ROSH REVIEW
MUSCULOSKELETALQUESTIONS
WITH CORRCT ANSWERS GRADED
A+ FOR 2026-2027 ASSURED EXCEL!!
A 16-year-old boy presents complaining of right ankle pain after injuring himself while playing
basketball. He states that he "twisted his ankle" when he landed on another players foot trying
to get a rebound. He has not been able to walk on his right foot since this occurred two hours
ago and cannot do so in the ED. On examination, his pulses are intact. Strength and sensation
are normal. The ankle is swollen laterally. He is tender over the lateral malleolus and at the base
of the fifth metatarsal. No tenderness or swelling is noted over the proximal tibia and fibula.
Which of the following is true regarding emergency department radiographic work-up of this
patient?
A A complete ankle series is the only indicated study
B A complete foot series is the only indicated study
C Both a complete ankle and a complete foot series are indicated
D No radiographic imaging is indicated at this time
. - CORRECT ANSWERS-Correct Answer ( C )
Explanation:
The patient should undergo X-rays of both the ankle and the foot. The Ottawa Ankle Rules (OAR)
are a clinical decision making tool used to help determine the need for radiographic imaging
following blunt ankle injury. They apply to acute injuries that have occurred within the previous
48 hours, however are not useful in the subacute or chronic phase. The OAR were not designed
to be general guidelines for foot injuries; the foot rules only apply to the midfoot and do not
apply to the hindfoot or forefoot
A 45-year-old man presents with left leg pain. He describes a sudden onset pain in his calf area
while playing basketball with his son. On exam, you squeeze his right calf and elicit plantar
flexion of the right foot. When you do the same with his left calf there is no plantar flexion of his
,left foot. You administer ibuprofen and place the left leg in a posterior splint. Which of the
following is the most appropriate next step in management?
A Obtain X-rays of the ankle and foot
B Prescribe physical therapy
C Refer to orthopedic surgery
D Screen for autoimmune diseases - CORRECT ANSWERS-C Refer to orthopedic surgery
This patient has an abnormal Thompson test, a common clinical test used to diagnosed Achilles
tendon rupture. Achilles tendon rupture typically occurs in the setting of sudden and forced
dorsiflexion during athletic activity. Patients often report an audible "pop" and sudden pain in
the calf area that improves or subsides quickly, followed by decreased ability to plantar flex the
foot. The diagnosis is typically clinical. On physical examination, patients may exhibit a palpable
tendon defect in the lower calf area. Some plantar flexion is usually maintained, even in cases of
complete tendon rupture, due to the actions of the surrounding muscles. The Thompson test is
a classic maneuver to assess the Achilles tendon. The patient lies prone, with the legs flexed at
the knee at 90 degrees. The examiner then squeezes the calf muscles and observes for passive
plantar flexion of the foot. The injured extremity will have a weakened or no response
compared to the uninjured side. Risk factors for Achilles tendon rupture include
rheumatological diseases, chronic renal failure, steroid use, and recent treatment with
fluoroquinolone antibiotics. Controversy remains regarding the best treatment. While early
operative repair is associated with lower risk of rerupture and possibly improved functional
outcome, it also has a higher rate of complications. Nonoperative management consists of a
series of casts. Ultimately, the decision depends on the patient's age, activity level and
preference, and is best made on a non-emergent basis in consultation with an orthopedic
surgeon or sports medicine physician. Thus, initial management includes non-steroidal anti-
inflammatory analgesics, crutches, non-weightbearing status, immobilization of the ankle in
plantar flexion with a splint, and outpatient referral.
A 22-year-old woman presents with pain and swelling of the plantar surface of her foot. She
reports that two days prior to arrival she was walking in sneakers and stepped on a nail that
punctured her foot. Physical examination demonstrates 3 cm of warm, blanching erythema
without induration or fluctuance. Her tetanus vaccination is up-to-date. An X-ray does not show
,any foreign body. Which antibiotic is an appropriate choice to cover the organism at risk from
her shoe?
A Ciprofloxacin
B Dicloxacillin
C Linezolid
D Trimethoprim-sulfamethoxazole - CORRECT ANSWERS-Correct Answer ( A )
Explanation:
PunctureRwoundsRonRtheRbottomRofRtheRfootRareRatRhighRriskRforRinfectionRandRalsoRforeignRbodyRr
etention.RParticularlyRinRtheRsettingRofRaRpunctureRwoundRthatRpassesRthroughRtheRsoleRofRaRshoe,R
PseudomonasRaeruginosaRisRtheRcausativeRorganismRrequiringRtreatment.RInRtheory,RtheRorganism
RhasRanRaffinityRforRrubberRorRplasticRmaterialsRandRthereforeRisRtransferredRtoRtheRskinRthroughRth
eRpuncture.RInRgeneral,RPseudomonasRrarelyRcausesRskinRandRsoftRtissueRinfections.RCiprofloxacinRi
sRanRoralRfluoroquinoloneRwithRadequateRPseudomonasRaeruginosaRcoverage.RCareRmustRbeRtake
nRinRchildrenRwithRciprofloxacinRbecauseRofRconcernRoverRtheRdevelopmentRofRtendonopathy.RInRc
onsideringRallRskinRandRsoftRtissueRinfections,RStaphRandRStrepRareRstillRtheRmostRcommonRcausativ
eRorganisms,RbutRthisRparticularRclinicalRscenarioRmandatesRcoverageRforRPseudomonas.
