Kuhn

1. Kuhn Question #6A 72 year old woman who was playing golf inadvertantly struck the ground during a drive and noted the sudden onset of pain and was unable to elevate her arm. Examination the following day revealed a lump in the area of her biceps muscle. Initial management consisted of a period of rest and anti-inflammatory drugs. Four weeks after the injury she continues to have pain and weakness in elevation. What is the best course of action?1. Electromyography of the axillary nerve2. Ultrasound of the long head of the biceps3. MRI4. Physical therapy5. Arthroscopic labral repair

2. Question dropped: This question was dropped from the scoring. Presumably this woman sustained an acute rupture of her biceps tendon with associated pain and obvious deformity. However, the failure of her symptoms to resolve over time with conservative therapy and the difficulty with elevation suggests further pathology. Rotator cuff pathology is very common in this age group and could be the source of pain and weakness with elevation. Electrodiagnostic studies of the axillary nerve will likley be unhelpful. She is not reported to have numbness in the axillary distribution and the low energy mechanism of injury is unlikely to cause nerve injury. Ultrasound of the long head of the biceps seems unnecessary given the obvious deformity. Also a biceps tendon rupture alone should not cause persistent weakness with elevation. An MRI would likely be helpful but maybe premature since this patient has had minimal nonoperative treatment up until this point. An arthroscopic labral repair is not indicated because we have been given no information to suggest the diagnosis of labral injury. The most reasonable answer is an initial trial of physical therapy. She has been resting the shoulder for a month and some of her pain and weakness may simply be attributed to weakness. However, the thought of rotator cuff tear should still be considered in this elderly patient, her nonoperative treatment should be maximized and risk/benefit ration should be thoroughly evaluated before considering surgical treatment in this elderly patient.

3. Question 22 (Deleted) A standard rehabilitation program for an acute ulnar collateral ligament sprain begins with which of the follow protocols? 1. Unrestricted active elbow ROM 2. Full-time elbow immobilization for 3 weeks 3. Isotonic elbow strengthening 4. Isometric elbow strengthening 5. Rhythmic stabilization drills

4. Clarke Answer: 4 Conservative treatment is attempted with partial tears and sprains of the UCL, although surgical reconstruction may be warranted for complete tears, or if nonoperative treatment is unsuccessful. CONSERVATIVE TREATMENT FOLLOWING ULNAR COLLATERAL SPRAINS OF THE ELBOW Immediate motion phase (weeks 0–2) 1. Brace (optional); nonpainful ROM [20°–90°]2. Active assisted range of motion (A/AROM), PROM elbow and wrist (nonpainful range)Exercises 1. Isometrics—wrist and elbow musculature2. Shoulder strengthening (no external rotation strengthening)Ice and compression

5. Remainder of Rehabilitation Protocol Clarke Intermediate phase (weeks 3–6)ROM: gradually increase motion to 135° (increase 100° per week).Exercises: initiate isotonic exercises: wrist curls, wrist extensions, pronation/supination, biceps/triceps, Dumbbells (external rotation, deltoid, supraspinatus, rhomboids, internal rotation)Ice and compression Advanced phase (weeks 7–12)Criteria to progress: full ROM, no pain or tenderness, no increase in laxity, strength 4/5 of elbow flexor/extensor Exercises: Initiate exercise tubing, shoulder program; Thrower's ten program; Biceps/triceps program; Supination/pronation; Wrist extension/flexion; Plyometrics throwing drills IV. Return to Activity Phase (week 12 through 14)Criteria to progress to return to throwing: Full, nonpainful ROM, No Increase in laxity, Isokinetic test fulfills criteria, Satisfactory clinical examinationExercises: Initiate interval throwing, Continue thrower's ten program, Continue plyometrics. Wilk KE. Rehabilitation of the thrower's elbow. Clin Sports Med - 01-OCT-2004; 23(4): 765-801, xii

6. Question 47 - Which of the following substances is labeled with technetium Tc 99m in a conventional bone scan? 1. Calcium 2. Phosphate 3. Alkaline Phosphatase 4. Bisphosphonate 5. Type I collagen

7. Answer: Item deleted C DewingOBS discusses Tc99 binding phosphate complexes, so this would be the preferred response.

8. Question 77 Which of the following structures is most responsible for limiting shoulder external rotation and inferior glenohumeral translation with the arm held at the side? 1. Coracohumeral ligament 2. Coracoacromial ligament 3. Superior glenohumeral ligament 4. Anterior band of the IGHL 5. Posterior labrum

9. Samantha Grillo Answer: Item deleted.There is no clear answer to this question. The CH ligament is taut in external rotation and resists inferior subluxation of the joint but the reference notes that this provides no inferior stability in neutral or IR. The CA ligament prevents superior translation/dislocation. The SGHL is similar to the CH ligament in that it acts as a restraint to inferiorly directed forces, but again it has its maximum effect in external rotation. The anterior IGHL is a restraint to translation with the arm abducted to 90degrees, extended, and externally rotated to 90 degrees. Finally, the labrum adds overally stability by increasing the depth and area of the glenoid cavity.Morrey BF, Itoi E, An K: Biomechanics of the Shoulder, in Rockwood CA, Matsen FA (eds): Rockwood and Matsen, The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998

10. Question 78 What characteristic change occurs in late-stage osteoarthritis? 1. Swelling of the matrix 2. Longer glycosaminoglycan side chains 3. Increase in keratin sulfate concentration 4. Increase in type II collagen 5. Clusters of chondrocytes

11. Samantha Grillo Answer: Item DeletedPer OBS, the most likely answer should be number 1 – swelling of the matrix. One of the earliest detectable changes in OA is an increase in water content that is statistically significant vs normal tissues. This remains true through the late stages of OA.Other changes in OA include decreased glycosaminoglycan chain length, decreased keratin sulfate concentrations, and a decreased number of chondrocytes. However, chondrocytes may be seen grouped together in a cloning attempt to heal a defect. (Thus, depending on how you define clusters, this could be the answer). Finally, the collagen makeup of degenerative cartilage remains predominantly type II. However, the exact mixture (percentage) remains debatable. Buckwalter, JA, Einhorn TA, Simon SR (eds): Orthopedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp477-488.

12. 108. As it relates to systems-based patient safety, computerized physician order entry (CPOE) has been shown to result in a 1 – significant increase in adverse drug events. 2 – significant increase in medication prescribing errors. 3 – significant increase in rule violations. 4 – significant decrease in sentinel events. 5 – high cost of implementation (conversion from paper systems).

13. Answer – Deleted item Carter Maurer This question was probably one of the trial questions used by OITE to test new ideas. Test taking skills can help answer this question. CPOE is either good or bad. It would be to hard to decide between 1,2, and 3, so therefore it must be good. If it is good, 4 is likely true. Answer 5 is difficult to eliminate as the system probably has some start up costs. Review of some of the literature states these systems have significant cost savings (although still no comments on initial start up costs). Remember for next year – CPOE is good, that will be the answer. Koppel R, et al: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. JAMA 2005;293:1197-1203.

14. S. Youngblood Question 142 Standard therapeutic ultrasound used as a modality operates at what therapeutic range? 1. 15,000 to 20,000 Hz 2. 25,000 to 50,000 Hz 3. 100,000 to 500,000 Hz 4. 750,000 to 1,000,000 Hz 5. 1,000,000 to 1,500,000 Hz

15. Question 142 S. Youngblood Preferred Response: Item Deleted“Who cares?” was not an option. Oh well… Ultrasound refers to frequencies above human hearing. According to OKU3 Sports Medicine, therapeutic ultrasound, used by physical therapists, is usually 0.5 MHz, which would make option #3 correct. However, several other sources I found placed the frequency range between 0.75 and 3 MHz, which would make #4 and #5 also correct. Lower frequencies penetrate further. Therefore, 1 MHz or lower is used for deep-seated (2-5 cm) lesions, while 2-3 MHz is used for more superficial lesions (1-2 cm). This confusion is probably why this already stupid question was thrown out. Therapeutic ultrasound can deliver as a high an energy level as 1-3 W/cm2, thus heating the tissues and theoretically increasing blood flow and stimulating healing.(?)

16. Q 142 The really interesting fact is that various RCT’s and Cochrane reviews have failed to show any statistical benefit to the use of “therapeutic ultrasound” as a modality for ankle sprains, knee OA, patellofemoral pain, carpal tunnel syndrome, and plantar heel pain to name a few. Nevertheless, it made it on the OITE and is one of the most prominently featured “modalities” in physical therapy. (Hey, my shoulder is getting hot! It must be working!!!) Meanwhile, several prospective RCT’s in the recent orthopaedic literature have shown a clinical benefit of low intensity ultrasound in speeding the healing of fractures. These applications generally use 1.5 MHz, and deliver much less energy, 30 mW/cm2. References:OKU3 Sports Medicine, AAOS, pp. 353-359Speed CA. Therapeutic Ultrasound in Soft Tissue Lesions. Rheum. 2001. 40. pp.1331-1336.Rubin et al, The Use of Low-Intensity Ultrasound to Accelerate the Healing of Fractures. Current Concepts Review. JBJS, 83-A, No. 2, pp. 259-270.