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Knee Sports MCQs

Practice Set 42 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 821

Topic: Knee Sports

A 26-year-old man has recurrent right knee pain. Figures 9a and 9b show consecutive sagittal T2-weighted MRI scans, and Figure 9c shows a coronal T1-weighted MRI scan. What is the most likely diagnosis?

. Bucket-handle tear of the lateral meniscus
. Medial meniscus tear
. Discoid lateral meniscus
. Posterior cruciate ligament tear
. Normal MRI of the knee

Correct Answer & Explanation

. Discoid lateral meniscus

Explanation

A discoid meniscus is a large disk-like meniscus. It is seen in the lateral meniscus in 3% of the population; a discoid medial meniscus is much less common. It can be identified on the coronal view by noting meniscal tissue extending into the tibial spine at the intercondylar notch. The average width of a normal meniscus is less than 11 mm. A bow-tie appearance should not be seen on more than two consecutive sagittal images because the conventional thickness of the sagittal slices is 3 mm and the interval between two consecutive slices is 1.5 mm. Two sagittal slices will cover a 9-mm thickness. A discoid meniscus can be diagnosed on the sagittal views by noting a bow-tie appearance on more than two consecutive images. Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.

Question 822

Topic: Knee Sports

Figures 28a and 28b show AP and lateral radiographs of the knee. Based on these findings, which of the following structures has most likely been injured?

. Popliteal artery
. Quadriceps tendon
. Patellar tendon
. Anterior cruciate ligament
. Peroneal nerve

Correct Answer & Explanation

. Popliteal artery

Explanation

The radiographs show a posterior knee dislocation. Knee dislocations almost always involve rupture of both the anterior and posterior cruciate ligaments. Collateral ligament injuries also are common. Arterial, nerve, and tendon injuries each occur in less than half of knee dislocations. Schenck RC Jr, Hunter RE, Ostrum RF, et al: Knee dislocations. Instr Course Lect 1999;48:515-522.

Question 823

Topic: Knee Sports
A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?
. Ligament of Humphrey
. Patellar ligament
. Quadriceps tendon
. Lateral compartment
. Medial compartment

Correct Answer & Explanation

. Medial compartment

Explanation

Complete rupture of the PCL leads to increased contact pressures in the patellofemoral and medial compartments of the knee. However, whether degenerative arthritis will develop and in which compartments still remains controversial.

Question 824

Topic: Knee Sports

An 18-year-old football player lands on a flexed knee and ankle after being tackled. Examination reveals increased external rotation and posterior translation and varus at 30 degrees of flexion, which decreases as the knee is flexed to 90 degrees. What is the most likely diagnosis?

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 16

. Torn posterolateral corner
. Torn posterior cruciate ligament (PCL) and posterolateral corner
. Torn PCL
. Rupture of the quadriceps tendon
. Rupture of the lateral collateral ligament

Correct Answer & Explanation

. Torn posterolateral corner

Explanation

The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury. The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule). This results in increased posterior translation and external rotation, as well as varus that is most notable at 30 degrees of flexion and decreases as the knee is further flexed to 90 degrees. Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90 degrees from 30 degrees, while isolated PCL tears show the greatest degree of instability at 90 degrees of flexion. A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30 degrees of knee flexion without posterior translation. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 825

Topic: Knee Sports

What is the most anatomic location for placement of the femoral tunnel in anterior cruciate ligament reconstruction?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 20

. As far superior in the notch as possible
. As far posterior as possible on the lateral femoral condyle
. As far posterior as possible on the medial femoral condyle
. Directly across from the posterior cruciate femoral insertion
. At resident's ridge

Correct Answer & Explanation

. As far posterior as possible on the lateral femoral condyle

Explanation

It is critical for graft isometry and knee stability that the femoral tunnel be placed as far posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the one o'clock position on the left knee. Resident's ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement results in a variety of complications, including an unstable knee, early graft failure, and joint stiffness. Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA: The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74:140-151.

Question 826

Topic: Knee Sports

A 12 1/2-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

. immobilization.
. 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

. immobilization.

