Case-based MCQ

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Correct Answer Is B Sciatic nerve palsies have been reported in patients undergoing CABG (coronary artery bypass graft) due to prolonged nerve pressure compounded by low arterial pressure provided by cardiopulmonary bypass. The sciatic nerve is formed by the ventral rami of L4-S3. The sciatic nerve also indirectly innervates many other muscles, via its two terminal branches: 1-Tibial Nerve -the muscles of the posterior leg and some of the intrinsic muscles of the foot. 2-Common Fibular Nerve- the muscles of the anterior leg, lateral leg, and the remaining intrinsic foot muscles. The sciatic nerve continues down the posterior thigh, giving rise to motor branches for the hamstring muscles. When the sciatic nerve reaches the apex of the popliteal fossa, it terminates by bifurcating into the tibial and common fibular nerves. The sciatic nerve provides motor innervation to the muscles of the posterior compartment of the thigh, the hamstring part of Adductor Magnus and all muscles of the leg and foot. The sciatic nerve provides sensory innervation to the skin of the lateral aspect of the leg (anterolateral and posterolateral), and almost all of the foot (exception is the medial part of the foot that is innervated by saphenous nerve). Signs of L4 nerve root injury include weak quadriceps extension, positive squat and rise test, and diminished knee-jerk reflex. L5 nerve root injury is suggested by foot drop with the weakness of the anterior tibial, posterior tibial, and peroneal muscles. There is a sensory loss over the shin and dorsal foot. Injury to S1 nerve root is suggested by impaired ankle plantar flexion and loss of ankle jerk. There is a sensory loss over lateral calf and foot. This patient has a combination of signs and symptoms suggestive of sciatic nerve injury.

A 60-year-old male undergoes CABG for acute coronary artery disease. On second-day post procedure, he is found to have absent right ankle jerk with the inability to perform dorsiflexion and plantar flexion. Inversion and eversion of the foot are also lost. What is the most likely diagnosis? A. Injury of common peroneal nerve B. Injury of sciatic nerve C. Injury tibial nerve D. Injury of L5 E. Spinal cord compression

Correct Answer Is E Primary care physicians frequently encounter patients with foot and ankle pain. Common causes of pain in the proximal foot include ankle sprains, plantar fasciitis, and tarsal tunnel syndrome. Ankle sprains result from trauma with stretching of the lateral ankle ligaments. Swelling and bruising distal to the lateral malleolus are common. Evidence-based guidelines (Ottawa rules) suggests that the only patients who need x-rays of the ankle are those who cannot bear weight immediately after the injury or in the emergency department and those with point tenderness over the medial or lateral malleolus. Plantar fasciitis typically causes heel pain that is worse for the first few steps in the morning or after sitting. This is a common condition of runners after an increase in exercise intensity. The tarsal tunnel is a pathway along the medial malleolus between bone and the flexor retinaculum. The posterior tibial nerve runs through this path. Inflammation in this area can result in nerve irritation which causes pain in the ankle and heel and numbness of the sole of the foot at night. This condition is referred to as tarsal tunnel syndrome. Common causes of pain in the distal part of the foot include podagra (acute gout of the first metatarsal phalangeal joint, which comes on abruptly and is associated with swelling and redness), metatarsal stress fracture (which comes on abruptly, is made worse by weight-bearing, is associated with point tenderness, and may be associated with normal x-rays), hallux valgus (which is bunion formation as a result of lateral deviation of the great toe at the metatarsal joint) and Morton neuroma (which typically causes pain and numbness on the ball of the foot, and is made better by taking off shoes). Charcot joint is collapse of the arch of the associated with severe peripheral neuropathy.

A 54-year-old woman complains of pain and burning over the bottom of the forefoot; her symptoms are relieved by going barefoot. What is the appropriate disease? A. Plantar Fasciitis B. Metatarsal stress fracture C. Tarsal tunnel syndrome D. Hallux Valgus E. Morton neuroma

Correct Answer Is D During examination, patient was unable to plantar flex his left foot against resistance. Loss of the left ankle jerk was noted. This is supported by the radiological finding which showed a prolapse L5/S1 disc, subsequently causing left S1 nerve root impingement. Bladder function is mediated by autonomic outflow of lower sacral nerves. Foot drop is caused by weakness of the tibialis anterior, ankle and toe extensors which are supplied from the L5 nerve root through the common peroneal nerve, often associated with high-stepping gait. Quadriceps are innervated by the femoral nerve (L2-4). Knee jerk is controlled by quadriceps, hence the same nerve roots.

A 24-year-old man presented to the orthopaedic clinic with minimal back discomfort and complained of difficulty walking for the past two days. One month earlier, he developed a severe lower back pain while lifting a heavy load. MRI lumbosacral joint was ordered. Which one of the neurological findings would be consistent with this imaging? A. Loss of bladder function B. Weakness of left quadriceps C. Loss of left knee jerk D. Loss of left ankle jerk E. Left foot drop

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Correct Answer Is A This patient has symptoms of L4 radiculopathy. In L5 radiculopathy,pain usually is referred to posterolateral buttock,posterior thigh and lateral leg. In S1 radiculopathy,pain radiates through posterior buttocks,posterior calf and lateral foot.Ankle jerk is diminished as well in S1 radiculopathy. L5-S1 radiculopathy is mixture of both lesions. Sciatica is involvement of sciatic nerve causing shooting radiating pain through posterior thigh and posterior leg to little toe.

