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 2081
Topic: 5. Sports Medicine
A 28-year-old active male requires an osteochondral allograft (OCA) for a 4 square centimeter full-thickness chondral defect on the medial femoral condyle. To optimize chondrocyte viability, what is the current gold standard for storage of the OCA graft prior to implantation?
Correct Answer & Explanation
. Fresh storage at 4 degrees Celsius for up to 28 days
Explanation
Fresh storage at 4 degrees Celsius in a nutrient medium is the standard for OCA, maintaining adequate chondrocyte viability for up to 28 days. Freezing or lyophilization significantly decreases or eliminates living chondrocytes, which are essential for long-term graft survival.
Question 2082
Topic: Knee Sports
During a medial patellofemoral ligament (MPFL) reconstruction, placing the femoral tunnel proximal to the true anatomic footprint (Schottle point) will result in which of the following kinematic abnormalities?
Correct Answer & Explanation
. The graft will be overly tight in deep flexion
Explanation
A femoral tunnel placed too proximal during MPFL reconstruction causes the graft to act non-isometrically, becoming overly tight in knee flexion. This can lead to restricted flexion, increased patellofemoral contact pressures, and accelerated arthrosis.
Question 2083
Topic: Knee Sports
A 26-year-old male presents with recurrent instability 3 years after primary ACL reconstruction. Radiographs and CT show malpositioned, expanded femoral and tibial tunnels. What is the accepted threshold of tunnel widening that generally necessitates a two-stage revision with initial bone grafting?
Correct Answer & Explanation
. 14 mm
Explanation
Tunnel widening greater than 14-15 mm typically compromises fixation in a single-stage revision ACL reconstruction. A two-stage procedure with initial bone grafting of the defects followed by reconstruction months later is recommended.
Question 2084
Topic: 5. Sports Medicine
A 45-year-old male is referred for a missed, 4-month-old patellar tendon rupture. Examination shows a proximally migrated patella (patella alta) and severe quadriceps contracture. During reconstruction using an Achilles tendon allograft with a calcaneal bone block, where is the bone block optimally placed?
Correct Answer & Explanation
. Press-fit into a trough created in the tibial tubercle
Explanation
In chronic patellar tendon reconstruction, an Achilles allograft is commonly used. The calcaneal bone block is press-fit and secured into a trough at the tibial tubercle to provide rigid, bone-to-bone healing, while the tendinous portion is passed through or over the patella.
Question 2085
Topic: Shoulder & Hip Sports
Figure 20 shows the plain radiograph of a 70-year-old woman who has shoulder pain and is unable to reach above chest level as a result of a fall 3 months ago. An MRI scan of the shoulder shows a large rotator cuff tear. Examination reveals atrophy of the infraspinatus muscle, active forward elevation of 40 degrees, active external rotation of 30 degrees, passive forward elevation of 150 degrees, and passive external rotation of 60 degrees. The patient has no external rotation strength against resistance. Treatment should include
Correct Answer & Explanation
. rehabilitation of the shoulder
Explanation
This defines a 70y/o lady who 3 months ago sustained a large, to massive rotator cuff tear, not only by MRI, but by physical exam as well. In any age group or duration from injury, massive rotator cuff tears do poorly with surgical intervention. Now add in 3months duration and 70 yr age and boy doesn't rehabilitation sound good.
Question 2086
Topic: Shoulder & Hip Sports
When comparing the addition of a trough at the greater tuberosity to direct repair of cortical bone, simulated rotator cuff repair in animal models has shown what type of change in the strength of the repair?
Correct Answer & Explanation
. 0% increase
Explanation
DISCUSSION: There was no difference observed in the healing of tendon to bone when comparing healing to cortical bone and to a cancellous trough. REFERENCE: St Pierre P, Olson EJ, Elliott JJ, et al: Tendon healing to cortical bone compared with healing to a cancellous trough. J Bone Joint Surg Am 1995;77:1858-1866.
Question 2087
Topic: 5. Sports Medicine
A 36-year-old recreational tennis player sustains the injury shown in Figure 16. Management should consist of
Correct Answer & Explanation
. primary repair.
Explanation
DISCUSSION: The MRI scan shows a rupture of the patellar tendon. This injury is most appropriately addressed with primary repair. For athletic individuals, the results of nonsurgical management are suboptimal. Reconstructive procedures are not necessary. REFERENCES: Matava MJ: Patellar tendon ruptures. J Am Acad Orthop Surg 1996;4:287-296. Marder RA, Timmerman LA: Primary repair of patellar tendon rupture without augmentation. Am J Sports Med 1999;27:304-307.
Question 2088
Topic: 5. Sports Medicine
A 6-year-old Little League pitcher has had pain in the right elbow for the past 2 weeks. Examination reveals mild lateral elbow joint tenderness with full range of motion and no effusion or collateral laxity. A radiograph is shown in Figure 38. Initial management should consist of
Correct Answer & Explanation
. cessation of throwing activities.
Explanation
DISCUSSION: The radiograph shows osteochondritis dissecans (OCD) of the capitellum, one manifestation of โpitcherโs elbow.โ The lesion is nondisplaced, and healing is possible if the inciting throwing activities are curtailed. Long arm cast treatment may be reasonable for the noncompliant patient but should not exceed 6 weeks duration. Surgical treatment is indicated for loose bodies or cartilage flaps. Elbow OCD lesions are now being seen in younger children as more participate in organized sports, especially baseball and gymnastics. REFERENCES: Bauer M, Jonsson K, Josefsson PO, et al: Osteochondritis dissecans of the elbow: A long-term follow-up study. Clin Orthop 1992;284:156-160. Takahara M, Ogino T, Sasaki I, et al: Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop 1999;363:108-115. Byrd JW, Jones KS: Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: Minimum three-year follow-up. Am J Sports Med 2002;30:474-478.
Question 2089
Topic: 5. Sports Medicine
A 24-year-old professional male soccer player has lower abdominal pain on exertion. He has pain with resisted hip adduction and with sit-ups. There is no palpable inguinal hernia with a Valsalva maneuver. Nonsurgical management has failed to provide relief. After ruling out malignancies, what is the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. Additional nonsurgical management
Explanation
The patient has a sports hernia or athletic pubalgia. The exact nature of this pathology is not well understood. MRI scans are not very helpful in making a diagnosis. In high-performance athletes who have failed to respond to nonsurgical management, surgical intervention is needed to strengthen the anterior pelvic floor. Additional nonsurgical management at this point will not improve symptoms. Cortisone injection will not strengthen the pelvic floor. CT scan of the pelvis is valuable to rule out bony injuries such as osteitis pubis. Ultrasound of the scrotum will have no additional diagnostic use in management of this patient.
Question 2090
Topic: 5. Sports Medicine
A 30-year-old man sustained an acute injury to his left shoulder while lifting weights. He reports pain with abduction and external rotation of the shoulder, and he has weakness with internal rotation. Inspection shows loss of contour of the axillary fold. Definitive management should consist of Review Topic
Correct Answer & Explanation
. rest, ice, anti-inflammatory drugs, and a gradual return to physical activity.
Explanation
Pectoralis major muscle injuries occur primarily in weightlifting, football, and wrestling activities. Initial swelling, pain, and ecchymosis often make diagnosis difficult in the acute setting. Over time, chest ecchymosis, loss of axillary contour, and asymmetry of the anterior chest wall can be diagnostic. MRI can aid in the diagnosis, especially to differentiate between complete and incomplete injuries. Surgical intervention is indicated for most complete tears, especially in the younger, athletic population. Acute repair is technically easier with less surrounding scar tissue, and it minimizes the potential need for late reconstruction and possible allograft use.
Question 2091
Topic: Shoulder & Hip Sports
A 29-year-old male rugby player presents for further evaluation and management of left shoulder instability. He initially dislocated his left shoulder six years ago while snowboarding. Since that time, he has sustained five dislocations requiring reduction. He has participated in multiple rounds of physical therapy without improvement. His CT scan and 3D reconstruction are pictured in Figures A and B. Which of the following is the most appropriate treatment for this patient? Review Topic
Correct Answer & Explanation
. Open capsular shift
Explanation
This patient has recurrent anterior glenohumeral instability with >20% glenoid bone loss and therefore would benefit most from an open coracoid transfer (Latarjet procedure).Recurrent anterior shoulder instability occurs in 33-67% of patients who sustain an initial traumatic dislocation. Specific risk factors include age < 25 years, male gender, anterior glenoid (Bankart) and/or posterior humeral (Hill-Sachs) osseous defect(s) and participation in contact sports. Surgical management of recurrent instability depends on the presence or absence of glenohumeral bone loss. Patients with < 20% glenoid bone loss can be managed with arthroscopic Bankart repair. An engaging Hill-Sachs lesion, meaning the humeral head defect engages the glenoid rim in abduction (ABD) and external rotation (ER) [see Illustration B], in the setting of minimal glenoid bone loss can be managed with remplissage. Patients with > 20% glenoid bone loss require greater stabilization, mostly commonly in the form of an open coracoid transfer (Latarjet procedure).Burkhart et al. (2000) found arthroscopic Bankart repairs equivalent to open Bankart repairs if no substantial bone defects were present. However, patients with an โinverted pearโ glenoid secondary to significant anteroinferior bone loss or an engaging Hill-Sachs lesion of the humerus had a 67% recurrence rate overall and an 89% recurrence rate if they were contact athletes. Therefore, contact athletes with structural bone deficits require open surgery and often necessitate reconstruction with bone-block procedures.Itoi et al. determined that an osseous defect with a width of >/= 21% of the glenoid length was associated with anteroinferior instability in ABD and internal rotation (IR), as well as loss of external rotation following Bankart repair. The authors concluded that while Bankart repair in the setting of a substantial bone loss conferred adequate stability in ABD and ER, it did so at the cost of overtightening the anterior structures which limited ER and did not affect stability in IR when the anterior capsuloligamentous structures are lax.Burkhart et al. (2007) concluded that in the setting of significant glenohumeral bone deficiency, an open Latarjet procedure had only a 4.9% recurrence rate as compared to a 67% recurrence rate following arthroscopic Bankart repair. The Latarjet procedure works to extend the bony glenoid concavity, provide a dynamic sling from the conjoint tendon, preserve the lower third of the subscapularis and repair the capsule.Figures A and B are the axial CT scan and 3D reconstruction en face view of the glenoid demonstrating significant anteroinferior glenoid bone loss of approximately 40%. Illustration A is an algorithm for the management of anterior shoulder instability based on pertinent risk factors and glenohumeral bone loss. Illustration B compares non-engaging and engaging Hill Sachs lesions. Size and depth of the Hill-Sachs lesion as well as glenoid bone deficiency both contribute to risk of engagement. Illustration C depicts a simplistic version of the Latarjet procedure.Incorrect Responses:
Question 2092
Topic: 5. Sports Medicine
A 15-year-old female field hockey player sustains a blow to the mouth from a hockey stick. Three front teeth are knocked out and shown in Figure 4. In addition to calling a dentist immediately, what is the next best step in management?
Correct Answer & Explanation
. Pour normal saline solution on the teeth and then place them in milk.
Explanation
Discussion: Tooth avulsions can occur in contact or collision sports. An avulsed tooth is a medical emergency. The likelihood of survival of the tooth depends on the length of time that the tooth is out of the socket and the degree to which the periodontal ligament is damaged. The tooth should be handled only by the crown end and not the root end. It can be rinsed of debris with water or normal saline solution. The tooth should not be brushed or cleaned otherwise. During transport, the tooth must be kept moist. An avulsed tooth can be transported in whole milk, saliva, sterile saline solution, or commercially available kits with physiologic buffer solutions. The tooth and the athlete should be transported to the dentist for reinsertion as soon as possible and preferably within an hour.