DicloxacillinR(B)RisRaRpenicillinRderivativeRcommonlyRusedRtoRtreatRinfectionsRcausedRbyRStaphRaure
us.RStaphRaureusRcoverageRisRrequiredRinRskinRinfectionsRgivenRtheRprevalenceRofRthatRorganismRinR
cellulitisRinfections.RHowever,RitRdoesRnotRcoverRPseudomonas.RLinezolidR(C)RisRanRoxazolidinoneRa
ntibioticRwithRactivityRagainstRGram-
positiveRorganisms.RItRisRtypicallyRreservedRforRresistantRinfectionsRlikeRMethicillin-
resistantRStaphRaureusRandRVancomycin-
resistantREnterococcus.RItRisRavailableRasRanRoralRagentRallowingRforRtransitionRtoRoralRtherapyRfro
mRIVRmedicationRinRtheRhospital.RTrimethoprim-sulfamethoxazoleR(D)RisRaRsulfa-
basedRantibioticRwithRinRtheRsettingRofRskinRinfectionsRhasRwidespreadRactivityRagainstRcommunity
-associatedRMethicillin-
resistantRStaphRaureus.RItRdoesRnotRhaveRanyRactivityRagainstRPseudomonasRandRwouldRnotRbeRindi
catedRinRthisRclinicalRscenario.
OneRStepRFurther
, Question:RWhatRotherRclassicRskinRinfectionRdoesRPseudomonas
AR6-year-
oldRboyRpresentsRwithRankleRpainRafterRgettingRkickedRwhileRplayingRsoccer.RHeRhasRtendernessRant
eriorlyRalongRtheRankleRjoint.RAnRX-
rayRisRshownRabove.RTheRpatientRhasRsignificantRpainRwhenRwalking.RWhichRofRtheRfollowingRisRtheR
mostRappropriateRmanagement?
ARAnalgesicsRandRfollowRupRinR2Rweeks
BRCTRscanRofRtheRankle
CRImmobilizationRofRtheRankleRandRnon-weightRbearing
DRImmobilizationRofRtheRankleRandRweightRbearingRasRtoleratedR-RRCORRECTRANSWERS-
CorrectRAnswerR(RCR)
Explanation:
ThisRpatientRpresentsRwithRsignsRandRsymptomsRconcerningRforRaRSalter-
HarrisRTypeRIRfractureRandRshouldRbeRimmobilizedRandRmadeRnon-
weightRbearing.RChildren'sRbones,RunlikeRthoseRofRadults,RcontainRcartilaginousRcentersRnearRtheRe
ndRofRtheRboneRthatRgiveRriseRtoRnewRboneRgrowthR(epiphysis).RBecauseRtheseRareasRareRradioluce
nt,RtheyRareRnotRvisualizedRonRradiographs.RInjuriesRtoRtheRepiphysisRmayRresultRinRabnormalRboneR
growthRifRtheyRdoRnotRheal.RTherefore,RwhenRinjuryRtoRthisRareaRisRsuspected,RconservativeRmanag
ementRwithRsplintingRandRnon-
weightRbearingR(ifRlowerRextremity)RstatusRisRrecommendedRtoRpromoteRhealingRandRdiscourageR
worseningRinjury.RInjuriesRtoRtheseRareasRareRreferredRtoRasRSalter-
HarrisRTypeRIRinjuriesR(displacementRofRtheRepiphysis).RTheRSalter-
HarrisRclassificationRsystemRwasRdesignedRtoRaidRinRtheRdescriptionRandRmanagementRofRpediatricR
fractures.
AnalgesicsR(A)RmayRbeRrequiredRbutRtheRpatientRshouldRbeRmadeRnon-
weightRbearingRandRsplintedRpriorRtoRdischarge.RCTRscanRofRtheRankleR(B)RisRnotRnecessaryRasRitRwo
uldRnotRchangeRtreatmentRatRthisRpoint.RImmobilizationRisRvitalRbutRtheRpatientRshouldRnotRbeRallo
wedRtoRplaceRweightRonRtheRextremityR(D).
