An 84-year-old woman with Alzheimer dementia is brought to the emergency department for evaluation after refusing to get out of bed.  She has been known to wander the halls at her facility, and a nursing aide reported finding her on the floor next to her bed earlier that day.  Vital signs are within normal limits.  On examination, the patient is in pain.  Her right leg appears shorter than her left.  She is able to wiggle her toes but has significant external rotation of the right lower extremity compared with the left.  There is no evidence of head trauma and the lower leg compartments are soft.  Which of the following is the most likely diagnosis in this patient?

A. Femoral neck fracture
B. Femoral shaft fracture
C. Posterior hip dislocation
D. Pubic ramus fracture
E. Trochanteric fracture

Explanation:
Correct Answer Is A
This elderly woman has an acutely shortened, externally rotated leg following a fall.  This presentation is most consistent with either a femoral neck or an intertrochanteric fracture, which are the most common hip fractures in older adults, typically occurring due to mechanical falls.  The classic pattern of shortening and external rotation of the leg compared with the contralateral side is primarily due to contraction of the psoas and iliacus without the normal acetabular counterforce.  This pattern is also seen in anterior hip dislocation, which is significantly less common than fracture and typically occurs following severe trauma (eg, industrial accident, motor vehicle collision).  An x-ray generally confirms the diagnosis of fracture.

Hip fractures are classified as either intracapsular (femoral head and neck) or extracapsular (intertrochanteric or subtrochanteric).  Intracapsular fractures typically present without significant ecchymoses and have a higher risk of avascular necrosis.  Extracapsular fractures are at higher risk for displacement and usually have visible ecchymosis.  Both types generally require surgical correction (eg, open reduction with internal fixation).  In stable patients, surgery within 48 hours is associated with lower mortality and a lower risk of pressure ulcers and pneumonia.

Femoral shaft fracture in elderly patients can present with shortening of the leg, often with angulation.  Pubic ramus fracture can occur from minor (or no) trauma in elderly patients and also can cause shortening of the ipsilateral leg.  However, external rotation is more typical of femoral neck fracture.

Posterior hip dislocation typically presents with adduction and internal rotation at the hip.  It usually occurs from an axial force on the femur (eg, dashboard injury), and some patients have neurologic manifestations due to involvement of the sciatic nerve.

Isolated fracture of the greater trochanter can occur due to a ground-level fall in older patients.  Typical features include pain with abduction and tenderness at the trochanter.  However, leg length is not affected.

Femoral neck and intertrochanteric fractures are the most common hip fractures in older adults and most typically occur due to mechanical falls.  Examination findings include shortening and external rotation of the leg compared with the contralateral side.

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🧩 Medical Mnemonics


Learn frog-eye appearance 🐸 with #visual_mnemonics.

━━━━━━━━━━━━━━━━
🖥 IMAGING Explanation

Ultrasound of the foetal head shows the absence of foetal brain parenchyma and calvaria with the classic ‘frog-eye’ appearance.


💻 Follow our official Instagram page: Online Medical School

#radiology
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics

A 6-year-old girl is brought to the clinic for evaluation of knee pain.  The patient first had soreness in her right knee 4 days ago, after her first gymnastics class.  Her mother gave her acetaminophen and massaged her knee, but this did not help.  The patient also developed a limp over the past 2 days.  She has no chronic medical conditions and does not take daily medications.  Height is at the 50th percentile and weight is at the 75th percentile.  Temperature is 37.9 C (100.2 F).  When walking, she limits weight-bearing on her right side.  When supine, the right hip is held flexed with the knee pointed laterally.  There is limited internal rotation and extension of the right hip.  The right knee has full range of motion and there is no tenderness on palpation around the knee.  Laboratory evaluation shows leukocyte count of 11,500/mm3 and C-reactive protein of 8 mg/L (normal: <10).  Ultrasound of the hips shows small, bilateral effusions.  Which of the following is the most likely diagnosis in this patient?

A. Juvenile idiopathic arthritis
B. Osgood-Schlatter disease
C. Septic arthritis
D. Slipped capital femoral epiphysis
E. Transient synovitis

Correct Answer Is E

This child with knee pain has limited hip mobility and bilateral hip effusions, consistent with transient synovitis (TS).  TS is a common, self-limiting, inflammatory hip condition that occurs in children age 3-8.  The aetiology is unclear but often involves postviral or, less commonly, posttraumatic (eg, gymnastics class) joint inflammation.  In some cases, no preceding trigger is identified.

