MSK :

1-This patient's presentation (acute, severe knee pain, swelling, and fever) can be caused by gout, pseudogout, or septic
arthritis. While acute gouty arthritis is the most likely diagnosis in this patient, arthrocentesis and synovial fluid analysis
(SFA) are indicated to establish a definitive diagnosis -----------Elevated serum uric acid levels may be found in
individuals with acute gout flares. However, they usually fluctuate during flares and patients can have
low/normal levels, therefore, serum uric acid is not a reliable indicator for the diagnosis of this condition. The
best time to measure serum uric acid in patients with suspected flares is ≥ 2 weeks after the flare subsides.
Serum uric acid levels are used primarily to monitor chronic gout and the success of uric acid-lowering therapy
(e.g., allopurinol). (FOR ACUTE GOUT ARTHROCENTESIS IS BETTER THAN SERUM URIC ACID ).

2-This patient presents with progressive heel pain suggestive of plantar fasciitis, a condition thought to be
caused by degeneration of the plantar aponeurosis. Heel pain in plantar fasciitis is typically located on the
inferior heel over the medial calcaneal tuberosity (the site of insertion of the plantar aponeurosis) and can be
elicited by stretching the aponeurosis through passive dorsiflexion of the toes and simultaneous palpation
along the plantar fascia. The pain is usually worse in the morning, gradually lessens with activity, and
increases again towards the end of the day after long periods of weight-bearing. Obesity and overtraining
(e.g., running) are risk factors associated with this condition. An x-ray of the foot is often normal; however, in
some patients, a concurrent calcaneal heel spur is visible. Imaging is not necessary to establish the diagnosis but
can help rule out differentials (e.g., fractures).

The initial treatment is conservative and includes rest, ice massage, a 2–3 week trial with NSAIDs, avoidance
of flat shoes and barefoot walking, and stretching and strengthening exercises. Patients who do not improve
under conservative therapy can be treated with locally injected glucocorticoids.
3- Transient synovitis has the same Local symptoms +LOW Grade fever of septic arthritis but not have the
systemic symptoms

4- clavicle fracture treatment :

Midshaft (group I) fractures

 Mostly conservative treatment (e.g., simple shoulder sling) for 4–6 weeks
 Exception: excessively shortened or displaced fractures (require surgery)

Lateral (group II) fractures

 Stable fractures: conservative treatment (e.g., simple shoulder sling)

 Unstable fractures
o Surgical fixation (e.g., tension banding, clavicular plate) is typically indicated
o If needed, ligament repair

Medial (group III) fractures

 Conservative treatment (similar to group I fractures)

 Displacement is uncommon due to strong ligamentous attachments
.5-Turf toe : affects the first metatarsophalangeal joint. It is also most commonly seen in football or soccer
players that play on artificial turf, not marathon runners.

Morton's neuroma usually occurs in the third and fourth intermetatarsal spaces.

6- ttt of RA

7-Further radiographic findings of CPPD disease include chondrocalcinosis and degenerative changes (e.g.,
subchondral cysts) in affected joints.

8-If there is strong suspicion for a scaphoid fracture, immobilization of the thumb and wrist with a thumb
spica cast is indicated even if there are initially no x-ray findings of a scaphoid fracture. This procedure is
important because a delay in immobilization increases the risk of complications such as nonunion and avascular
necrosis of the scaphoid.

8-Nonseptic bursitis:Rest, ice or heat, elevation, and NSAIDs

Septic bursitis : Antibiotics

 Bursal aspiration: for persistent purulent effusion

 Surgical intervention: Consider for severe, recurrent, or refractory purulent effusions. [2][5]
o Bursectomy

9-Anti-cyclical citrullinated peptide antibodies (anti-CCP antibodies) are a highly specific marker for RA (specificity >
90%). High anti-CCP antibody titers are also associated with a more aggressive disease course (e.g., erosive arthritis or
extra-articular manifestations, such as rheumatoid nodules and Felty syndrome). Although rare, Felty syndrome can
occur in severe, long-standing, seropositive RA. Increased destruction of platelets and RBCs by the enlarged spleen
(hypersplenism) results in thrombocytopenia and low hematocrit, which may be further aggravated by anemia of
chronic disease.