MUSCULOSKELETALQUESTIONS
WITH CORRCT ANSWERS GRADED
A+ FOR 2026-2027 ASSURED EXCEL!!
A 16-year-old boy presents complaining of right ankle pain after injuring himself while playing
basketball. He states that he "twisted his ankle" when he landed on another players foot trying
to get a rebound. He has not been able to walk on his right foot since this occurred two hours
ago and cannot do so in the ED. On examination, his pulses are intact. Strength and sensation
are normal. The ankle is swollen laterally. He is tender over the lateral malleolus and at the base
of the fifth metatarsal. No tenderness or swelling is noted over the proximal tibia and fibula.
Which of the following is true regarding emergency department radiographic work-up of this
patient?
A A complete ankle series is the only indicated study
B A complete foot series is the only indicated study
C Both a complete ankle and a complete foot series are indicated
D No radiographic imaging is indicated at this time
. - CORRECT ANSWERS-Correct Answer ( C )
Explanation:
The patient should undergo X-rays of both the ankle and the foot. The Ottawa Ankle Rules (OAR)
are a clinical decision making tool used to help determine the need for radiographic imaging
following blunt ankle injury. They apply to acute injuries that have occurred within the previous
48 hours, however are not useful in the subacute or chronic phase. The OAR were not designed
to be general guidelines for foot injuries; the foot rules only apply to the midfoot and do not
apply to the hindfoot or forefoot
A 45-year-old man presents with left leg pain. He describes a sudden onset pain in his calf area
while playing basketball with his son. On exam, you squeeze his right calf and elicit plantar
flexion of the right foot. When you do the same with his left calf there is no plantar flexion of his
,left foot. You administer ibuprofen and place the left leg in a posterior splint. Which of the
following is the most appropriate next step in management?
A Obtain X-rays of the ankle and foot
B Prescribe physical therapy
C Refer to orthopedic surgery
D Screen for autoimmune diseases - CORRECT ANSWERS-C Refer to orthopedic surgery
This patient has an abnormal Thompson test, a common clinical test used to diagnosed Achilles
tendon rupture. Achilles tendon rupture typically occurs in the setting of sudden and forced
dorsiflexion during athletic activity. Patients often report an audible "pop" and sudden pain in
the calf area that improves or subsides quickly, followed by decreased ability to plantar flex the
foot. The diagnosis is typically clinical. On physical examination, patients may exhibit a palpable
tendon defect in the lower calf area. Some plantar flexion is usually maintained, even in cases of
complete tendon rupture, due to the actions of the surrounding muscles. The Thompson test is
a classic maneuver to assess the Achilles tendon. The patient lies prone, with the legs flexed at
the knee at 90 degrees. The examiner then squeezes the calf muscles and observes for passive
plantar flexion of the foot. The injured extremity will have a weakened or no response
compared to the uninjured side. Risk factors for Achilles tendon rupture include
rheumatological diseases, chronic renal failure, steroid use, and recent treatment with
fluoroquinolone antibiotics. Controversy remains regarding the best treatment. While early
operative repair is associated with lower risk of rerupture and possibly improved functional
outcome, it also has a higher rate of complications. Nonoperative management consists of a
series of casts. Ultimately, the decision depends on the patient's age, activity level and
preference, and is best made on a non-emergent basis in consultation with an orthopedic
surgeon or sports medicine physician. Thus, initial management includes non-steroidal anti-
inflammatory analgesics, crutches, non-weightbearing status, immobilization of the ankle in
plantar flexion with a splint, and outpatient referral.
A 22-year-old woman presents with pain and swelling of the plantar surface of her foot. She
reports that two days prior to arrival she was walking in sneakers and stepped on a nail that
punctured her foot. Physical examination demonstrates 3 cm of warm, blanching erythema
without induration or fluctuance. Her tetanus vaccination is up-to-date. An X-ray does not show
,any foreign body. Which antibiotic is an appropriate choice to cover the organism at risk from
her shoe?
A Ciprofloxacin
B Dicloxacillin
C Linezolid
D Trimethoprim-sulfamethoxazole - CORRECT ANSWERS-Correct Answer ( A )
Explanation:
PunctureRwoundsRonRtheRbottomRofRtheRfootRareRatRhighRriskRforRinfectionRandRalsoRforeignRbodyRr
etention.RParticularlyRinRtheRsettingRofRaRpunctureRwoundRthatRpassesRthroughRtheRsoleRofRaRshoe,R
PseudomonasRaeruginosaRisRtheRcausativeRorganismRrequiringRtreatment.RInRtheory,RtheRorganism
RhasRanRaffinityRforRrubberRorRplasticRmaterialsRandRthereforeRisRtransferredRtoRtheRskinRthroughRth
eRpuncture.RInRgeneral,RPseudomonasRrarelyRcausesRskinRandRsoftRtissueRinfections.RCiprofloxacinRi
sRanRoralRfluoroquinoloneRwithRadequateRPseudomonasRaeruginosaRcoverage.RCareRmustRbeRtake
nRinRchildrenRwithRciprofloxacinRbecauseRofRconcernRoverRtheRdevelopmentRofRtendonopathy.RInRc
onsideringRallRskinRandRsoftRtissueRinfections,RStaphRandRStrepRareRstillRtheRmostRcommonRcausativ
eRorganisms,RbutRthisRparticularRclinicalRscenarioRmandatesRcoverageRforRPseudomonas.
