Family Practice Written Board Exam Sample Questions (2000)
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QUESTION

5. A 22-year-old defensive back for the local university football team runs off the field after a tackle holding his arm limply by his side. You are the team physician on the sideline and the trainer wants you to evaluate him. The athlete complains of burning pain down his arm with slight weakness. As you are walking over to examine him, he is noted to be "shaking" the arm slowly and by the time you reach him, all of his symptoms have cleared.  His physical examination is completely normal.

The MOST appropriate diagnosis is

A) Acute cervical strain
B) Deltoid muscle contusion
C) Burner Syndrome
D) Acromioclavicular separation
E) Clavicular fracture

ANSWER

5. C "Burner" Syndrome

"Burners" or "stingers" are a rather common occurrence with tackling in football.  It is a nerve injury resulting from trauma to the neck and shoulder. The pain is a burning sensation radiating down one upper extremity.  Paresthesias, weakness, and numbness may accompany it.  A burner represents a dysfunction or injury to a peripheral nerve, usually in the brachial plexus.  It is a self-limited and brief injury with rapid recovery the rule. Acute cervical strain is not a brief situation and is associated with cervical muscle spasm and a decreased range of motion.  The pain is usually limited to the neck region. Deltoid muscle contusion is associated with pain, tenderness, and decreased motion of the deltoid muscle alone.  Acromioclavicular separation is noted to have specific tenderness to palpation over the AC joint with or without swelling.  There is no burning sensation radiating down the arm and motion, although decreased, may be full with associated pain on abduction. The obvious deformity, swelling and pain of the clavicle would easily diagnose a clavicular fracture.

1. Kuhlman GS, McKeag DB. The "Burner": A common nerve injury in contact sports. Am Fam Phys. 60(7):2035-42, 1999.

QUESTION

14. A 30-month-old child is brought to the emergency department by the parents. The child has been crying intermittently for the last several hours. As you observe the child, you note that there is little or no movement of the left upper extremity. In fact, this arm is held in elbow extension and forearm pronation. The father relates the history that he was playfully swinging the child around by both arms when his gripped slipped on the right hand causing an excessive "pulling" force on the left arm. Since this event the child began crying immediately with refusal to remove the arm. Examination of this extremity is basically normal with the exception of pain on palpation of the radiocapitellar joint. Radiographs are obtained and found to be without evidence of fracture or dislocation.

The MOST likely diagnosis is

A) Shoulder separation
B) Radial head subluxation
C) Supracondylar fracture
D) Elbow contusion
E) Fracture of wrist

ANSWER

14. B Radial head subluxation

Radial head subluxation or nursemaid's elbow is usually a subtle presentation. It usually occurs in children between the ages of 2 and 3 years and is caused by an abrupt axial force applied to the radius. The result is subluxation of the (nonossified) radial head from the capitellum and through the annular ligament. The sudden "jerk" of the extended arm results in the subluxation. The presentation as described is the usual one. Radiographs are normal although an associated fracture must be ruled out. The reduction is accomplished by holding a thumb over the radial head with slow elbow flexion while rotating the forearm into full supination. A palpable "click" is often indicative of a successful reduction. Shoulder separation results from a direct blow to the acromioclavicular joint and has point tenderness overlying this area. Supracondylar fracture might be suspected but usually occurs in children between the ages of 5 and 8 years with a history of a fall. These are serious fractures that should be managed by an orthopedist and may be diagnosed by radiographs.

A blow to the elbow would cause elbow contusion and although tender should not have significant restriction of movement. Some discoloration may be noted as well. A fracture of the wrist would be noted on physical examination by swelling, extreme tenderness, and markedly decreased range of motion. Radiographs would confirm the diagnosis.

1. Steinberg GG, Akins CM, Baran DT (eds). Orthopedics in Primary Care. 3^rd edition. Lippincott Williams & Wilkins, Philadelphia PA. 1999:92-3.

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