10-the knee pain in PAPS manifests along the medial aspect of the knee and proximal tibia, rather than the lateral knee.

Iliotibial band syndrome (ITBS) manifests with knee pain over the lateral femoral epicondyle and a positive Noble test.
ITBS is an overuse injury that is mainly seen in runners, cyclists, and military personnel. The pain in ITBS is initially sharp
or burning, poorly localized, and only present during exercise, but can develop into a deep, dull ache that persists even
during rest. ITBS is mainly a clinical diagnosis; treatment includes rest, ice, and NSAIDs during the acute phase, followed
by muscle strengthening (e.g., physiotherapy, supervised exercise program) and flexibility exercises (e.g., stretching, use
of foam rollers).

11-Ottawa ankle and foot rules

The Ottawa ankle and foot rules apply to patients presenting to the emergency department (ED) with traumatic
ankle and/or foot injuries.
Ankle x-rays are indicated in the presence of pain in the malleolar zone AND one or both of the following:
- Tenderness along the posterior distal 6 cm of the lateral OR medial malleolus
- Inability to weight-bear both immediately post-injury AND for at least 4 steps in the ED

Foot x-rays are indicated in the presence of pain in the midfoot zone AND one or both of the following:
- Tenderness at the base of the 5th metatarsal OR the navicular bone
- Inability to weight-bear both immediately post-injury AND for at least 4 steps in the ED

12-Lateral epicondylitis is caused by activities that involve repetitive wrist extension and forearm pronation/supination,
such as backhand shots in racket sports. The pain can typically be exacerbated by resisted supination, resisted wrist
extension, and tight grasping of objects. Lateral epicondylitis is a clinical diagnosis, and imaging is usually not necessary.
If performed, musculoskeletal ultrasound typically shows thickening and edema of the tendinous origin of the extensor
carpi radialis brevis. Initial management consists of conservative treatment including rest, cooling, NSAIDs, physical
therapy, and modification of activity (e.g., training proper technique). In patients with severe pain, a local corticosteroid
injection may be indicated; note that corticosteroids can cause tendon rupture in insertional tendinopathy. If symptoms
do not subside after 6 months of conservative therapy, surgical release of the extensor carpi radialis brevis tendon can
be considered.

13-paget disease ttt =bisphosphonate

14-Radiculopathy reflexes

15-Elevated serum alkaline phosphatase (ALP) and normal Ca2+, phosphate, and parathyroid hormone (PTH) are most
consistent with PDB.
16-
The x-ray shows deformity, malalignment, and severe degenerative changes of the second and third metatarsal
heads. These findings, in conjunction with unilateral, painless swelling of the foot and symmetrical decreased
sensation in the distal lower extremities in a patient with diabetes mellitus suggest diabetic neuropathic
arthropathy, also known as Charcot foot.

17-vertebral osteomyelitis and epidural abcess

18-Posterior hip dislocation is the most common type of hip dislocation (approx. 90% of cases) and classically occurs
following high-energy trauma, in which a posteriorly directed force (e.g., dashboard during a motor vehicle accident) is
directed towards the hip. The affected leg is typically shortened, mildly flexed, internally rotated, and adducted. Given
the considerable amount of force required for posterior hip dislocation, associated fractures of the femoral head or the
acetabulum are common.

Patients with an anterior hip dislocation may present with pain in the groin, and a mild flexion deformity of the
hip. However, the leg would be lengthened, externally rotated, and mildly abducted.

19- A laterally displaced patella, right knee effusion and pain, a past history of similar episodes, and a history of Ehlers-
Danlos syndrome make the diagnosis of acute patellar dislocation highly likely. The osteochondral fragment within the
knee joint indicates an avulsion fracture of the lateral femoral condyle or patella.