Explanation

This skeletally immature patient has a small OCD lesion that appears stable, and he has not undergone any treatment. Therefore, a trial of immobilization until pain resolves is the best initial choice. Thereafter, 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. Good results with stable in situ lesions that have failed to respond to nonsurgical management have been reported with both transarticular and retroarticular drilling. Results after excision alone are poor at 5-year follow-up, and it is unclear if microfracture will improve the long-term outcome. Mosaicplasty may be the next best option for patients who remain or become symptomatic after excision of the fragment and microfracture. Wall E, Von Stein D: Juvenile osteochondritis dissecans. Orthop Clin North Am 2003;34:341-353.

Question 827

Topic: Knee Sports

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

. Anterior cruciate
. Posterior cruciate
. Lateral collateral
. Oblique popliteal
. Intermeniscal

Correct Answer & Explanation

. Anterior cruciate

Explanation

The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci. Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.

Question 828

Topic: Knee Sports

A 55-year-old woman feels a 'pop' in the back of her knee while squatting. An MRI is shown:

A posterior horn medial meniscus root tear is identified. Biomechanically, a complete medial meniscus posterior root tear alters contact pressures to a degree equivalent to which of the following?

. Total meniscectomy
. Partial meniscectomy
. Anterior cruciate ligament tear
. Posterior cruciate ligament tear
. Medial collateral ligament tear

Correct Answer & Explanation

. Total meniscectomy

Explanation

A complete posterior root tear of the medial meniscus leads to a complete loss of hoop stresses, resulting in meniscal extrusion. Biomechanically, this alters peak tibiofemoral contact pressures and reduces contact area to a degree equivalent to a total meniscectomy, leading to rapid articular cartilage degeneration.

Question 829

Topic: Knee Sports

A 19-year-old female soccer player is undergoing an arthroscopic anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. If the surgeon drills the femoral tunnel in an excessively anterior (shallow) position within the intercondylar notch relative to the native anatomic footprint, what will be the resultant kinematic behavior of the graft?

. Tight in extension and loose in flexion
. Loose in extension and tight in flexion
. Tight throughout the entire range of motion
. Loose throughout the entire range of motion
. Impingement against the posterior cruciate ligament (PCL)

Correct Answer & Explanation

. Loose in extension and tight in flexion

Explanation

Femoral tunnel positioning is critical for successful ACL reconstruction. An excessively anterior (shallow/high in the notch) femoral tunnel placement creates a graft that is non-anatomic. Because the tunnel is anterior to the isometric point, the distance between the tibial and femoral tunnels increases as the knee flexes. This results in a graft that is excessively tight in flexion (causing loss of flexion or graft failure) and loose in extension.

Question 830

Topic: Knee Sports

A 24-year-old male sustains a severe twisting injury to his knee during a rugby match. Physical examination under anesthesia reveals 15 degrees of increased tibial external rotation compared to the contralateral knee at both 30 degrees and 90 degrees of knee flexion (Positive Dial Test). Based on this physical exam finding, which of the following structural combinations is definitively injured?

. Anterior cruciate ligament (ACL) and posterolateral corner (PLC)
. Posterior cruciate ligament (PCL) and posterolateral corner (PLC)
. Medial collateral ligament (MCL) and posterior oblique ligament (POL)
. Isolated posterolateral corner (PLC)
. Isolated posterior cruciate ligament (PCL)

Correct Answer & Explanation

. Isolated posterolateral corner (PLC)

Explanation

The Dial test measures external rotation of the tibia relative to the femur. Increased external rotation (>10 degrees asymmetry) at 30 degrees of flexion, but normal at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. Increased external rotation at BOTH 30 degrees and 90 degrees of flexion indicates a combined injury to both the PLC and the posterior cruciate ligament (PCL).

Question 831

Topic: Knee Sports

Which bundle of the posterior cruciate ligament (PCL) is the primary restraint to posterior tibial translation at 90 degrees of knee flexion?

. Posterolateral bundle
. Anteromedial bundle
. Anterolateral bundle
. Posteromedial bundle
. Meniscofemoral ligament of Wrisberg

Correct Answer & Explanation

. Anterolateral bundle

Explanation

The PCL has two main bundles: the anterolateral (AL) and posterolateral (PL) bundles. The AL bundle is larger, tighter in flexion, and acts as the primary restraint to posterior tibial translation at 90 degrees of knee flexion. The PL bundle is tighter in extension. Reconstructing the AL bundle is the primary goal in single-bundle PCL reconstruction.

