This practice set contains high-yield board review questions covering key concepts in 5. Sports Medicine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 1981
Topic: 5. Sports Medicine
Massive cortical structural allografts are commonly used in oncologic and arthroplasty surgery. What percent of cortical structural allografts fracture due to insufficiency?
Correct Answer & Explanation
. 15% to 30%
Explanation
Allograft is available in particulate and structural forms. Particulate allograft has a higher rate of incorporation than structural but adds little structural support. Cortical allograft incorporation occurs slowly and the bulk of the graft fails to remodel and remains devascularized. Stress fractures eventually occur in approximately 25% of structural grafts used in tumor surgery.
Question 1982
Topic: 5. Sports Medicine
A 17-year-old male lacrosse player sustains an ACL tear. Imaging reveals closed physes and you recommend a transphyseal ACL reconstruction. His mother asks whether a “cadaver tendon” can be used to reconstruct his ACL instead of using his own tendon. What is the most appropriate response regarding the use of allograft compared to autograft for ACL reconstruction in an active adolescent? Review Topic
Correct Answer & Explanation
. There is a significantly higher risk of graft failure and need for revision surgery.
Explanation
In an active adolescent, anterior cruciate ligament reconstruction (ACLR) with allograft has a significantly higher risk of graft failure and need for revision surgery compared to ACLR with autograft.The incidence of anterior cruciate ligament (ACL) injuries in adolescent athletes has significantly increased over the recent years, now comprising 24.5% of all ligamentous knee injuries in high school athletes. In skeletally mature adolescents, transphyseal ACLR is often performed, similar to adult patients. Proposed advantages of allograft reconstruction in patients of all ages include lack of donor-site morbidity, absence of size limitation, preservation of knee flexor/extensor mechanism, less risk of postoperative knee stiffness/pain and cosmetic appearance. Benefits of autografts include strong structural and fixation properties as well as optimal biologic incorporation.Kraeutler et al. performed a meta-analysis comparing bone-patellar tendon-bone (BPTB) autograft to allograft for ACLR. Patients who underwent ACLR with BPTB autograft demonstrated lower rates of graft rupture, lower levels of knee laxity, improved single-legged hop test results and were more satisfied postoperatively compared to ACLR with BPTB allograft. The authors therefore recommended BPTBautograftACLR,particularlyinyoungactivepatients.Engelman et al. performed a case-control study comparing ACLR in an adolescent cohort using autograft or allograft. Postoperative knee laxity and use of allograft were significantly related to graft failure and need for revision surgery. There was no difference in functional outcome scores, knee range of motion, infection or growth disturbance. There was no difference in graft survival between low-dose (<2 Mrad) gamma-irradiated allografts and nonirradiated allografts.Pallis et al reported a prospective cohort study of 122 ACLR performed in cadets prior to matriculation at the United States Military Academy (USMA). Cadets who entered the USMA with an allograft ACLR were 7.7 times more likely to experience graft failure compared to BPTB and hamstring (HS) autograft groups. There was no significant difference in failure between the BPTB and HS autograft groups. The authors recommend autograft ACLR for young, active individuals.IncorrectResponses:
Question 1983
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
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.
Question 1984
Topic: Shoulder & Hip Sports
Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest
Correct Answer & Explanation
. Both CT and MRI have equivalent cost for the patient.
Explanation
A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?A. Inability to flex the distal interphalangeal joint of the index fingerB. Positive Froment’s signC. Weakness with wrist extensionD. Decreased capillary refill
Question 1985
Topic: 5. Sports Medicine
The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them? Review Topic
Correct Answer & Explanation
. ACL injuries are more common in men younger than 30 years of age.
Explanation
ACL injuries are five to eight times more common in young women. The highest incidence is associated with basketball and soccer. These sports require rapid directional and rotational changes. Use of neuromuscular training programs has not been associated with a decrease in ACL injuries. It is recommended that there be more frequent rests. ACL injuries are commonly associated with meniscal injury.
