PANCE Musculoskeletal 3 — Questions and Answers
Question 1: A 45-year-old male presents with acute monoarticular arthritis of the first MTP joint, red/hot/swollen, after a celebratory dinner. Arthrocentesis shows negatively birefringent needle-shaped crystals. What is the acute treatment?
- Allopurinol
- Indomethacin or colchicine (Correct answer)
- Methotrexate
- Probenecid
Correct answer: Indomethacin or colchicine
Acute gout is treated with NSAIDs (indomethacin), colchicine, or corticosteroids; urate-lowering agents like allopurinol are not started during acute attacks.
Question 2: A patient with a humeral shaft fracture develops wrist drop and inability to extend the fingers. Which nerve is most likely injured?
- Ulnar nerve
- Median nerve
- Radial nerve (Correct answer)
- Musculocutaneous nerve
Correct answer: Radial nerve
The radial nerve runs in the spiral groove of the humerus and is commonly injured in mid-shaft humeral fractures, causing wrist drop and finger extension weakness.
Question 3: A 50-year-old woman presents with shoulder pain and inability to abduct the arm past 90 degrees. MRI shows a full-thickness supraspinatus tear. What is the most appropriate initial management?
- Immediate surgical repair
- Physical therapy and NSAIDs for 6-12 weeks (Correct answer)
- Corticosteroid injection only
- Sling immobilization for 8 weeks
Correct answer: Physical therapy and NSAIDs for 6-12 weeks
Most rotator cuff tears are initially managed conservatively with physical therapy and anti-inflammatory medications; surgery is reserved for refractory cases or large acute tears.
Question 4: An 8-year-old boy presents with a limp and hip pain radiating to the knee for 2 months. X-ray shows flattening and sclerosis of the femoral head. What is the diagnosis?
- Septic arthritis
- Transient synovitis
- Legg-Calvé-Perthes disease (Correct answer)
- Slipped capital femoral epiphysis
Correct answer: Legg-Calvé-Perthes disease
Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children aged 4-10, presenting with chronic hip pain, limp, and X-ray changes of femoral head collapse.
Question 5: A 65-year-old woman with RA on methotrexate develops bilateral hip pain worsened by weight-bearing. X-ray shows subchondral collapse. What complication has occurred?
- Septic arthritis
- Avascular necrosis (Correct answer)
- Stress fracture
- Trochanteric bursitis
Correct answer: Avascular necrosis
Long-term corticosteroid use (often used in RA management) is a major risk factor for avascular necrosis of the femoral head, presenting with subchondral collapse on imaging.
Question 6: A construction worker presents with pain and crepitus of the shoulder with overhead activities. Neer and Hawkins-Kennedy tests are positive. What is the most likely diagnosis?
- Bicipital tendinopathy
- AC joint separation
- Subacromial impingement syndrome (Correct answer)
- Glenohumeral instability
Correct answer: Subacromial impingement syndrome
Subacromial impingement presents with positive Neer and Hawkins-Kennedy signs, pain with overhead activity, and crepitus due to compression of the rotator cuff beneath the acromion.
Question 7: A 30-year-old female presents with bilateral hand stiffness in the morning lasting 2 hours, fatigue, and symmetric swollen PIPs and MCPs. RF is negative but anti-CCP is positive. What is the diagnosis?
- Systemic lupus erythematosus
- Seronegative rheumatoid arthritis
- Seropositive rheumatoid arthritis (Correct answer)
- Psoriatic arthritis
Correct answer: Seropositive rheumatoid arthritis
Anti-CCP antibody is more specific than RF for RA; a positive anti-CCP with negative RF still qualifies as seropositive RA by current classification criteria.
PANCE Musculoskeletal 3
A 45-year-old male presents with acute monoarticular arthritis of the first MTP joint, red/hot/swollen, after a celebratory dinner.
Arthrocentesis shows negatively birefringent needle-shaped crystals.
What is the acute treatment?