Question 2093
Topic: 5. Sports Medicine
A 14-year-old Little League pitcher who plays in 2 leagues concurrently has pain in his throwing shoulder while pitching but not at rest.
Correct Answer & Explanation
. Proximal humeral physeal injury
Explanation
Discussion: Little League shoulder is an overuse injury typically seen in baseball pitchers who are around 14 years of age. It is an osteochondrosis of the proximal humeral epiphysis attributable to overuse from throwing.
Question 2094
Topic: Shoulder & Hip Sports
A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of Review Topic
Correct Answer & Explanation
. repair of the superior labrum.
Explanation
The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be source of surgical failure.
Question 2095
Topic: 5. Sports Medicine
A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10 years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3ยฐ shy of full extension to 130ยฐ of flexion. He has negative Lachman and posterior drawer test results. He demonstrates no lateral thrust with ambulation. What imaging study is most appropriate to determine treatment options for this patient?
Correct Answer & Explanation
. Full-length weight-bearing radiographs of both legs
Explanation
This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patientโs symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patientโs young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a patient with severe medial compartment arthritis. The patientโs young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patientโs BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 years is anindication for HTO but does not influence technique.
Question 2096
Topic: Shoulder & Hip Sports
The usual presentation of traumatic subscapularis tears is most often seen after forced Review Topic
Correct Answer & Explanation
. internal rotation.
Explanation
The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance.
Question 2097
Topic: 5. Sports Medicine
Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a 2-month history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?
Correct Answer & Explanation
. Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90ยฐ
Explanation
MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result (pain with internal rotation and adduction while supine with the hip and knee flexed 90ยฐ).
Question 2098
Topic: Knee Sports
What do the T2-weighted, fat-saturated MRI scans shown in Figures 76a through 76d reveal? Review Topic
The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.
Question 2099
Topic: Shoulder & Hip Sports
03 The sagittal oblique MRI scan shown in Figure 70 reveals a lesion in the shoulder that typically affects what neurologic structure?
Correct Answer & Explanation
. โ Axillary nerve
Explanation
Ganglion cysts in the shoulder has been reported in the literature and when they occur in the shoulder typically compress the suprascapular nerve at the spinoglenoid notch primarily affecting the infraspinatus muscle, but depending on their size may also affect the supraspinatus motor brances.The cysts form either because of a lesion of the capsulolabral complex at the superior/posterosuperior glenoid in the shoulder or because of myxoid degeneration of the capsule.back to this question next question
Question 2100
Topic: Knee Sports
The function of which of the following structures is to resist internal tibial rotation with the knee in full extension? Review Topic
Correct Answer & Explanation
. Anterior cruciate ligament
Explanation
The primary function of the posterior oblique ligament is to resist internal tibial rotation with the knee in full extension.The posterior oblique ligament is a structure within the posteromedial corner of the knee, with attachments proximally to the adductor tubercle of the femur and distally to the tibia/posterior knee capsule. The posterior oblique ligament and posteromedial capsule play a significant role in the prevention of additional posterior tibial translation in the knee in the setting of posterior cruciate ligament injury. They also act to resist internal tibial rotation with the knee in full extension.Griffith et al. reports that the posterior oblique ligament provides significant resistance to valgus and internal rotation forces with knee extension. They used a cadaver model and demonstrated that the superficial MCL resists valgus and external rotation forces more than the posterior oblique ligament, while the posterior oblique ligament is more involved in resisting internal rotation.Tibor et al. reviews the anatomy of the posteromedial corner of the knee. They report that failing to recognize injury to these structures may cause failure of cruciate ligament reconstruction surgery, and that reconstruction or repair of the posteromedial corner may be indicated in the face of multiple ligament injuries.Illustration A shows the posteromedial corner of the knee, including the posterior oblique ligament.Incorrect answers:1-4: These structures are not primary restraints to internal tibial rotation in full extension.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.