Question 1986
Topic: 5. Sports Medicine
A 22-year-old college basketball player who was hit from behind while going up for a rebound is rendered immediately quadriparetic for approximately 10 minutes, followed by complete resolution of motor loss and return of full sensation. The radiograph and MRI scan of the cervical spine reveal a canal diameter of 13 mm, loss of cerebrospinal fluid space about the spinal cord, and no signal change within the cord. What is the best course of action?
Correct Answer & Explanation
. Discuss the relative risks with the player, parents, and coach regarding participation in the athlete’s sport of choice.
Explanation
The correct decision on return to sports participation after episodes of transient quadriparesis is controversial. Cantu and Mueller feel strongly that the loss of cerebrospinal fluid space about the spinal cord signifies an unacceptable risk for future spinal cord injury if the athlete returns to sports. However, Watkins and Torg and Lasgow have reported no evidence of increased spinal cord injury in athletes with narrow spinal canals, even in football. These authors suggest judgment be used in advising return to contact or high-energy sports and that the physician’s responsibility is to give accurate and relevant information, allowing the athlete to make his or her own choice regarding return to sports participation.
Question 1987
Topic: 5. Sports Medicine
Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction?
Correct Answer & Explanation
. Graft collapse during revascularization
Explanation
Mechanical loosening and infection can occur as complications after surgery, but the most common cause of osteoarticular allograft failure is graft collapse during revascularization. Clinical rejection because of an immune response is an unusual means of failure.
Question 1988
Topic: 5. Sports Medicine
Which of the following is considered the appropriate initial management protocol for an unconscious football player without spontaneous respirations?
Correct Answer & Explanation
. Stabilize the head and neck, log roll to a supine position, remove the face mask, and begin assisted breathing
Explanation
The on-field evaluation and management of the seriously injured athlete requires advance preparation and planning. It is imperative that the health care team have a game plan in place and the proper equipment readily available. The initial step consists of stabilizing the head and neck by manually holding the head and neck in a neutral position. Then, in the following order, check for breathing, pulses, and level of consciousness. If the athlete is breathing, simply remove the mouth guard and maintain the airway. If the athlete is not breathing, the face mask must be removed and the chin strap left in place. An open airway must be established, followed by assisted breathing. CPR is only instituted when breathing and circulation are compromised. If the athlete is unconscious or has a suspected cervical spine injury, the helmet must not be removed until the athlete has been transported to an appropriate facility and the cervical spine has been completely evaluated.
Question 1989
Topic: 5. Sports Medicine
A relative contraindication for anteromedial tibial tubercle transfer for patellar instability is arthrosis in what portion of the patella?
Correct Answer & Explanation
. Medial and proximal
Explanation
Anteromedial displacement of the tibial tubercle unloads the distal and lateral facets of the patella and shifts the forces to the proximal and medial facets. Therefore, if findings indicate arthrosis predominately in the medial and proximal areas of the patella, this is considered a relative contraindication because it may accentuate arthritic symptoms.
Question 1990
Topic: 5. Sports Medicine
A college athlete has a knee injury requiring surgery. He has acne, gynecomastia, and well-developed muscles related to the use of anabolic steroids. What association with steroid use is concerning for surgery and anesthesia?
Correct Answer & Explanation
. Fluid and electrolyte imbalance
Explanation
DISCUSSION: Anabolic steroids increase procoagulant factors VII and IX and thromboxane, all of which lead to hypercoagulability which would decrease bleeding time. Liver function is usually upregulated as oral steroids induce hepatic enzymes and patients are therefore less sensitive to anesthetic agents. Anabolic steroids have a mineralocorticoid effect and users frequently use diuretics to mask this effect. Both can lead to fluid and electrolyte imbalances. Cardiovascular effects include hypertension, left ventricular hypertrophy, impaired diastolic filling, and thrombosis. Large muscle mass and high calorie intake lead to high ventilatory requirements caused by increased oxygen consumption and carbon dioxide production. Anabolic steroids have no effect on the spleen. REFERENCES: Kam PC, Yarrow M: Anabolic steroid abuse: Physiological and anesthetic considerations. Anaesthesia 2005;60:685-692. Ansell JE, Tiarks C, Fairchild VK: Coagulation abnormalities associated with the use of anabolic steroids. Am Heart J 1993;125:367-371.