Question 832

Topic: Knee Sports

During a posterior-stabilized total knee arthroplasty, the surgeon assesses the flexion and extension gaps.

The extension gap is symmetric and perfectly balanced, but the flexion gap is excessively tight. Which of the following is the most appropriate surgical adjustment?

. Resect more proximal tibia
. Downsize the femoral component to decrease the anteroposterior dimension
. Release the posterior cruciate ligament (PCL)
. Release the posterior capsule
. Increase the distal femoral resection

Correct Answer & Explanation

. Downsize the femoral component to decrease the anteroposterior dimension

Explanation

When the extension gap is balanced but the flexion gap is tight, the goal is to increase the flexion gap without altering the extension gap. This can be achieved by decreasing the anteroposterior (AP) size of the femoral component, translating the femoral component anteriorly, or recessing the PCL (if retaining it, though this is a PS knee so PCL is already gone). Resecting more proximal tibia affects both gaps. Downsizing the AP femur size uniquely increases the flexion gap.

Question 833

Topic: Knee Sports

During an anatomical reconstruction of the posterolateral corner (PLC) of the knee, the surgeon is carefully defining the insertions on the proximal fibula. Which of the following structures inserts slightly anterior and distal to the tip (styloid) on the lateral aspect of the fibular head?

. Biceps femoris
. Popliteofibular ligament
. Fibular collateral ligament (FCL)
. Arcuate ligament
. Fabellofibular ligament

Correct Answer & Explanation

. Fibular collateral ligament (FCL)

Explanation

The fibular collateral ligament (FCL) inserts on the lateral aspect of the fibular head, approximately 8.2 mm posterior to the anterior margin of the fibular head and 28.4 mm distal to the tip of the fibular styloid. The popliteofibular ligament (PFL) inserts on the posteromedial aspect of the fibular styloid.

Question 834

Topic: Knee Sports

During a primary anterior cruciate ligament (ACL) reconstruction, the surgeon is carefully determining femoral tunnel placement.

Placing the femoral tunnel too anteriorly (shallow) relative to the anatomic footprint will result in which of the following kinematic abnormalities of the graft?

. Laxity in flexion and tightness in extension
. Tightness in flexion and laxity in extension
. Equal tension throughout the full range of motion
. Impingement against the PCL in extension
. Isolated rotatory instability with a normal Lachman test

Correct Answer & Explanation

. Tightness in flexion and laxity in extension

Explanation

Anterior placement of the femoral tunnel (too shallow in the notch) brings the femoral attachment of the ACL graft anterior to the knee's axis of rotation. During knee flexion, the distance between the tibial and femoral tunnels increases, causing the graft to become exceedingly tight in flexion, limiting motion or leading to graft failure. Conversely, the graft will be loose in extension.

Question 835

Topic: Knee Sports

A 22-year-old soccer player sustains a twisting injury to the knee resulting in a rapid effusion. MRI demonstrates a complete midsubstance rupture of the anterior cruciate ligament (ACL).

Which of the following concomitant meniscal injuries is statistically most commonly associated with an acute ACL rupture?

. Medial meniscus bucket-handle tear
. Lateral meniscus posterior horn tear
. Medial meniscus root tear
. Lateral meniscus anterior horn tear
. Discoid lateral meniscus tear

Correct Answer & Explanation

. Lateral meniscus posterior horn tear

Explanation

In the setting of an acute ACL tear, tears of the lateral meniscus (particularly the posterior horn) are the most common concomitant meniscal injury, seen in roughly 50-70% of acute cases. Conversely, in the chronic ACL-deficient knee, medial meniscus tears become much more common due to the long-term altered kinematics and repeated anterior translation of the tibia, which puts the posterior horn of the medial meniscus under chronic shear stress.

Question 836

Topic: Knee Sports

When comparing the tibial inlay technique to the transtibial tunnel technique for posterior cruciate ligament (PCL) reconstruction, the tibial inlay technique has the theoretical biomechanical advantage of decreasing what phenomenon?

