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Knee Sports MCQs

Practice Set 26 of 102

This practice set contains high-yield board review questions covering key concepts in Knee Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 501

Topic: Knee Sports

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

. Anterior horn of the lateral meniscus
. Posterior cruciate ligament
. Posterior horn of the medial meniscus
. Popliteus tendon
. Quadriceps muscle

Correct Answer & Explanation

. Posterior horn of the medial meniscus

Explanation

Cadaveric studies have demonstrated the important role of the posterior horn of the medial meniscus in stabilizing the anterior cruciate ligament-deficient knee with significantly greater resultant force in the medial meniscus when subjected to anterior tibial loads. The posterior horn of the medial meniscus is thought to limit anterior tibial translation by acting as a buttress by wedging against the posterior aspect of the medial femoral condyle. The other soft tissues mentioned do not play any significant role in prevention of anterior tibial translation in the anterior cruciate ligament-deficient knee.

Question 502

Topic: Knee Sports
Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?
. Anterior cruciate ligament
. Posterior cruciate ligament
. Ligament of Wrisberg
. Ligamentum mucosum
. Popliteus tendon

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

DISCUSSION: The anterior cruciate ligament can be visualized on an axial MRI scan as a low-signal structure lying in the lateral aspect of the intercondylar notch. Visualization in multiple planes increases the accuracy of MRI to view the anterior cruciate ligament. The posterior cruciate ligament and ligament of Wrisberg are located on the medial wall of the notch. The ligamentum mucosum is anterior to the notch, and the popliteus tendon is posterior to the lateral femoral condyle. REFERENCES: Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 675-699. Fitzgerald SW, Remer EM, Friedman H, Rogers LF, Hendrix RW, Schafer MF: MR evaluation of the anterior cruciate ligament: Value of supplementing sagittal images with coronal and axial images. Am J Roentgenol 1993;160:1233-1237.

Question 503

Topic: Knee Sports
A 19-year-old rugby player has severe knee pain after being injured in a game 2 weeks ago. Examination reveals a knee effusion, limited motion, and increased 3+ Lachman’s test and anterior drawer. There is also increased external rotation at 30 degrees of knee flexion when the patient is placed in the prone position. Based on these findings, which of the following actions would most likely increase the risk of anterior cruciate ligament (ACL) reconstruction failure?
. Inadvertent rotation of the graft 90 degrees internally prior to its final fixation
. Lack of full knee extension at the time of surgery
. Persistent posterolateral corner injury
. Leaving 1 to 2 mm of bone posterior to the femoral tunnel at the time of the ACL reconstruction
. Placing the tibial tunnel within the ACL footprint

Correct Answer & Explanation

. Persistent posterolateral corner injury

Explanation

The patient has a combined ACL and posterolateral corner injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. The tibial external rotation test is best performed with the patient in the prone position. A 10-degree side-to-side difference of external rotation at 30 degrees of knee flexion indicates injury to the posterolateral corner.

Question 504

Topic: Knee Sports

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet “pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical examination findings likely include

. positive Lachman test, normal posterior drawer, positive pivot shift.
. positive Lachman test, positive posterior drawer, negative pivot shift.
. normal Lachman test, positive posterior drawer, positive pivot shift.
. normal Lachman test, positive posterior drawer, negative pivot shift.

Correct Answer & Explanation

. positive Lachman test, normal posterior drawer, positive pivot shift.

Explanation

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation;this must be avoided by careful attention to initial resting position and station of the knee.

Question 505

Topic: Knee Sports
A 48-year-old man has recurrent right knee pain. Figure 52a shows the sagittal proton density T2-weighted MRI scan, and Figure 52b shows the sagittal T2-weighted MRI scan at the same level. The arrow is pointing to a
. popliteal cyst.
. posterior cruciate ligament tear.
. torn and displaced posterior horn of the medial meniscus.
. normal meniscofemoral ligament of Humphry.
. normal meniscofemoral ligament of Wrisberg.

Correct Answer & Explanation

. torn and displaced posterior horn of the medial meniscus.