Question 1991
Topic: 5. Sports Medicine
A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular examination is normal. Arthroscopy reveals a partial rotator cuff tear on the bursal side measuring 60% of the tendon thickness. What is the next most appropriate step in management?
Correct Answer & Explanation
. Repair of the partial rotator cuff tear and subacromial decompression
Explanation
DISCUSSION: Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient. REFERENCES: Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears. Am J Sports Med 2005;33:1405-1417. Fukuda H: The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br 2003;85:3-11.
Question 1992
Topic: 5. Sports Medicine
A 36-year-old professional baseball player reports the acute onset of severe right groin pain while attempting to avoid being hit by a baseball while at bat. Examination reveals tenderness, soft-tissue swelling, and ecchymosis in the right groin extending over the medial thigh. MRI scans are shown in Figures 8a and 8b. Management should consist of
Correct Answer & Explanation
. rest, ice, and rehabilitation.
Explanation
DISCUSSION: The MRI scans reveal a severe avulsion injury of the adductor muscle from the pubic ramus with muscle edema and hemorrhage. Injury to the adductor muscle group, a “pulled groin,” is caused by forceful external rotation of an abducted leg. Pain is immediate and severe in the groin region. Tenderness is at the site of injury along the subcutaneous border of the pubic ramus. Treatment is dictated by the severity of the symptoms but generally consists of rest, ice, and protected weight bearing, followed by a rehabilitation program that begins with gentle stretching and progresses to resistance exercise with a gradual return to sports. Immobilization should be avoided because this promotes muscle tightness and scarring. No data exist to suggest that open repair yields a better outcome than nonsurgical management. Tenotomy has been performed in high-level athletes with chronic groin pain following injury. REFERENCES: Gilmore J: Groin pain in the soccer athlete: Fact, fiction, and treatment. Clin Sports Med 1998;17:787-793. Irshad K, Feldman LS, Lavoie C, et al: Operative management of “hockey groin syndrome”: 12 years of experience in National Hockey League players. Surgery 2001;130:759-766.
Question 1993
Topic: 5. Sports Medicine
A 35-year-old skier presents with pain in the left buttock and proximal posterior thigh after a fall. His clinical appearance is shown in Figure A. He is enrolled in 8 weeks of physical therapy after 2 weeks of rest, icing and NSAIDs. He returns for follow-up 6 months after his injury and has persistent ischial tuberosity pain with running. Examination confirms focal ischial tuberosity tenderness. MRI images are seen in Figures B and C. Which surgical option is most appropriate?
Correct Answer & Explanation
. Repair to the ischial tuberosity
Explanation
This patient has a partial hamstring avulsion injury. If symptoms persist after a period of therapy and rest, operative repair to the ischial tuberosity is indicated. Untreated partial hamstring ruptures may present with residual pain, weakness and hamstring dysfunction. The mechanism is eccentric lengthening (sprinting or cutting). A proposed treatment algorithm is: (1) Nonoperative management for single tendon avulsion with <2cm retraction. The ruptured tendon scars to intact tendons. (2) Repair for acute 3-tendon rupture (semitendinosus, semimembranosus, biceps femoris) with retraction >= 2cm. (3) Surgery for young (<50y) patients with 2 tendon avulsion and retraction >= 2cm. Bowman et al. examined the outcomes of operative management of partial hamstring tears in 17 patients. They found no postoperative difficulties with ADLs, and no recurrent surgery was required. All patients returned to their preoperative level of activity. They concluded that surgery can lead to good function with low complications and is reserved for patients who have failed nonoperative management. Hofmann et al. retrospectively reviewed 19 patients with nonoperatively managed complete hamstring avulsions. They found diminished SF-12 scores, diminished hamstring strength at 45° and 90° of flexion (62% and 66%, respectively) compared with the normal side. They concluded that nonsurgical management leads to both subjective functional and objective strength deficits.
