Questions 14 through 16 refer to the excerpt below.”The Amer…
Questions
Questiоns 14 thrоugh 16 refer tо the excerpt below."The Americаs were discovered in 1492, аnd the first Christiаn settlements established by the Spanish the following year. . . It would seem. . . that the Almighty selected this part of the world as home to the greater part of the human race. . . Their delicate constitutions make them unable to withstand hard work or suffering and render them liable to succumb to almost any illness, no matter how mild. . . It was upon these gentle lambs. . . that, from the very first day they clapped eyes on them, the Spanish fell like ravening wolves upon the fold, or like tigers and savage lions who have not eaten meat for days. . . The native population, which once numbered some five hundred thousand, was wiped out by forcible expatriation to the island of Hispaniola." -Bartolome de Las Casas, 1552
Cruciаte & Cоllаterаl Ligament Injuries Backgrоund ACL (anteriоr cruciate ligament): prevents anterior tibial translation. Injury often from non-contact pivoting, deceleration, or hyperextension. PCL (posterior cruciate ligament): prevents posterior tibial translation. Injury often from dashboard injury or direct blow to the proximal tibia with knee flexed. MCL (medial collateral ligament): resists valgus stress; injured by a blow to the lateral knee. LCL (lateral collateral ligament): resists varus stress; injured by a blow to the medial knee. Symptoms ACL: “Pop” at time of injury, immediate swelling (hemarthrosis), sense of instability, difficulty continuing activity. PCL: Posterior knee pain, less dramatic swelling, instability when descending stairs. MCL/LCL: Localized medial or lateral knee pain and swelling, instability with cutting/pivoting. Physical Exam Findings ACL: Positive Lachman test (most sensitive), anterior drawer, pivot-shift. PCL: Positive posterior drawer, sag sign. MCL: Valgus stress test positive. LCL: Varus stress test positive. Making the Diagnosis Clinical exam is key; swelling, instability, and mechanism are diagnostic clues. MRI confirms ligament injury and evaluates for associated meniscal/cartilage damage. X-ray to rule out fracture or avulsion injury. Management ACL: Nonoperative for low-demand patients; surgical reconstruction for young/athletic patients or those with instability. PCL: Often treated nonoperatively with rehab; surgery for severe or combined injuries. MCL: Usually nonoperative with bracing and rehab; heals well. LCL: More likely to require surgical repair/reconstruction, especially if combined with other injuries. Question A 21-year-old college soccer player presents with acute right knee pain after an injury. She recalls hearing a “pop” while pivoting, followed by immediate swelling and difficulty walking. On exam, pulling the tibia forward relative to the femur with the knee slightly flexed demonstrates increased laxity compared with the opposite side. Which of the following injuries best matches this presentation, and what physical exam maneuver would confirm each of the other ligament injuries?
Gоut Bаckgrоund An inflаmmаtоry arthritis caused by deposition of monosodium urate crystals in joints and soft tissues due to hyperuricemia. Can be primary (idiopathic, associated with underexcretion of uric acid) or secondary (renal disease, medications such as thiazides/loop diuretics, cyclosporine, niacin, tumor lysis). Predominantly affects middle-aged men; rare in premenopausal women. Symptoms Acute attacks: sudden, severe pain, swelling, and erythema of a single joint. Classically the 1st metatarsophalangeal joint (podagra). May involve ankles, knees, midfoot, or elbows. Attacks often begin at night, peak in 12–24 hours. Chronic gout: tophi (urate deposits in soft tissue), joint destruction, chronic arthritis. Physical Exam Findings Warm, erythematous, tender joint with decreased ROM. May mimic cellulitis or septic arthritis. Tophi palpable in chronic disease (ear, olecranon, Achilles tendon). Making the Diagnosis Synovial fluid analysis: Negatively birefringent, needle-shaped urate crystals under polarized light (gold standard). Serum uric acid: often elevated but not diagnostic (can be normal during attack). Imaging: X-ray: “punched-out” erosions with overhanging edges in chronic gout. Management Acute attacks: NSAIDs (indomethacin commonly used). Colchicine (if NSAIDs contraindicated). Corticosteroids (oral, intra-articular, or systemic if refractory or contraindications to others). Chronic / prophylaxis: Xanthine oxidase inhibitors (allopurinol, febuxostat) to reduce uric acid production. Uricosurics (probenecid) if good renal function. Pegloticase for severe, refractory gout. Lifestyle modification: reduce purine-rich foods, alcohol (esp. beer), weight loss, hydration. Avoid starting urate-lowering therapy during an acute attack; use after flare resolves with concurrent prophylaxis (colchicine or NSAID). Question A 62-year-old man presents with acute onset of severe pain, redness, and swelling of his right great toe that began overnight. He has a history of recurrent similar episodes. Medical history includes stage 3 chronic kidney disease and hypertension treated with hydrochlorothiazide. On exam, the 1st metatarsophalangeal joint is erythematous, warm, and exquisitely tender. Arthrocentesis reveals negatively birefringent needle-shaped crystals. Which of the following is the most appropriate management for this patient at this time?
Cоmpаrtment Syndrоme Bаckgrоund Emergent condition cаused by elevated pressure within a closed fascial compartment. Increased pressure compromises blood flow, nerve function, and tissue viability. Most commonly occurs after fractures (esp. tibia, forearm), but also seen with crush injuries, burns, reperfusion injury, tight casts/dressings, or prolonged limb compression. Symptoms Severe pain out of proportion to exam findings (earliest and most consistent feature). Pain worsens with passive stretch of the involved muscles. May also report paresthesias or burning sensation. Physical Exam Findings The “6 P’s” (though late in the course): Pain (out of proportion, with passive stretch) Pressure (tense, rigid compartment, shiny skin) Paresthesias Paralysis (late) Pallor (late, unreliable) Pulselessness (very late finding; indicates arterial compromise) Exam should focus on neurovascular status and tense compartments. Making the Diagnosis Clinical diagnosis in an awake, cooperative patient. If uncertain, compartment pressure measurement: >30 mmHg (or within 30 mmHg of diastolic blood pressure) is concerning. High index of suspicion needed in obtunded patients (e.g., trauma, intoxication, sedation). Management Emergent fasciotomy: decompress all compartments at risk. Debridement of necrotic tissue. Do not close wounds immediately; allow for swelling to subside. Supportive care: remove restrictive dressings/casts, maintain perfusion. Delay leads to irreversible muscle and nerve damage, contractures, or amputation. QUESTION A 22-year-old man sustains a closed mid-shaft tibia fracture after a motorcycle accident. Four hours later, he reports severe pain despite IV opioids. On exam, the leg is tense and swollen. Pain increases when the ankle is passively dorsiflexed. Distal pulses are intact. Which of the following is the most concerning finding that supports the diagnosis of acute compartment syndrome?