Presentation includes a well-appearing child with acute hip pain or referred knee pain.  Knee examination is normal (as in this case), and patients often hold the hip flexed, abducted, and externally rotated to relieve pressure in the joint space.  Limping is common, although patients can usually bear weight on the affected leg.  Fever is typically absent (or low-grade), and laboratory evaluation (eg, C-reactive protein, white blood cell count) is usually normal.

Ultrasound reveals small unilateral or bilateral effusions (even when symptoms are confined to one hip).  Treatment of TS is conservative (eg, nonsteroidal anti-inflammatory medications), and symptoms generally resolve within days to weeks.

Juvenile idiopathic arthritis presents with chronic joint pain and inflammation and may be associated with rash and fever.  The hips are rarely involved, and elevated inflammatory markers are expected.

Osgood-Schlatter disease, or osteochondritis of the tibial tubercle, presents in active adolescents with chronic anterior knee pain that is worse with running and jumping.  Tenderness over the tibial tubercle is a characteristic finding not seen on this patient’s examination.

Septic arthritis typically presents in ill-appearing, febrile children with acute joint pain and inflammation.  Patients classically refuse to bear weight on the affected extremity, unlike in this case.  In addition, leukocytosis and elevated inflammatory markers are typical, and ultrasound reveals a unilateral (not bilateral) effusion.

Slipped capital femoral epiphysis occurs when the femoral diaphysis is displaced anteriorly along the growth plate relative to the femoral head.  Typical presentation involves an obese adolescent with chronic hip (or referred knee) pain, limp, and limited internal rotation of the hip.  Ultrasound may detect the slippage but would not show effusions, as seen in this patient.

Transient synovitis is a self-limiting, inflammatory hip condition most common in children age 3-8.  Presentation may include limp (with ability to bear weight), hip pain, or pain referred to the knee.  Most patients are afebrile with normal laboratory studies (eg, white blood cell count, C-reactive protein) and small, bilateral hip effusions.

🧩 Medical Mnemonics


Protein synthesis inhibitors “Buy at 30, ccel (sell) at 50.”

👉 30S inhibitors
🫧 Aminoglycosides
🫧 Tetracyclines

👉 50S inhibitors
🫧 Chloramphenicol, Clindamycin
Erythromycin (macrolides) and Linezolid.

#microbiology
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics

A 45-year-old man comes to the office due to mild pain in his left foot and difficulty walking for the past several months.  He now walks with a cane and recently began using an ankle brace for support.  Medical history is significant for type 1 diabetes mellitus, hypertension, and hypercholesterolemia.  Physical examination is notable for a significantly deformed left ankle and a mildly deformed left foot.  Peripheral pulses are full and symmetric.  X-ray of the left foot and ankle with weight bearing reveals osseous fragmentation, new bone formation, and sclerosis, as seen in the image below.  Which of the following is the most likely cause of this patient’s foot condition?



A. Age-related degenerative osteoarthritis
B. Atherosclerosis of the tibial arteries
C. Autoimmune inflammatory arthritis
D. Bony destruction from bacterial infection
E. Impaired sensation and joint proprioception

Explanation:

Correct Answer Is E

This patient has foot and ankle deformities and x-ray findings that indicate neuropathic (Charcot) arthropathy, which occurs most commonly in patients with diabetes mellitus (particularly those with peripheral neuropathy).  Neuropathic arthropathy involves repetitive bone and tissue trauma caused by impaired sensation and joint proprioception that prevent the patient from adjusting weight bearing to avoid mechanically induced wear and tear.

Neuropathic arthropathy can present in either of 2 stages:

Acute:  Characterized by inflammatory erythema, warmth, and edema of the foot 1-2 days after minor trauma.  X-rays at this stage usually show only soft tissue swelling without bone involvement.
Chronic:  Characterized by bone deformities noted on x-ray that typically include osseous fragmentation, new bone formation, and subluxation/dislocation predominantly in the mid and hind foot.  Other common signs are loss of the metatarsal heads (pencil pointing) with osteopenia and phalangeal osteolysis.  These changes often lead to neuropathic ulcers, arch collapse (rocker bottom feet), and callus formation.
Osteoarthritis of the foot typically affects the first metatarsophalangeal joint with subchondral sclerosis and osteophyte formation rather than diffuse bone destruction as found in neuropathic arthropathy.

Decreased perfusion of the extremities due to atherosclerosis of the tibial arteries (ie, peripheral artery disease) can cause pain (ie, claudication) but would not cause significant bone deformities.  This patient’s peripheral pulses are full and symmetric.

Isolated foot involvement due to autoimmune inflammatory arthritis is uncommon but may occur in patients with rheumatoid arthritis.  When it does, it typically presents with bilateral involvement rather than unilateral as in this patient.  However, x-ray findings in advanced rheumatoid arthritis commonly include periarticular osteoporosis, joint erosion, and joint space narrowing rather than grossly destructive changes.