This is a good answer option to consider because closed reduction of the patella is the treatment of choice in cases of
uncomplicated patellar dislocation. ‫ لكن‬question aims at testing the management of patella dislocation complicated by
an osteochondral fracture=ARTHROSCOPY REMOVAL OF THE AVULSED

20-Pattern of joint involvement and iridocyclitis in juvenile idiopathic arthritis (JIA)

– Oligoarthritis: asymmetrical oligoarthritis involving ≤ 4 joints (within 6 months of onset); associated with
iridocyclitis
– Seronegative polyarthritis: asymmetrical or symmetrical oligoarthritis; associated with iridocyclitis
– Seropositive polyarthritis: symmetrical polyarthritis involving ≥ 5 joints (within 6 months of onset)

CHILD 2-4 YEARS WITH NUMEROUS ARTHRIRIS IN APERIOD OF TIME +_ IRIDOCYCLITIS )

POSITIVE ANA ,ELEVATED ESR

21-Contrast-enhanced MRI of the spine is the imaging modality of choice for suspected vertebral bone
metastasis,

22-The patient's short stature, history of fractures after minor trauma, bone deformities (kyphoscoliosis, bowed
tibias), joint hypermobility, and family history of recurrent fractures is highly suggestive of osteogenesis
imperfecta (OI).

Hearing impairment

Hearing impairment is a common clinical manifestation of OI, and results from fracture, dislocation, or
abnormal formation of the ossicles. Additional findings in patients with OI include blue sclerae (due to
choroidal veins appearing through the overlying thin sclerae), easy bruisability, and brittle, opalescent teeth
(i.e., dentinogenesis imperfect). Depending on the type of OI, manifestations may range from mildly
symptomatic (type I) to perinatally lethal (type II). This patient likely has moderate to severe OI (comprised of
types III-IX) given her early presentation, short stature, and significant bone deformities.

23-Greater trochanteric pain syndrome (GTPS) results from tendinopathy at the attachment of the gluteus
medius and/or minimus muscle. GTPS affects women more frequently and manifests with lateral thigh or hip
pain near the great trochanter. Typical findings include tenderness to palpation over the greater trochanter,
exacerbation of pain by lying on the affected side, and triggering of pain by resisted abduction, all of which
are present in this patient. In patients with classic features of GTPS, imaging is not required to establish the
diagnosis. X-ray is usually normal and essentially rules out bone involvement. Management of GTPS is mainly
conservative and includes physical therapy and modified activities to strengthen the gluteal muscles without
causing damage to the gluteal tendons from overexertion, as well as oral NSAIDs or glucocorticoid injections
at the greater trochanter for pain.
 Common cause of lateral hip pain
 Pain is usually localized to the greater trochanter at the proximal end of the femur.
 Tenderness to palpation over the greater trochanter Pain is triggered by resisting active abduction or standing
only on the affected leg
24-The amputated fingertip should be gently rinsed with water, wrapped in damp gauze, sealed in a
watertight bag, and then placed in a bag with ice water. An amputated limb should never be placed directly
on ice because of the potential for cold damage (i.e., frostbite). The aim is to preserve the finger as best as
possible in order to maximize the chances of successful reattachment (replantation). The patient and their
amputated fingertip should then be transported immediately to the emergency department.

Once in the emergency department, the patient's hand would be anesthetized and debrided. The decision to
attempt reattachment is typically left to specialist consultation and is decided on a case-by-case basis, although
it is not commonly attempted in adults.

25 -hearing loss in paget : hearing loss (due to ankylosis of the ossicles or compression of the vestibulocochlear
nerve).

26-Accumulation of blood within the rectus sheath causes a rectus sheath hematoma (RSH). This condition typically
results from a sudden, forceful contraction of the rectus abdominis muscle (RAM) causing a tear in an epigastric artery
or in the RAM itself. RSH manifests with acute abdominal pain and a tender mass that is located within the abdominal
wall and does not cross the midline. Carnett sign and Fothergill sign, both seen here, are characteristic of this condition.
If the RSH is large enough, the patient may develop hypovolemia, signs that mimic peritonitis (e.g., abdominal guarding),
and abdominal compartment syndrome. A contrast-enhanced abdominal CT is used to confirm the diagnosis of RSH.
Management includes treating the underlying cause (e.g., treatment of severe hypertension, reversal of anticoagulation)
and providing hemodynamic support as needed. Selective arterial embolization and surgery are reserved for severe
cases (e.g., refractory hypovolemia, abdominal compartment syndrome).

