracture of the proximal (Maisonneuve fracture) or midshaft fibula should be sought. If there is no associated fibular injury, injury to the talofibular syndesmotic complex at the distal lower leg may be present. This can be identified with a crossedleg test, which can elicit pain at the syndesmotic complex site indicating syndesmotic sprain.
Peroneal tendon subluxation or dislocation from its site at the posterior aspect of the lateral malleolus may occur with sudden hyperdorsiflexion of the foot with eversion. This results in tenderness and bruising over the posterolateral aspect of the lateral malleolus, which may mimic lateral ankle sprain.
Regarding radiographic assessment of an ankle in a patient who has a clinical diagnosis of an acute ankle sprain, which ONE of the following statements is INCORRECT?
Answer: C: In a patient with a clinical diagnosis of an acute ankle sprain, X-rays should be obtained following application of the Ottawa ankle rule. X-rays help to exclude fractures and to detect joint instability. Three standard views of the ankle (antero-posterior, lateral and mortise) should be obtained.
The presence of avulsion fractures usually indicate the location of ligamentous injuries and they may be present at malleoli, posterior malleolus, the lateral process of the talus, the lateral aspect of the calcaneus and the base of the fifth metatarsal.
In the presence of a joint effusion, the distended joint capsule can be seen anterior and posterior to the lower end of the tibia as a ‘tear drop’ on the lateral view. The presence of a joint effusion may suggest a subtle intra-articular fracture such as a fracture of the talar dome. In the mortise view, articular surfaces between the dome of the talus and the mortise should be parallel. The medial part of the joint space should not exceed 4 mm.
Anteroposterior view is important to assess the distal tibiofibular syndesmosis. In this view, usually there is an overlap between the distal tibia and fibula. Measurements outside the following suggest distal tibiofibular diastasis:
Reference:
Regarding an Achilles tendon rupture, which ONE of the following statements is INCORRECT?
Answer: B: In the diagnosis of Achilles tendon rupture the following may be helpful:
Weak active plantar flexion is still possible with a complete rupture as tibialis posterior, peroneal and long flexor muscles contribute to this movement. Weak plantar flexion should not be attributed to a partial tear. This is frequently a reason for misdiagnosis of a complete rupture.
In selected patients, especially older patients with smaller defects, non-operative management with a below-knee cast with the foot in gravity or maximal equinus position is indicated. Operative repair is mainly indicated in younger patients with large defects.
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