Explanation

DISCUSSION: Meniscal tears have many configurations and locations. The normal medial meniscus has a bow-tie configuration on the two most medial consecutive sagittal views. Toward the center of the joint the anterior and posterior horns have a triangular shape. These images show an abnormal intra-articular low-signal structure located anterior to the intact posterior cruciate ligament. This most likely represents a torn and displaced posterior horn of the medial meniscus, sometimes called “double PCL sign.” A popliteal cyst and ligaments of Wrisberg and Humphry are not visible on these figures. REFERENCES: Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191. Mink JH, Deutsch AL: The knee, in MRI of the Musculoskeletal System, ed 1. New York, NY, Raven Press, 1990, pp 251-387.

Question 506

Topic: Knee Sports
Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures?
. Loose body
. Plica
. Displaced meniscus tear
. Torn retinaculum
. Osteochondral defect

Correct Answer & Explanation

. Plica

Explanation

Synovial folds or plicae are the result of incomplete or partial resorption of the synovial membranes during fetal development of the knee. The arthroscopic view shows a medial patellar plica, which has been noted in 5% to 55% of all individuals but becomes symptomatic in only a small number of patients. Symptoms may include crepitus, pain, snapping, and swelling and often respond to nonsurgical management.

Question 507

Topic: Knee Sports
A 12.5-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full range of motion without effusion. Radiographs reveal an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI scans are shown in Figures 14a and 14b. Initial treatment should consist of:
. Activity modification
. Arthroscopic evaluation of fragment stability
. Transarticular drilling of the lesion with 0.045 Kirschner wire
. Arthroscopic excision of the fragment and microfracture of underlying cancellous bone
. Excision of the fragment and mosaicplasty

Correct Answer & Explanation

. Activity modification

Explanation

This skeletally immature patient has a small OCD lesion that appears stable, and he has not undergone any treatment. Therefore, a trial of activity modification and limited weight bearing until pain resolves is the best initial choice. Cessation of sport activities for 4 to 6 months may allow healing of the lesion. Surgical treatment of juvenile OCD lesions is reserved for unstable lesions, patients who have not shown radiographic evidence of healing and are still symptomatic after 6 months of nonsurgical management, or patients who are approaching skeletal maturity.

Question 508

Topic: Knee Sports

A 20-year-old basketball player sustains a knee injury during a game and is seen in the orthopaedic clinic 3 days after injury. Examination reveals a positive Lachman, pivot shift, joint line tenderness, and moderate effusion. Which of the following tissue injuries is most likely causing the jointline tenderness? Review Topic

. Medial meniscus tear
. Popliteus tendon rupture
. Lateral meniscus tear
. Proximal tibia-fibula disruption
. Pes anserine bursitis

Correct Answer & Explanation

. Lateral meniscus tear

Explanation

The physical examination findings are consistent with an acute anterior cruciate ligament tear. In the acute setting, a lateral meniscus tear is a more common secondary injury than a medial meniscus tear. In one study of acute anterior cruciate ligament tears in alpine skiers, the incidence of lateral meniscus tears was over four times that of medial meniscus tears. Medial meniscus tears are more common in the chronic setting, most likely secondary to its role as a secondary restraint.

Question 509

Topic: Knee Sports

Failure of posterolateral corner repair or reconstruction of the knee may be associated with which of the following? Review Topic

. Valgus malalignment
. Varus malalignment
. Anterior cruciate ligament reconstruction
. Posterior cruciate ligament reconstruction
. Medial collateral ligament reconstruction

Correct Answer & Explanation

. Varus malalignment

Explanation

Failure to reconstruct a torn anterior cruciate ligament or posterior cruciate ligament at the time of posterolateral corner (PLC) repair or reconstruction dramatically increases the likelihood of PLC failure. Uncorrected varus malalignment places extensive tension on a PLC reconstruction and is a well recognized cause of failure. Valgus malalignment and medial collateral ligament reconstruction are not recognized means of failure.

Question 510

Topic: Knee Sports

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

. the player but not the team.
. the team but not the player.
. neither the team nor the player.
. both the team and the player.
. the team, the player, and the media

Correct Answer & Explanation

. the player but not the team.

Explanation

When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media.

