SPEX Exam Musculoskeletal and Orthopedics — Questions and Answers
Question 1: A 28-year-old man presents 4 hours after a forearm fracture with severe pain out of proportion to the injury, paresthesias in the hand, and a tense compartment on palpation. The most appropriate immediate management is:
- Emergency fasciotomy (Correct answer)
- Elevation of the extremity and ice application
- Urgent MRI of the forearm
- IV morphine and reassessment in 2 hours
Correct answer: Emergency fasciotomy
The clinical triad of pain out of proportion, paresthesias, and a tense compartment strongly indicates acute compartment syndrome. Fasciotomy is the definitive emergency treatment; delay causes irreversible ischemic injury (Volkmann contracture, rhabdomyolysis). Elevation and ice reduce swelling but do not relieve elevated compartment pressure. MRI and analgesia waste critical time.
Question 2: A 55-year-old woman with type 2 diabetes reports a 3-month history of bilateral hand numbness that is worse at night and relieved by shaking the hands. Physical examination reveals decreased sensation over the palmar aspect of the first three fingers. The most likely diagnosis is:
- Cubital tunnel syndrome
- Carpal tunnel syndrome (Correct answer)
- Cervical radiculopathy at C6
- Raynaud phenomenon
Correct answer: Carpal tunnel syndrome
Carpal tunnel syndrome (median nerve compression) classically presents with nocturnal numbness and paresthesias in the first 3.5 fingers relieved by wrist flicking ('flick sign'). Cubital tunnel (ulnar nerve) affects the ring and small fingers. C6 radiculopathy can mimic but typically includes neck pain and deltoid/biceps weakness. Raynaud causes color changes, not fixed sensory distribution.
Question 3: A 70-year-old woman with no prior fractures has a DEXA T-score of −2.7 at the femoral neck. She has no secondary causes of bone loss and no history of fracture. Which intervention is MOST appropriate?
- Calcium and vitamin D supplementation alone
- Initiate bisphosphonate therapy plus calcium and vitamin D (Correct answer)
- Teriparatide (PTH analogue) as first-line therapy
- Repeat DEXA in 2 years before deciding on treatment
Correct answer: Initiate bisphosphonate therapy plus calcium and vitamin D
A T-score ≤ −2.5 meets the WHO definition of osteoporosis and crosses the pharmacotherapy threshold per AACE/NOF guidelines. Bisphosphonates (e.g., alendronate) plus calcium/vitamin D are first-line. Teriparatide is reserved for severe osteoporosis or bisphosphonate failure. Calcium/D alone is insufficient at this T-score, and waiting 2 years is not appropriate given established osteoporosis.
Question 4: A 35-year-old pitcher develops anterior shoulder pain during the throwing motion. On examination, there is a positive 'empty can' test and weakness with resisted external rotation. Which structure is most likely injured?
- Long head of the biceps tendon
- Supraspinatus tendon (Correct answer)
- Subscapularis tendon
- Glenoid labrum (SLAP tear)
Correct answer: Supraspinatus tendon
The empty can test (Jobe's test) isolates the supraspinatus by positioning the arm at 90° abduction in the scapular plane with the thumb pointing down. Weakness or pain is highly specific for supraspinatus pathology (tear or tendinopathy). The biceps long head produces Speed's test pain. Subscapularis is tested with the lift-off test. SLAP tears cause deep shoulder pain with clicking but have different provocative tests.
Question 5: A patient with acute low back pain radiating down the left leg to the foot has a positive straight-leg raise at 40°. Imaging shows L4–L5 disc herniation. After 6 weeks of conservative management, which finding would be the STRONGEST indication for urgent surgical referral?
- Persistent pain VAS 6/10 despite NSAIDs
- Absence of improvement in walking distance
- New onset saddle anesthesia and urinary retention (Correct answer)
- Positive Lasègue sign bilaterally
Correct answer: New onset saddle anesthesia and urinary retention
Saddle anesthesia (perianal numbness) with urinary retention constitutes cauda equina syndrome—a surgical emergency requiring decompression within 24–48 hours to prevent permanent bowel/bladder dysfunction and lower-extremity paralysis. Persistent pain and functional limitations guide elective surgical timing. Bilateral Lasègue is concerning but does not mandate emergency surgery in isolation.
Question 6: According to the Ottawa Ankle Rules, plain radiographs of the ankle are indicated when the patient has:
- Significant swelling and bruising around the lateral malleolus regardless of weight-bearing ability
- Pain in the malleolar zone AND inability to bear weight for four steps both immediately and in the ED (Correct answer)
- Tenderness anywhere along the fibula above the lateral malleolus
- Pain onset during sports activity rather than a fall
Correct answer: Pain in the malleolar zone AND inability to bear weight for four steps both immediately and in the ED
The Ottawa Ankle Rules require ankle X-rays when there is pain in the malleolar zone PLUS either (1) bone tenderness at the posterior edge or tip of either malleolus, or (2) inability to bear weight for four steps both immediately after injury and in the ED. Swelling alone, proximal fibula tenderness, or mechanism of injury are not Ottawa criteria. These validated rules reduce unnecessary radiographs without missing clinically significant fractures.
SPEX Exam Musculoskeletal and Orthopedics
A 28-year-old man presents 4 hours after a forearm fracture with severe pain out of proportion to the injury, paresthesias in the hand, and a tense compartment on palpation.
The most appropriate immediate management is: