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 5701
Topic: Shoulder & Hip Sports
A patient reports a 'grinding' or 'catching' sensation in their shoulder, particularly when moving their arm overhead. Which labral injury is MOST likely based on this symptom?
Correct Answer & Explanation
. SLAP lesion
Explanation
A 'grinding' or 'catching' sensation, particularly with overhead activities, is a common symptom of a superior labral anterior-posterior (SLAP) lesion, as the biceps anchor (which is part of the superior labrum) can be unstable or irritated. While other labral tears can also cause similar symptoms, SLAP lesions are specifically associated with overhead activity and sometimes 'popping' or 'catching.' Bankart and posterior labral tears are more commonly associated with instability or clunking during specific movements. HAGL and glenoid rim fractures are also distinct pathologies.
Question 5702
Topic: Shoulder & Hip Sports
Which finding during an examination for shoulder instability is MOST consistent with a large Hill-Sachs lesion?
Correct Answer & Explanation
. Engagement of the humeral head defect against the anterior glenoid during external rotation and abduction
Explanation
A large Hill-Sachs lesion, which is an impaction fracture on the posterior-superior humeral head, can 'engage' or 'lock' against the anterior glenoid rim during abduction and external rotation. This engagement contributes significantly to recurrent anterior instability. A palpable defect on the anterior glenoid rim would suggest a Bankart lesion. Pain with resisted elbow flexion suggests biceps pathology. Scapular dyskinesis is a pattern of abnormal scapular movement. Increased internal rotation ROM is generally not associated with Hill-Sachs; rather, limited ER due to engagement.
Question 5703
Topic: Shoulder & Hip Sports
Which of the following is considered a 'red flag' during the initial assessment of a shoulder dislocation, mandating immediate senior orthopedic review?
Correct Answer & Explanation
. Absence of radial pulse and cool, pale hand
Explanation
An absent radial pulse combined with signs of ischemia (cool, pale hand) indicates acute limb-threatening vascular compromise (e.g., axillary artery injury), which is a surgical emergency and mandates immediate senior orthopedic and often vascular surgery review. First-time dislocation, Hill-Sachs, and seizure-induced dislocation are common scenarios. While pain control is important, it is not a 'red flag' signaling immediate limb threat like vascular compromise.
Question 5704
Topic: Shoulder & Hip Sports
What is the primary goal of physical examination after reduction of a shoulder dislocation?
Correct Answer & Explanation
. To confirm stability and rule out neurovascular compromise
Explanation
After reduction, the primary goals of the physical exam are to confirm that the shoulder is stably reduced (checking for smooth, pain-free range of motion) and to meticulously re-assess neurovascular status to ensure no new compromise has occurred during the reduction maneuver. Hill-Sachs is an pre-existing bony lesion. Long-term prognosis and arthritis are not immediate post-reduction concerns. Immediate aggressive rehab is not typical.
Question 5705
Topic: Shoulder & Hip Sports
A patient presents with a locked anterior shoulder dislocation that has been unreduced for 3 days. What is the MOST appropriate imaging study prior to attempted reduction?
Correct Answer & Explanation
. CT scan of the shoulder
Explanation
For a chronic or 'locked' dislocation, particularly one unreduced for several days, there is an increased risk of significant associated bony lesions (e.g., large Hill-Sachs, bony Bankart, surgical neck fracture, or glenoid rim fracture) that can complicate reduction or make closed reduction impossible. A CT scan provides excellent bony detail to assess the size and location of these lesions, which is crucial for planning the safest and most effective reduction strategy. While MRI shows soft tissue, bony detail is paramount here. Plain films may miss subtle but significant fractures. Ultrasound and bone scan are not indicated.
Question 5706
Topic: 5. Sports Medicine
For an atrophic nonunion, what is the most critical component of surgical management, in addition to achieving stable fixation?
Correct Answer & Explanation
. Bone grafting (autograft or allograft) to provide osteogenic, osteoinductive, and osteoconductive properties
Explanation
Atrophic nonunions are biologically inert and lack sufficient osteogenic cells and growth factors. Therefore, stable fixation must be combined with biological augmentation, most commonly through bone grafting (autograft being the gold standard) to provide osteogenic (living cells), osteoinductive (growth factors), and osteoconductive (scaffold) properties. External bone stimulators may be adjunctive but usually insufficient alone. Corticosteroids would hinder healing. Minimally invasive approaches may be used, but not without addressing the biological deficiency.
Question 5707
Topic: Knee Sports
Which of the following statements regarding bioabsorbable screws is FALSE?
Correct Answer & Explanation
. Their strength typically exceeds that of metallic screws.
