In the Jan. 12, 1999 issue, we published "Med Grads Flunk Musculoskeletal Exam." The results of the test were annotated in a recent study in the Journal of Bone and Joint Surgery.1
Eighty-five first-year medical and surgical residents at the University of Pennsylvania School of Medicine took a 25-question test; 82% failed to get a passing score. The study concluded: "Current medical school training in musculoskeletal medicine is inadequate."
We've received many inquiries about the study, including quite a few requests to see the questions.
Here they are. The answers appear at the bottom of the page. Basic competency is judged to be a score of 73%.
Basic-Competency Examination in Musculoskeletal Medicine*
Question - What common problem must all newborns be examined for?
- What is a compartment syndrome?
- Acute septic arthritis of the knee may be differentiated from inflammatory arthritis by which laboratory test?
- A patient dislocates his knee in a car accident. What structure(s) is/are at risk for injury and therefore must be evaluated?
- A patient punches his companion in the face and sustains a fracture of the 5th metacarpal and a 3mm break in the skin over the fracture. What is the correct treatment and why?
- A patient comes to the office complaining of low back pain that wakes him up from sleep. What two diagnoses are you concerned about?
- How is compartment syndrome treated?
- A patient lands on his hand. It is tender to palpation in the "snuff box" (space between the thumb extensor and abductor tendons). Initial radiographs do not show a fracture. What diagnosis must be considered?
- A 25-year-old male is involved in a motor-vehicle accident. His left limb is in a position of flexion at the knee and hip, with internal rotation and adduction of the hip. What is the most likely diagnosis?
- What nerve is compressed in carpal tunnel syndrome?
- A patient has a disc herniation pressing on the 5th lumbar nerve root. How is motor function of the 5th lumbar nerve root. How is motor function of the 5th lumbar nerve root tested?
- How is motor function of the median nerve tested in the hand?
- A 12-year-old boy severely twists his ankle. Radiographs show only soft-tissue swelling. He is tender at the distal aspect of the fibula. What are two possible diagnoses?
- A patient presents with new onset low back pain. Under what conditions are plain radiographs indicated? Please name five (example: history of trauma).
- A patient has a displaced fracture near the fibular neck. What structure is at risk for injury?
- A 20-year-old injured his knee playing football. You see him on the same day; he has a knee effusion. An aspiration shows frank blood. What are the three most common diagnoses?
- What are the five most common sources of cancer metastatic to bone?
- Name two differences between rheumatoid arthritis and osteoarthrosis.
- Which malignancy may be present in bone yet typically is not detected with a bone scan?
- What is the function of the normal anterior cruciate ligament at the knee?
- What is the difference between osteoporosis and osteomalacia?
- In elderly patients, displaced fractures of the femoral neck are typically treated with joint replacement, whereas fractures near the trochanter are treated with plates and screws. Why?
- What muscle(s) is/are involved in lateral epicondylitis (tennis elbow)?
- Rupture of the biceps at the elbow results in weakness of both elbow flexion and _______________?
- What muscle(s) control(s) external rotation of the humerus with the arm at the side?
* The items are listed in order of the importance scores. + On a scale of 1 to 10.
Answers
- Congenital dislocation of the hip (CDH dislocation, subluxation also accepted); 1 point
- Increased pressure in a closed fascial space: 1 point
- Any analysis of fluid from aspiration (cell count, gram stain, culture): 1 point
- Must mention popliteal artery: 1 point
- Irrigation and debridement; risk of infection: 1/2 point each
- Tumor and infection: 1/2 point each
- Fasciotomy (surgery also accepted): 1 point
- Scaphoid fracture (carpal bone fracture also accepted): 1 point
- Hip dislocation: 1 point
- Median nerve: 1 point
- Dorsiflexion of the great toe (toe extensors also accepted): 1 point
- Any median function (metacarpophalangeal finger flexion; thumb opposition, flexion, or abduction): 1 point
- Ligament sprain and Salter-Harris I fracture (sprain, fracture also accepted): 1/2 point each
- Age > 50, neurological deficit;Îbowel or bladder changes; history of cancer, pregnancy, drug use, or steroid use; systemic symptoms (night pain, fever); pediatric population: 1/4 point each; full credit for 4 correct responses
- Common peroneal nerve 1 point
- Ligament tear, fracture, peripheral meniscal tear (capsular tear, patellar dislocation also accepted): 1/2 point each, full credit for 2 correct responses
- Breast, prostate, lung, kidney, thyroid: 1/4 point each, full credit for 4 correct responses
- Any two correct statements (i.e., inflammatory vs. degenerative, proximal interphalangeal joint vs. distal interphalangeal joint, etc.): 1/2 point each
- Myeloma (full credit for hematological malignancies --leukemia, lymphoma):1 point
- To prevent anterior displacement of the tibia on the femur: 1 point
- To prevent anterior displacement of the tibia on the femur: 1 point
- Osteoporosis -- decreased bone density; osteomalacia -- decreased bone mineralization (any true statement about epidemiology, pathophysiology --e.g., estrogen vs vitamin D -- also accepted): 1 point
- Blood supply to femoral head (avascular necrosis, nonunion also accepted):1 point
- Wrist extensors (full credit for any wrist extensor -- extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis): 1 point
- Infraspinatus or teres minor accepted (full credit for rotator cuff): 1 point
| Residents' Mean Score (percent) | Chairpersons' Importance Score+ (points) |
99
95
76
70
54
33
94
54
35
94
20
75
67
50
62
44
86
76
51
53
40
40
18
49
28 | 9.1
9.0
8.5
8.4
8.4
8.0
7.9
7.8
7.6
7.4
7.2
7.0
7.0
7.0
6.8
6.8
6.7
6.6
6.4
6.2
5.7
5.2
5.1
5.1
4.6 |
Reference
1. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone and Joint Surg, 80-A:1421-1427. Oct. 1998.