Question 511

Topic: Knee Sports
During reconstruction of the medial patellofemoral ligament (MPFL) for recurrent patellar instability, accurate identification of the anatomic femoral attachment (Schöttle's point) is critical to prevent graft anisometry. On a strictly lateral radiograph of the knee, where is Schöttle's point accurately located?
. 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line
. 5 mm posterior to the posterior cortex extension line, exactly centered on Blumensaat's line
. 2 mm anterior to the anterior cortex extension line, distal to the deepest portion of the trochlear groove
. 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and distal to Blumensaat's line
. Exactly at the intersection of the posterior cortex extension line and Blumensaat's line

Correct Answer & Explanation

. 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line

Explanation

According to Schöttle et al., the radiographic landmark for the femoral footprint of the MPFL on a strict lateral radiograph is 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and distinctly proximal to the posterior extension of Blumensaat's line. Placing the graft here ensures optimal isometry during knee flexion and extension.

Question 512

Topic: Knee Sports

A 45-year-old female presents with acute medial knee pain after a squatting maneuver. MRI reveals a complete radial tear at the posterior root of the medial meniscus, with 4 mm of medial meniscal extrusion. Biomechanically, this specific injury pattern is most equivalent to which of the following conditions?

. Total medial meniscectomy
. Loss of exactly 50% of the medial meniscal volume
. Anterior cruciate ligament deficiency
. Isolated deep medial collateral ligament tear
. Loss of the meniscofemoral ligaments of Wrisberg and Humphrey

Correct Answer & Explanation

. Total medial meniscectomy

Explanation

The meniscal roots securely anchor the meniscus to the tibial plateau, allowing the meniscus to convert axial loads into circumferential 'hoop stresses'. A complete tear of the posterior root disrupts these hoop stresses entirely, leading to meniscal extrusion. Biomechanical studies have demonstrated that a root tear results in contact pressures and kinematics that are statistically equivalent to a total meniscectomy.

Question 513

Topic: Knee Sports

During an anterior cruciate ligament (ACL) reconstruction, the surgeon inadvertently places the femoral tunnel too anterior (shallow) in the intercondylar notch. What is the expected kinematic consequence of this technical error?

. Excessive graft tension in extension and laxity in flexion
. Excessive graft tension in flexion and laxity in extension
. Equal tension throughout the entire range of motion
. Severe graft impingement in the intercondylar notch during extension
. Medial compartment overload leading to early arthrosis

Correct Answer & Explanation

. Excessive graft tension in extension and laxity in flexion

Explanation

An anteriorly (shallow) placed femoral tunnel in ACL reconstruction captures a rotational axis that causes the graft to become excessively tight in flexion and loose in extension, potentially limiting terminal flexion.

Question 514

Topic: Knee Sports

During medial patellofemoral ligament (MPFL) reconstruction, the surgeon places the femoral tunnel proximal and anterior to the true anatomic insertion (Schottle point). What is the primary kinematic abnormality caused by this error?

. Excessive graft tightness in extension
. Excessive graft tightness in flexion
. Lateral patellar subluxation in deep flexion
. Medial patellar subluxation in extension
. No significant effect on patellar tracking

Correct Answer & Explanation

. Excessive graft tightness in extension

Explanation

A femoral tunnel placed too proximal and anterior in MPFL reconstruction will result in the graft increasing in tension as the knee flexes. This excessive tightness in flexion restricts motion and increases medial patellofemoral contact pressures.

Question 515

Topic: Knee Sports
During medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the surgeon uses fluoroscopy to identify Schöttle's point for the femoral tunnel. Which of the following radiographic landmarks correctly defines this location on a strict lateral radiograph?
. 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior articular border, and proximal to Blumensaat's line
. 1 mm anterior to the posterior cortex extension line, 2.5 mm proximal to the posterior articular border, and proximal to Blumensaat's line
. 2 mm posterior to the anterior cortex extension line, and distal to Blumensaat's line
. At the exact center of the medial femoral epicondyle
. At the intersection of the adductor tubercle and the medial epicondyle

Correct Answer & Explanation

. 1 mm anterior to the posterior cortex extension line, 2.5 mm proximal to the posterior articular border, and proximal to Blumensaat's line

Explanation

Schöttle's point identifies the anatomic femoral origin of the MPFL. On a strict lateral view, it is located 1 mm anterior to a line extending the posterior femoral cortex, 2.5 mm proximal to the posterior articular border, and proximal to Blumensaat's line.

Question 516

Topic: Knee Sports

During reconstruction of the posterior cruciate ligament (PCL), anatomically recreating the anterolateral (AL) bundle is crucial for restoring native kinematics. What is the primary biomechanical function of the AL bundle of the PCL?