Explanation
Bioabsorbable screws are designed to degrade over time, eliminating the need for removal. They are indeed commonly used in soft tissue fixation (e.g., ACL reconstruction). However, their strength is generallylowerthan that of metallic screws, and they lose strength over time as they degrade. They can also cause inflammatory reactions (sterile effusions) and their degradation products can alter local pH. Therefore, the statement that their strength typically exceeds metallic screws is false.
Question 5708
Topic: 5. Sports Medicine
During anterior cruciate ligament (ACL) reconstruction, what is the primary biomechanical advantage of using a bone-patellar tendon-bone (BTB) autograft compared to a hamstring autograft?
Correct Answer & Explanation
. Faster graft incorporation via bone-to-bone healing
Explanation
The primary advantage of BTB autografts is the rapid bone-to-bone healing within the osseous tunnels (typically 6 weeks), compared to the slower soft-tissue-to-bone healing of hamstring grafts (8-12 weeks). Hamstring grafts have a higher ultimate tensile load and lower donor site morbidity (less anterior knee pain).
Question 5709
Topic: Shoulder & Hip Sports
A 22-year-old athlete sustains a recurrent anterior shoulder dislocation. Preoperative imaging demonstrates an 'engaging' Hill-Sachs lesion. What specific adjunctive surgical procedure is most commonly performed alongside a Bankart repair to address this lesion?
Correct Answer & Explanation
. Remplissage procedure
Explanation
An engaging Hill-Sachs lesion can lever the humeral head out of the glenoid during abduction and external rotation. The Remplissage procedure addresses this by tenodesing the infraspinatus tendon and posterior capsule into the defect, preventing it from engaging the anterior glenoid rim. Latarjet addresses glenoid bone loss.
Question 5710
Topic: 5. Sports Medicine
A 42-year-old recreational athlete sustains an acute Achilles tendon rupture. When comparing modern non-operative management (utilizing an early functional rehabilitation protocol) to open surgical repair, which of the following statements regarding outcomes is most accurate based on current high-level evidence?
Correct Answer & Explanation
. Surgical repair and non-operative management with early functional rehab have similar re-rupture rates.
Explanation
Recent Level 1 evidence (including large randomized controlled trials) demonstrates that when modern, dynamic early functional rehabilitation protocols are employed, the re-rupture rates between non-operative and operative management of acute Achilles tendon ruptures are remarkably similar (and low). Operative management carries a higher risk of wound complications and infection. Plantarflexion strength is generally equivalent or slightly favored in surgical groups depending on the study, but not significantly superior in non-operative groups.
Question 5711
Topic: Knee Sports
A 22-year-old male collegiate football player sustains a valgus and external rotation injury to his right knee. Physical examination reveals gross instability to valgus stress at 0 and 30 degrees of flexion, a positive Lachman test, and significant posterolateral rotatory instability (positive Dial test at both 30 and 90 degrees). Imaging confirms complete tears of the ACL, MCL, and injury to the posterolateral corner (PLC). What is the most appropriate initial surgical approach for this multi-ligamentous knee injury?
Correct Answer & Explanation
. Acute surgical repair or reconstruction of all injured ligaments (ACL, MCL, PLC) within 2-3 weeks of injury.
Explanation
This patient presents with a severe, multi-ligamentous knee injury involving the ACL, MCL, and PLC, along with significant rotatory instability. Such injuries, particularly those involving the PLC, are complex and lead to poor outcomes with non-operative management (E). Acute surgical intervention (within 2-3 weeks) to repair/reconstruct all damaged ligaments (D) is generally recommended. Delaying surgery for too long makes primary repair less feasible and increases the difficulty of reconstruction. ACL reconstruction alone (A) or MCL repair alone (B) will leave significant instability. Staged reconstruction (C) is often avoided if possible, as it can complicate rehabilitation and delay recovery, though sometimes necessary depending on swelling/patient factors. The current consensus generally favors addressing all significant instabilities simultaneously if conditions allow.
Question 5712
Topic: Shoulder & Hip Sports
A 25-year-old rugby player presents with recurrent anterior shoulder dislocations, occurring even with minimal trauma. MRI reveals a large bony Bankart lesion (glenoid bone loss >20%) and an engaging Hill-Sachs lesion. Which surgical procedure is most appropriate to address his instability and prevent recurrence?
Correct Answer & Explanation
. Latarjet procedure.
Explanation
For recurrent anterior shoulder instability, particularly in an active patient (e.g., rugby player) with significant glenoid bone loss (greater than 20-25%) and an engaging Hill-Sachs lesion, a Latarjet procedure is generally considered the gold standard. The Latarjet procedure involves transferring the coracoid process with its attached conjoined tendon to the anterior-inferior glenoid. This addresses the bony defect on the glenoid, provides a 'sling effect' from the conjoined tendon, and helps prevent engagement of the Hill-Sachs lesion. Arthroscopic Bankart repair is suitable for soft tissue Bankart lesions with minimal or no bone loss. Open capsular shift addresses capsular laxity but does not adequately manage significant bone loss. The Remplissage procedure fills the Hill-Sachs defect by tenodesing the infraspinatus and posterior capsule into the defect but does not directly address glenoid bone loss. Subscapularis tendon transfer is not a primary procedure for anterior instability.
Question 5713
Topic: 5. Sports Medicine
A 25-year-old semi-professional soccer player presents with a symptomatic large (4 cm²) full-thickness chondral defect on the medial femoral condyle, unresponsive to conservative treatment. He desires a return to high-level sports. Which advanced cartilage repair technique has shown promising results for larger defects in young, active patients, offering the potential for hyaline-like cartilage regeneration?
Correct Answer & Explanation
. Autologous Chondrocyte Implantation (ACI)
Explanation
Autologous Chondrocyte Implantation (ACI) is a two-stage procedure indicated for larger, symptomatic, full-thickness chondral defects (typically >2-2.5 cm² in size) in younger, active patients. It involves harvesting chondrocytes from a non-weight-bearing area, culturing them in vitro, and then reimplanting them into the defect. This technique aims to regenerate hyaline-like cartilage, offering superior long-term results compared to marrow stimulation techniques (microfracture, subchondral drilling) which produce fibrocartilage, or osteochondral autograft transplantation (OATS) which has donor site morbidity and limited applicability for large defects.
Question 5714
Topic: Shoulder & Hip Sports
A 22-year-old competitive dancer presents with chronic, debilitating hip pain unresponsive to physical therapy. MRI reveals a large cam-type femoroacetabular impingement (FAI) deformity, labral tearing, and early chondral damage. Diagnostic intra-articular injection provides significant but temporary relief. The patient desires to return to high-level activity. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Arthroscopic hip osteochondroplasty and labral repair/reconstruction
Explanation
For symptomatic cam-type FAI with associated labral tears and early chondral damage in a young, active patient who has failed conservative treatment, hip arthroscopy is the preferred surgical approach. It allows for osteochondroplasty (re-shaping of the femoral head-neck junction to correct the cam deformity), labral repair or reconstruction, and addressing chondral lesions, all while preserving the native hip joint. This minimally invasive approach facilitates an earlier return to activity compared to open procedures. Open surgical dislocation is a more invasive option usually reserved for complex FAI or when arthroscopic treatment is not feasible. THA is for end-stage arthritis, and PAO is for acetabular dysplasia.
Question 5715
Topic: 5. Sports Medicine
A 35-year-old athlete presents with chronic posterior knee pain and instability due to a Grade III PCL injury sustained 2 years ago. He has undergone extensive physiotherapy and attempted bracing without improvement in symptoms or function. Prior imaging shows intact menisci and other ligaments. What is the most appropriate surgical option for PCL reconstruction in this scenario?
Correct Answer & Explanation
. Double-bundle transtibial PCL reconstruction using an allograft.
Explanation
For chronic Grade III PCL injuries, especially in athletes, a double-bundle reconstruction is often favored to more accurately replicate the native PCL's anatomy and biomechanics, providing better AP and rotational stability. Allografts are commonly used for ease of harvest, reduced donor site morbidity, and are often preferred in chronic cases, revisions, or when autograft options may be limited. While single-bundle and autograft options exist, double-bundle allograft reconstruction is a robust and common choice for severe chronic PCL instability in active patients.
Question 5716
Topic: 5. Sports Medicine
A professional athlete presents with persistent knee pain and effusion despite conservative management. MRI with standard sequences shows subtle signal changes in the femoral trochlea, but the extent of articular cartilage damage and biochemical composition is unclear. Which advanced MRI sequence would be most beneficial for a more detailed assessment of articular cartilage integrity and composition?
Correct Answer & Explanation
. dGEMRIC (delayed Gadolinium Enhanced MR Imaging of Cartilage).
Explanation
dGEMRIC (delayed Gadolinium Enhanced MR Imaging of Cartilage) is an advanced quantitative MRI technique specifically designed to assess the biochemical composition of articular cartilage, particularly proteoglycan content. Gadolinium-based contrast agents distribute inversely with proteoglycan concentration, allowing for an indirect quantitative measure of cartilage health and early degeneration that may not be apparent on standard morphological sequences. This is crucial for early detection and monitoring of chondral lesions and their progression, especially in high-performance athletes.
Question 5717
Topic: 5. Sports Medicine
A collegiate athlete sustained a Grade II medial collateral ligament (MCL) injury and a concurrent high-grade chondral lesion in the knee. The athlete wishes to explore all options for accelerated recovery and return to play. Which emerging biological treatment strategy, currently under investigation, shows promise for improving both ligament healing and cartilage regeneration?
Correct Answer & Explanation
. Bone Marrow Aspirate Concentrate (BMAC).
Explanation
Bone Marrow Aspirate Concentrate (BMAC) contains a rich source of mesenchymal stem cells (MSCs), hematopoietic stem cells, and various growth factors. These components have multipotent differentiation capabilities and paracrine effects that can promote tissue repair and regeneration across different tissue types. For concurrent ligament healing (like MCL) and cartilage regeneration (chondral lesion), BMAC offers a comprehensive biological approach, showing promise in preclinical and early clinical studies. While Platelet-Rich Plasma (PRP) provides growth factors, BMAC is generally considered more potent for regeneration due to its higher stem cell content. ACI is specific to cartilage and not directly applicable to ligament healing.
Question 5718
Topic: Knee Sports
A 34-year-old male competitive athlete sustains an acute knee injury during a soccer match. He reports immediate pain, swelling, and a 'pop'. Lachman test is positive with a soft endpoint, pivot shift test is positive, and there is a mild varus thrust with stress testing. MRI confirms a complete ACL rupture and a Grade III posterolateral corner (PLC) injury involving the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and posterior capsule. What is the most appropriate acute surgical management strategy for this combined injury?
Correct Answer & Explanation
. Simultaneous acute ACL reconstruction and surgical repair/reconstruction of the PLC.
Explanation
Combined ACL and high-grade Posterolateral Corner (PLC) injuries (Grade III) represent a severe knee injury with significant rotational and varus instability. Leaving a Grade III PLC injury untreated or delaying its repair/reconstruction often leads to persistent instability, failure of the ACL reconstruction, and progressive degenerative changes. Therefore, simultaneous acute (within 2-3 weeks of injury) surgical repair and/or reconstruction of both the ACL and the PLC is generally recommended to restore stability and optimize outcomes. Options A and B risk persistent instability and potential failure of the reconstructed ligament due to the unaddressed concomitant injury. Conservative management (Option D) is generally insufficient for high-grade combined injuries in an athlete. Option E describes repair, but often reconstruction is needed for full Grade III tears, and debridement of ACL is not primary treatment.
Question 5719
Topic: Shoulder & Hip Sports
A patient undergoes antegrade intramedullary nailing for a mid-diaphyseal humeral fracture. Which of the following complications is most frequently associated with the entry point through the rotator cuff?
Correct Answer & Explanation
. B. Persistent shoulder pain and impingement symptoms.
Explanation
The entry point for antegrade humeral nailing often passes through or close to the rotator cuff (typically supraspinatus). This can lead to persistent shoulder pain and impingement symptoms (B) due to soft tissue irritation or hardware prominence. While iatrogenic cuff tears can occur, AVN (A) is not a direct consequence of a cuff tear. Radial nerve palsy (C) is more associated with fracture manipulation or plating. Nonunion (D) and infection (E) are general complications, not specific to the rotator cuff entry.
Question 5720
Topic: Knee Sports
A 28-year-old semi-professional athlete sustains a high-energy knee injury during a football game. Clinical examination reveals gross instability with a positive Lachman, posterior drawer, varus stress test at 0 and 30 degrees, and increased external rotation at 30 degrees, indicative of a combined ACL, PCL, posterolateral corner (PLC), and lateral collateral ligament (LCL) injury. He has no neurovascular deficits. What is the most appropriate surgical management strategy regarding timing and technique?
Correct Answer & Explanation
. Delayed, single-stage reconstruction of all torn ligaments at 3-6 weeks, allowing soft tissue swelling to subside.
Explanation
This patient has a severe, multiligamentous knee injury (combined ACL, PCL, PLC, LCL). Non-operative management is generally not recommended for such extensive injuries in athletes. Immediate repair within 24-48 hours is largely discouraged due to significant swelling, stiffness, and increased risk of arthrofibrosis. Staged reconstruction might be considered in very specific, complex cases, but generally increases morbidity, cost, and prolongs recovery without clear superiority. Open primary repair of the PLC/LCL followed by delayed ACL/PCL reconstruction could be an option for isolated PLC avulsions or specific repairable tears, but it is not the overall best strategy for all ligaments in a high-energy multiligamentous injury. The current consensus for most multiligamentous knee injuries in athletes, especially high-grade combined injuries, is delayed, single-stage reconstruction of all torn ligaments at 3-6 weeks, after the acute inflammatory phase has subsided and soft tissue swelling has decreased. This timing minimizes the risk of arthrofibrosis, allows for better surgical exposure, and optimizes the chances of good postoperative range of motion and functional recovery. Repairable ligaments are typically repaired, while non-repairable ligaments are reconstructed.
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