27-In adults, baker cysts commonly occur secondary to inflammatory diseases (such as RA), as well as

28-
Langerhans cell histiocytosis (LCH) is a rare disorder that most commonly affects children 5–10 years of age. LCH
manifests with single or multiple osteolytic lesions that cause bone pain and swelling. The skull is the most commonly
affected bone in children, although other bones such as the long bones, vertebrae, and ribs can also be affected. LCH
can also manifest with systemic findings such as rash, lymphadenopathy, hepatosplenomegaly, and central diabetes
insipidus. Secondary anemia may develop in patients with bone marrow involvement. Affected individuals typically have
normal serum calcium levels. degenerative (e.g., osteoarthritis), or traumatic (e.g. meniscal tears) joint conditions.

A biopsy of this mass, which is needed to confirm the diagnosis, will show heterogeneous collections of
polygonal, eosinophilic cells that contain Birbeck granules.

29-the characteristics of septic arthritis in the context of prosthetic joint infections, emphasizing key features and
associations with Staphylococcus species. Statement 1 focuses on early-onset infections associated with S. aureus(to 3
months ) , while Statement 2 discusses late-onset infections linked to S. epidermidis.to 5 months

30-AC joint injury is typically caused by a direct force to the superior aspect of the acromion (e.g., falling off a
bike) and can be suspected based on history and clinical features (e.g., AC joint tenderness and/or ecchymosis,
positive cross-arm adduction test) alone. However, an x-ray of the shoulder (in anterior-posterior, oblique, and
axillary views) is necessary to determine the type of AC joint injury, which will guide treatment. The
classification of AC joint injuries considers the extent of injury to the AC ligament and the coracoclavicular
ligament, as well as the displacement of the clavicle and type of dislocation in the AC joint. Mild injuries
(Rockwood types I, II, and III) are typically treated conservatively by sling immobilization, analgesia, and
physical therapy. Treatment of more severe injuries (Rockwood types IV and above) are managed surgically,
followed by physical therapy.

31-Reduced osteoblastic activity is an important component in the pathogenesis of osteoporosis. This patient
has multiple risk factors for osteoporosis (increased age, female sex, and daily alcohol consumption), making
it the most likely underlying cause of her fracture. Bone is constantly remodeled through the actions of
osteoclasts, which break down the bone matrix, and osteoblasts, which help create new bone matrix. In
osteoporosis, osteoblast activity is decreased relative to osteoclast activity, resulting in overall decreased bone
strength.

Treatment of osteoporosis in postmenopausal women includes oral bisphosphonates, which inhibit osteoclast
mediated bone resorption and can significantly decrease the risk of fractures.
32-Dual-energy x-ray absorptiometry is a screening test used to diagnose osteoporosis. This screening test is usually
reserved for women over the age of 65. However, women under the age of 65 who are at increased risk of
osteoporosis, such as this patient, should also receive screening. Risk factors for osteoporosis include a family history of
hip fracture, excessive alcohol consumption, smoking, and a low BMI. This patient is up-to-date on all other
recommended screenings and preventive measures based on her age and risk factors.
33-Osteochondritis dissecans (OD) is a focal aseptic necrosis of subchondral bone in which a fragment of bone and
cartilage detaches and is displaced in the joint space. OD is caused by overuse or repetitive microtrauma of the joint
(most commonly the knee joint), typically affects individuals aged 10–20 years, and manifests with joint pain that
worsens with activity, joint locking, crepitus, and tenderness to palpation. The diagnosis is confirmed with x-ray, which
shows a subchondral bony fragment surrounded by radiolucency. Conservative management with limited physical
activity and physical therapy is the first-line treatment for OD. Surgical therapy is indicated for most adult patients and
for children with detached and displaced intraarticular fragments or who do not respond to conservative management.
34-