Mr John,a 48 year-old man with known history of chronic back pain comes to your clinic complaining of pain radiating to the hip,anterior thigh,medial aspect of knee and calf. On examination,sensory impairment is noted over medial calf.Knee jerk is also diminished. Which of the following is most likely diagnosis?   A. L4 radiculopathy B. L5 radiculopathy C. S1 radicuolpathy D. L5-S1 radiculopathy E. Sciatica

Correct Answer Is A This patient has developed clinical features of anterior cruciate ligament (ACL) injury while playing football. The clinical features of ACL injury include: – A ‘pop’ classically occurs at the time of knee injury with immediate severe pain. – An effusion develops within the first hour, and it indicates hemarthrosis. – Any attempt to continue activity results in episodes of an instability of the knee, especially when changing direction. – A knee that functions well in the anterior-posterior axis but gives way to rotational movements (often painlessly) suggests ACL deficiency. The examination of the knee involves assessment of following: – Weight bearing status. – Inspection and palpation for tenderness and effusion. – Assessment of the range of movements and muscle strength. There are specific tests which need to be performed to assess for particular area of knee injury: – ACL (anterior cruciate ligaments) rupture-Lachman and pivot shift tests. – PCL (posterior cruciate ligament) injury-posterior draw test and posterior sag. – Meniscal injury-McMurray test. – Collateral ligament injury – varus and valgus stress tests. – Patella dislocation – patellar apprehension test. The initial treatment of ACL injury includes rest, ice, compression and elevation (RICE). However, the ACL injury almost always needs reconstructive surgery and 9–12 months of intensive rehabilitation before they can return to competitive sport.

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A 19-year-old woman comes to your clinic after a knee injury while playing football. She heard a “pop” in the knee, and there was an immediate swelling of the knee. It felt as if the knee gave away. On examination, there is large effusion suspected of hemarthrosis. There is a severe restriction of knee extension. What is the most likely diagnosis? A. Anterior cruciate ligament tear B. Medial meniscus tear C. Lateral meniscus tear D. Lateral collateral ligament tear E. Medial collateral ligament tear

Correct Answer Is C This neonate has got all clinical features of developmental dysplasia of the hip. Developmental dysplasia of the hip, also called congenital hip dislocation can result in subluxed, dislocated femoral heads which will lead to early degenerative joint disease of the hips. It is commonly found in first-born females with breech delivery. The knees are at unequal heights when the hips and knees are flexed (the dislocated side is lower) and asymmetric skin folds and limited abduction of the affected hips are also seen. Early detection is critical to allow for proper hip development. Osgood-Schlatter disease is the overuse apophysitis of the tibial tubercle causing localised pain, especially with quadriceps contraction in active young boys. The slipped capital femoral epiphysis is the separation of the proximal femoral epiphysis through the growth plate may be due to an imbalance between growth hormone and sex hormones. Legg-Calve-Perthes Disease is idiopathic avascular necrosis of the femoral head most commonly found in boy 4-10 years of age.

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You are working as a resident medical officer at a local children hospital in Adelaide. You are seeing a 1-week old baby for complete neonatal examination. All the physical examination is unremarkable except the following findings: – The knees were at different heights when the hips and knees were flexed. – Asymmetric skin folds and limited abduction of the affected hip were also seen. What is the most likely diagnosis? A. Osgood -Schlatter disease B. Slipped capital femoral epiphysis C. Developmental dysplasia of the hip D. Femoral head fracture E. Legg-Calve-Perthes disease

Correct Answer Is E Bisphosphonates are currently the most commonly anti-resorptive agents prescribed as first-line treamtent for most of osteoporotic patients. Of this drug family, alendronate(10mg/dayor 70mg/week,orally), residronate(5mg/dayor 35mg/week,orally) and zoledronlc acid are available in Australia. Bisphosphonates should be used for at least 12 months before their efficacy on treatment of osteoporosis is assessed. However, in cases where the patient suffers two or more minimal trauma fractures despite being on sufficient doses of an anti-resorptive drug, e.g. bisphosphonates, commencement of teriparatide is justified as the most appropriate option. Teriparaitde is the synthetic parathyroid hormone that predominantly acts by increasing the osteoblasts (bone-forming cells) and by Inducing new osteoblasts formation. This drug is costly and at least 18 months of continuous use is needed effectiveness. Based on these, this medication is only reimbursed by the PBS for patients with severe osteoporosis and very high risk of fractures who have: A BMD T-score of =<-3 OR had two or more minimal trauma fractures OR experienced at least one symptomatic new fracture after at least 12-months of continuous therapy with an anti- resorptive agent at adequate While Mary has developed new osteoporotic fractures due to severe osteoporosis, continuation of the same agent is not a wise management. Switching to other bisphosphonates such as alendronate or zoledronic acid does not add any benefit, as all members of this drug family have almost the same effectiveness. Mary is already on the recommended weekly dose for residronate and increasing the dose of residronate does not seem to benefit her

Three months ago you started Mary, aged 73, on residronate 35mg weekly, after she was diagnosed with osteoporosis confirmed with bone mineral density (BMD). Her presenting symptom at that time was back pain. Examination revealed height decrease and mild kyphosis, as well as tenderness over thoracic vertebrae. Despite being on residronate, not only did her symptoms persist, she also developed pain over new areas of her thoracic. Investigations have established new osteoporotic fractures. Which one of the following would be the most appropriate management option for her? A. Continue residronate at the same dose B. Switch to alendronate C. Increase the dose of residronate D. Switch to zoledronic acid E. Switch to teriparatide

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