Question 1994
Topic: 5. Sports Medicine
Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic
Correct Answer & Explanation
. Preservation of external rotation
Explanation
Arthroscopic anterior labral repair spares the subscapularis, and does not require significant mobilization or incision of the anterior capsule. Therefore, it is less likely to result in significant impairment in external rotation of the glenohumeral joint when compared with traditional open stabilization procedures. Recurrent instability rates are either slightly higher or equivalent to open procedures. Both procedures can be performed on an outpatient basis and require generally identical recovery times.
Question 1995
Topic: 5. Sports Medicine
A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?
Correct Answer & Explanation
. Hypertrophic cardiomyopathy
Explanation
The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death.
Question 1996
Topic: 5. Sports Medicine
Which of the following variables has been shown to have the greatest influence on the higher rate of anterior cruciate ligament (ACL) tears in women when compared to men for similar sports?
Correct Answer & Explanation
. Neuromuscular training
Explanation
DISCUSSION: All of the variables have been proposed as possible causes for the increased incidence of ACL tears in women versus men. The general differences in the level of neuromuscular training, however, specifically conditioning and muscle strength, have been shown to play the greatest role.
Question 1997
Topic: 5. Sports Medicine
Figure 40 shows the MRI scan of a 23-year-old man with a history of recurrent anterior shoulder instability. What is the most likely diagnosis?
DISCUSSION: The MRI scan shows an ALPSA lesion. This is also known as a medialized Bankart with medial displacement of the torn anterior labrum. During surgical stabilization, the labrum and periosteal sleeve must be mobilized and repaired laterally to reduce recurrent instability. A Perthes lesion is a nondisplaced labral tear. A GLAD lesion represents a nondisplaced anterior labral tear with an associated articular cartilage injury.
Question 1998
Topic: Shoulder & Hip Sports
A 47-year-old man who is an avid tennis player and laborer has had one year of shoulder pain and weakness. His pain occurs at night and radiates to the deltoid laterally. The patient denies any anterior based pain. He reports no prior surgeries and has been managed with steroid injections and physical therapy. On examination, he has full passive motion with significant weakness with external rotation. His neurologic examination is unremarkable. MRI evaluation reveals a posterior-superior rotator cuff tear with Goutallier grade 4 fatty infiltrate in the supraspinatus and infraspinatus with retraction beyond the glenoid. He is concerned about the lack of rotation of his arm and reports that this disability creates significant disability with his occupation as a mason. What is the best next step?
Correct Answer & Explanation
. Tendon transfer
Explanation
In younger active patients, tendon transfer is considered a preferable treatment option. The patient has failed a course of nonoperative management. Subacromial decompression may offer pain relief but may not be advisable in a patient with rotator cuff deficient shoulder. A total shoulder arthroplasty requires functionality of the supraspinatus and infraspinatus. A reverse total shoulder is an option to alleviate pain and perhaps improve forward flexion height and strength; however, reverse arthroplasty would not improve external rotation in this patient, and there is concern for longevity of the implant in youngerpatient populations.