. Resist posterior tibial translation in full extension
. Resist posterior tibial translation at 90 degrees of knee flexion
. Resist external tibial rotation at 30 degrees of flexion
. Resist anterior tibial translation in deep flexion
. Act as the primary restraint to varus stress

Correct Answer & Explanation

. Resist posterior tibial translation in full extension

Explanation

The PCL consists of two main bundles: the anterolateral (AL) and posteromedial (PM). The AL bundle is tightest in flexion and is the primary restraint to posterior tibial translation at 90 degrees of knee flexion, making it the primary target in single-bundle reconstructions.

Question 517

Topic: Knee Sports
Reconstruction of the medial patellofemoral ligament (MPFL) requires highly accurate femoral tunnel placement to ensure isometry. According to Schöttle's method, what is the correct radiographic location of the femoral footprint of the MPFL on a true lateral radiograph?
. Anterior to the posterior femoral cortex line and proximal to Blumensaat's line
. Anterior to the posterior femoral cortex line and distal to the posterior femoral condyle margin
. Posterior to the posterior femoral cortex line and proximal to Blumensaat's line
. Anterior to the posterior femoral cortex line, proximal to the posterior condyle margin, and between Blumensaat's line and the posterior cortex
. Posterior to the posterior femoral cortex line and distal to Blumensaat's line

Correct Answer & Explanation

. Anterior to the posterior femoral cortex line, proximal to the posterior condyle margin, and between Blumensaat's line and the posterior cortex

Explanation

Schöttle's point identifies the anatomic femoral origin of the MPFL. It is located just anterior to a line extending the posterior femoral cortex, proximal to the posterior articular margin, and just distal to the intersection of Blumensaat's line with the posterior cortex.

Question 518

Topic: Knee Sports

A 9-year-old male (Tanner Stage I) sustains a complete midsubstance anterior cruciate ligament (ACL) rupture. He has significant growth remaining. Which surgical technique is most appropriate to minimize the risk of iatrogenic limb length discrepancy and angular deformity?

. Transphyseal hamstring reconstruction
. All-epiphyseal ACL reconstruction
. Bone-patellar tendon-bone autograft
. Anteromedial portal transphyseal drilling
. Standard adult single-bundle reconstruction

Correct Answer & Explanation

. Transphyseal hamstring reconstruction

Explanation

In prepubescent patients with substantial growth remaining (Tanner Stage I or II), physeal-sparing techniques such as an all-epiphyseal or extra-articular reconstruction are indicated. Transphyseal techniques crossing the open physes risk premature arrest and subsequent angular or leg-length deformities.

Question 519

Topic: Knee Sports

A trauma patient presents with a suspected posterolateral corner (PLC) knee injury. The dial test demonstrates 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the uninjured side, but symmetric rotation at 90 degrees of flexion. This finding is diagnostic of an isolated injury to which structure?

. Anterior cruciate ligament
. Posterior cruciate ligament
. Posterolateral corner structures
. Medial collateral ligament
. Popliteus tendon alone

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

An increase in external rotation of more than 10 degrees at 30 degrees of flexion, but not at 90 degrees, indicates an isolated injury to the posterolateral corner (PLC). If increased external rotation is present at both 30 and 90 degrees, a combined PLC and PCL injury is diagnosed.

Question 520

Topic: Knee Sports

During reconstruction of the medial patellofemoral ligament (MPFL), identifying the anatomic femoral footprint (Schottle's point) is critical for graft isometry. Radiographically on a true lateral view, where is this point located?

. 1 mm anterior to the posterior femoral cortical line and just proximal to the extension of Blumensaat's line
. 5 mm posterior to the posterior femoral cortical line and distal to Blumensaat's line
. Directly centered on the medial epicondyle
. 3 mm anterior to the adductor tubercle
. 2 mm distal to the joint line and anterior to the collateral ligament origin

Correct Answer & Explanation

. 1 mm anterior to the posterior femoral cortical line and just proximal to the extension of Blumensaat's line

Explanation

Schottle's point defines the anatomic femoral origin of the MPFL. On a strict lateral radiograph, it is situated 1 mm anterior to the posterior cortex line, just proximal to the posterior extension of Blumensaat's line, and distal to the posterior origin of the medial femoral condyle.

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