Bony destruction from bacterial infection (ie, osteomyelitis) can manifest as periosteal thickening on x-ray, but infection would be unlikely to cause the significant bone deformities seen in this patient.  Osteomyelitis typically occurs in association with a neuropathic ulcer with sinus tracts or exposure of the underlying bone.

Chronic neuropathic (Charcot) arthropathy is characterized by bone deformities resulting from repetitive trauma to the foot and ankle.  It develops in patients who have impaired sensation and joint proprioception (eg, diabetic peripheral neuropathy) that prevent the patient from adjusting weight bearing to avoid mechanically induced wear and tear.

A 65-year-old man returns to the office for follow-up 10 days after receiving a subacromial corticosteroid injection for right-sided rotator cuff tendinopathy.  The tendinopathy was confirmed on musculoskeletal ultrasound of the shoulder prior to the injection.  The patient initially experienced mild improvement of the shoulder pain, but starting 2 days ago, the pain significantly worsened and is now accompanied by generalized body ache and fatigue.  He does not report trauma or excessive shoulder use since the injection.  Medical history includes type 2 diabetes mellitus and gout.  Temperature is 37.9 C, blood pressure is 130/85 mm Hg, and pulse is 109/min.  On examination, there is mild swelling in the lateral right shoulder.  Range of motion is limited in multiple axes due to significant pain, which is worse compared to examination prior to the injection.  Which of the following is the most appropriate next step in management of this patient?

A. Image-guided aspiration
B. Range-of-motion exercises and analgesic therapy
C. Repeat corticosteroid injection
D. Serum uric acid level
E. X-ray of the shoulder

Correct Answer Is A

This patient’s clinical features are worrisome for iatrogenic septic bursitis, presenting with acute pain following an initial positive response to corticosteroid injection.  Subacromial injections are used to treat subacromial bursitis, rotator cuff tendinopathy, and adhesive capsulitis.  During the procedure, the needle penetrates the subacromial bursa, depositing corticosteroids into the bursa and near the supraspinatus tendon.  However, injection can introduce skin flora (eg, Staphylococcus aureus, Streptococcus pyogenes) into the deep structures.

Infection typically manifests as worsening pain, redness, swelling, and systemic symptoms (eg, fever, myalgias) several days after the procedure.  In contrast, postcorticosteroid injection flare (ie, steroid-induced chemical synovitis) typically occurs rapidly and resolves within 48 hours.  In some cases, the bursa communicates with the glenohumeral joint capsule, and septic bursitis may progress to septic arthritis.  When infection is suspected, an image-guided (eg, ultrasound) aspiration of the bursa and/or joint is necessary to assess for infection.

Range-of-motion exercises and analgesics are appropriate for adhesive capsulitis, which presents with pain and reduced shoulder motion in multiple axes.  However, adhesive capsulitis is a chronic condition that presents insidiously; this patient’s acute pain, swelling, and myalgias are more consistent with septic bursitis.

Intraarticular and soft tissue corticosteroid injections are contraindicated when infection is suspected because they can worsen the infection.  In the absence of infection, repeat injections are typically separated by at least several months to reduce the risk of tendon rupture and cartilage damage.

Gout can cause acute inflammatory bursitis resembling septic bursitis but likely would have responded completely to the initial corticosteroid injection.  Furthermore, the serum uric acid level, even when elevated, does not rule out infection and cannot replace a diagnostic aspiration.

Shoulder x-ray is useful to assess for fracture (which is unlikely in the absence of trauma) but is not sufficient to rule out infection.

During a joint or bursal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as worsening pain several days following the procedure.  Diagnostic aspiration of the joint or bursa is necessary to assess for infection.

A young woman underwent a non-complicated cholecystectomy for painful gallstones.After 24 hours of surgery, she developed a cough and fever.Chest X-ray is done as shown below.

How would you manage?

A. Chest physiotherapy
B. Give morphine
C. Give antibiotics
D. Give steroids
E. Paracetamol as required

Correct Answer Is A

Chest X-ray shows loss of right heart border silhouette due to partial atelectasis of right middle lobe. Atelectasis is collapse or incomplete expansion of the lung or a part of the lung.
Postoperative atelectasis generally occurs within 48 hours. It is an extremely common post-operative complication with some degree of pulmonary collapse occurring after almost every abdominal or trans-thoracic procedure.

Postoperative atelactasis can be managed as follows:
1-Removal of impacted secretions by coughing, managed by physiotherapists, and involves active chest percussion and breathing exercises.
2-Passive postural drainage.

All other options are incorrect