DicloxacillinR(B)RisRaRpenicillinRderivativeRcommonlyRusedRtoRtreatRinfectionsRcausedRbyRStaphRaure
us.RStaphRaureusRcoverageRisRrequiredRinRskinRinfectionsRgivenRtheRprevalenceRofRthatRorganismRinR
cellulitisRinfections.RHowever,RitRdoesRnotRcoverRPseudomonas.RLinezolidR(C)RisRanRoxazolidinoneRa
ntibioticRwithRactivityRagainstRGram-
positiveRorganisms.RItRisRtypicallyRreservedRforRresistantRinfectionsRlikeRMethicillin-
resistantRStaphRaureusRandRVancomycin-
resistantREnterococcus.RItRisRavailableRasRanRoralRagentRallowingRforRtransitionRtoRoralRtherapyRfro
mRIVRmedicationRinRtheRhospital.RTrimethoprim-sulfamethoxazoleR(D)RisRaRsulfa-
basedRantibioticRwithRinRtheRsettingRofRskinRinfectionsRhasRwidespreadRactivityRagainstRcommunity
-associatedRMethicillin-
resistantRStaphRaureus.RItRdoesRnotRhaveRanyRactivityRagainstRPseudomonasRandRwouldRnotRbeRindi
catedRinRthisRclinicalRscenario.
OneRStepRFurther
, Question:RWhatRotherRclassicRskinRinfectionRdoesRPseudomonas
AR6-year-
oldRboyRpresentsRwithRankleRpainRafterRgettingRkickedRwhileRplayingRsoccer.RHeRhasRtendernessRant
eriorlyRalongRtheRankleRjoint.RAnRX-
rayRisRshownRabove.RTheRpatientRhasRsignificantRpainRwhenRwalking.RWhichRofRtheRfollowingRisRtheR
mostRappropriateRmanagement?
ARAnalgesicsRandRfollowRupRinR2Rweeks
BRCTRscanRofRtheRankle
CRImmobilizationRofRtheRankleRandRnon-weightRbearing
DRImmobilizationRofRtheRankleRandRweightRbearingRasRtoleratedR-RRCORRECTRANSWERS-
CorrectRAnswerR(RCR)
Explanation:
ThisRpatientRpresentsRwithRsignsRandRsymptomsRconcerningRforRaRSalter-
HarrisRTypeRIRfractureRandRshouldRbeRimmobilizedRandRmadeRnon-
weightRbearing.RChildren'sRbones,RunlikeRthoseRofRadults,RcontainRcartilaginousRcentersRnearRtheRe
ndRofRtheRboneRthatRgiveRriseRtoRnewRboneRgrowthR(epiphysis).RBecauseRtheseRareasRareRradioluce
nt,RtheyRareRnotRvisualizedRonRradiographs.RInjuriesRtoRtheRepiphysisRmayRresultRinRabnormalRboneR
growthRifRtheyRdoRnotRheal.RTherefore,RwhenRinjuryRtoRthisRareaRisRsuspected,RconservativeRmanag
ementRwithRsplintingRandRnon-
weightRbearingR(ifRlowerRextremity)RstatusRisRrecommendedRtoRpromoteRhealingRandRdiscourageR
worseningRinjury.RInjuriesRtoRtheseRareasRareRreferredRtoRasRSalter-
HarrisRTypeRIRinjuriesR(displacementRofRtheRepiphysis).RTheRSalter-
HarrisRclassificationRsystemRwasRdesignedRtoRaidRinRtheRdescriptionRandRmanagementRofRpediatricR
fractures.
AnalgesicsR(A)RmayRbeRrequiredRbutRtheRpatientRshouldRbeRmadeRnon-
weightRbearingRandRsplintedRpriorRtoRdischarge.RCTRscanRofRtheRankleR(B)RisRnotRnecessaryRasRitRwo
uldRnotRchangeRtreatmentRatRthisRpoint.RImmobilizationRisRvitalRbutRtheRpatientRshouldRnotRbeRallo
wedRtoRplaceRweightRonRtheRextremityR(D).