Question 1999
Topic: Knee Sports
If a surgeon inadvertently burrs through the midlateral wall of C5 during a anterior corpectomy, what structure is at greatest risk for injury? Review Topic
Correct Answer & Explanation
. C5 root
Explanation
The vertebral artery is contained within the vertebral foramen and thus tethered alongside the vertebral body, making it vulnerable to injury if a drill penetrates the lateral wall. The C5 root passes over the C5 pedicle and is not in the vicinity. The C6 root passes under the C5 pedicle but is posterior to the vertebral artery and is only vulnerable at the very posterior-inferior corner. The carotid artery and the vagus nerve are both within the carotid sheath and well anterior.(SBQ12SP.54) Integrity of the posterior ligamentous complex (PLC) is a critical predictor of spinal fracture stability. Components of the PLC include the supraspinous ligament, interspinous ligament, ligamentum flavum and:Review TopicFacet joint capsulesFacet joint capsules, and facet jointsFacet joint capsules, facet joints, and the posterior longitudinal ligamentFacet joint capsules, and the posterior longitudinal ligamentPosterior longitudinal ligamentComponents of the PLC include the supraspinous ligament, interspinous ligament, ligamentum flavum and facet joint capsules.Numerous methods have been used to evaluate for PLC injury. Palpation is unreliable and has low accuracy. Radiographs can show characteristic flexion-distraction fracture patterns with widening or malaligment of the spinous processes. Computed tomography (CT) is more reliable than radiographs to provide indirect evidence of ligament injury. Magnetic resonance image (MRI) can provide direct evidence of soft-tissue injury, making it the preferred method in diagnosing ligamentous injury. However, MRI may not always be utilized due to situations involving emergency operations or contraindications to MRI, such as certain metal implants.Vaccaro et al. introduced a new classification system for thoracolumbar injuries, TLICS, based on morphological appearance, integrity of the posterior ligamentous complex, and neurological status. They advocate use of the system for nonoperative versus operative decision making and communication between surgeons.Varccaro et al. sought to determine the accuracy of magnetic resonance imaging (MRI) in diagnosing injury of the posterior ligamentous complex (PLC) in patients with thoracolumbar trauma. Forty-two patients with 62 levels of injury were studied. The sensitivity for the various PLC components ranged from 79% (left facet capsule) to 90% (interspinous ligament). The specificity ranged from 53% (thoracolumbar fascia) to 65% (ligamentum flavum). They concluded that the integrity of the PLC as determined by MRI should not be used in isolation to determine treatment.Incorrect Answers:
Question 2000
Topic: 5. Sports Medicine
A 23-year-old student complains of recurrent left shoulder instability. He first dislocated his shoulder in high school while playing lacrosse and was managed with physical therapy. A second dislocation occurred one year later while skiing. He has since sustained two more dislocations and says that his shoulder feels “loose.” Examination reveals grade II anterior load and shift, positive apprehension and relocation tests, and normal rotator cuff strength. An MRI arthrogram is ordered and surgical treatment is recommended. What factor would most strongly represent an indication for a procedure including bone augmentation (e.g. Latarjet) rather than a soft-tissue-only stabilization (isolated labral repair/capsulorrhaphy)?
Correct Answer & Explanation
. Patient’s intention to resume lacrosse and other contact sports after surgery
Explanation
There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Barring other factors or concomitant pathology, however, there is no persuasive literature to suggest routine use of bone augmentation for contact athletes. Extensive labral involvement (here specifically implying posterior labral involvement, as well) will require a more extensive repair but does not, in and of itself, suggest the necessity forglenoid bone augmentation. A large Hill-Sachs lesion may be an indication for glenoid augmentation, primarily if it is in a location/orientation that engages the anterior glenoid rim. These are referred to as “off-track” lesions. Of these choices, the strongest indication for a Latarjet coracoid transfer or similar bone augmentation (other options include iliac crest autograft or distal tibial allograft) is high-grade glenoid bone loss. Classically, this is performed through an open approach, although arthroscopic techniques are increasing in popularity. Although the critical amount of bone loss is debated, most surgeons and studies suggest a cut-off of approximately 20% to 25%, abovewhich isolated soft-tissue stabilization alone is less likely to be successful in the long-term.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.