. Graft stretch-out
. The "killer turn" effect
. Arthrofibrosis
. Tunnel widening
. Anterior tibial translation

Correct Answer & Explanation

. The "killer turn" effect

Explanation

The transtibial tunnel technique for PCL reconstruction forces the graft to make an acute angle at the posterior aperture of the tibial tunnel, known as the "killer turn," which can lead to graft abrasion and attenuation. The tibial inlay technique avoids this acute angle.

Question 837

Topic: Knee Sports

During normal knee flexion, the phenomenon of femoral rollback is primarily facilitated by which of the following structures?

. Anterior cruciate ligament (ACL)
. Posterior cruciate ligament (PCL)
. Medial collateral ligament (MCL)
. Lateral collateral ligament (LCL)
. Popliteus tendon

Correct Answer & Explanation

. Posterior cruciate ligament (PCL)

Explanation

Femoral rollback is the posterior translation of the femur on the tibia during knee flexion, which allows for increased flexion before impingement occurs. This is primarily guided and facilitated by the tension in the posterior cruciate ligament (PCL). In PCL-restituting or substituting TKAs, maintaining this mechanism is critical.

Question 838

Topic: Knee Sports

During an anterior cruciate ligament (ACL) reconstruction, the surgeon chooses to drill the femoral tunnel independently using an anteromedial (AM) portal rather than a transtibial technique. Which of the following is an advantage of the AM portal technique?

. It decreases the risk of posterior wall blowout
. It allows for more anatomic placement of the femoral tunnel in the native footprint
. It prevents divergence of the interference screw
. It requires less knee hyperflexion during drilling
. It creates a more vertical femoral tunnel

Correct Answer & Explanation

. It allows for more anatomic placement of the femoral tunnel in the native footprint

Explanation

Independent drilling of the femoral tunnel through an anteromedial portal allows the surgeon to place the tunnel more anatomically within the native ACL footprint, independent of the tibial tunnel trajectory. Transtibial drilling often results in a more vertical, non-anatomic femoral tunnel. Disadvantages of the AM portal technique include the need for knee hyperflexion during drilling and a potentially shorter femoral tunnel.

Question 839

Topic: Knee Sports

The pivot shift test is widely considered the most specific clinical examination maneuver for an anterior cruciate ligament (ACL) tear. Which of the following best describes the biomechanics of a positive pivot shift test in an ACL-deficient knee?

. The tibia subluxates anteriorly in flexion and reduces in extension
. The tibia subluxates anteriorly in extension and reduces in flexion at 20-30 degrees
. The tibia subluxates posteriorly in extension and reduces in flexion
. The tibia subluxates anteriorly at 90 degrees of flexion and reduces in full extension
. The femur subluxates anteriorly in extension and reduces in flexion

Correct Answer & Explanation

. The tibia subluxates anteriorly in extension and reduces in flexion at 20-30 degrees

Explanation

In an ACL-deficient knee, the tibia rests in an anteriorly subluxated position when the knee is in full extension. As the examiner flexes the knee with a valgus and internal rotation force, the iliotibial band (ITB) transitions from acting as a knee extensor (anterior to the axis of rotation) to a knee flexor (posterior to the axis of rotation) at approximately 20-30 degrees of flexion. This vector change creates a posterior force on the tibia, abruptly reducing the joint and producing the classic 'clunk' of the pivot shift.

Question 840

Topic: Knee Sports

A 50-year-old woman complains of acute posterior knee pain and a 'pop' while squatting deeply. MRI reveals a complete tear of the medial meniscus posterior root.

Biomechanically, if left untreated, a complete posterior root tear of the medial meniscus acts as the equivalent to which of the following?

. A 25% partial medial meniscectomy
. A 50% partial medial meniscectomy
. A total medial meniscectomy
. An anterior cruciate ligament tear
. A medial collateral ligament tear

Correct Answer & Explanation

. A total medial meniscectomy

Explanation

The meniscal roots anchor the meniscus to the tibial plateau, allowing it to convert axial loads into circumferential hoop stresses. A complete disruption of the posterior root disrupts these hoop stresses entirely, rendering the meniscus functionally incompetent. Biomechanical studies have proven that a medial meniscus posterior root tear alters contact pressures and kinematics equivalent to those seen in a complete (total) medial meniscectomy, predisposing the joint to rapid osteoarthritis.

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