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Question 641

Topic: Knee Sports

An MRI of an L2 fracture demonstrates complete disruption of the interspinous ligaments, ligamentum flavum, and facet capsules. According to the Thoracolumbar Injury Classification and Severity Score (TLICS), how many points does this posterior ligamentous complex (PLC) status contribute to the total score?

. 0 points
. 1 point
. 2 points
. 3 points
. 4 points

Correct Answer & Explanation

. 3 points


Explanation

In the TLICS system, an intact PLC is 0 points, suspected/indeterminate injury is 2 points, and a definitively disrupted PLC is assigned 3 points.

Question 642

Topic: Shoulder & Hip Sports

A 50-year-old male undergoes ORIF of a displaced 3-part proximal humerus fracture. During the deltopectoral approach, the subscapularis muscle is managed to gain access to the humeral head. Which of the following is the most common and recommended method for managing the subscapularis tendon to expose the humeral head in this approach, as described in the case?

. A. Complete tenotomy of the subscapularis tendon at its insertion, followed by repair.
. B. Vertical splitting of the subscapularis muscle in the direction of its fibers.
. C. Detachment of the subscapularis from the lesser tuberosity, often with a cuff-sparing lesser tuberosity osteotomy.
. D. Retraction of the subscapularis medially without any incision or detachment.
. E. Resection of a portion of the subscapularis muscle to improve visualization.

Correct Answer & Explanation

. C. Detachment of the subscapularis from the lesser tuberosity, often with a cuff-sparing lesser tuberosity osteotomy.


Explanation

Correct Answer: CThe case content, under 'Detailed Surgical Approach and Technique' and 'Subscapularis Management' for the Deltopectoral Approach, states: 'For direct access to the humeral head, the subscapularis tendon is either detached from the lesser tuberosity (often with a cuff sparing lesser tuberosity osteotomy) or split vertically in the direction of its fibers. If detached, repair is paramount.'Option A (Complete tenotomy of the subscapularis tendon at its insertion, followed by repair):While detachment is mentioned, the phrase 'often with a cuff sparing lesser tuberosity osteotomy' implies a more controlled detachment that preserves the tendon's integrity for repair, rather than a simple tenotomy which might be less favorable for healing.Option B (Vertical splitting of the subscapularis muscle in the direction of its fibers):This is listed as an alternative method, but the primary method often described for direct access to the humeral head, especially for complex fractures, is detachment from the lesser tuberosity, often with an osteotomy.Option D (Retraction of the subscapularis medially without any incision or detachment):For direct access to the humeral head and fracture fragments, simple retraction is usually insufficient, especially for complex fractures requiring extensive exposure.Option E (Resection of a portion of the subscapularis muscle to improve visualization):Resection of muscle is generally avoided to preserve function and is not a standard technique for exposing the humeral head in this approach.

Question 643

Topic: 5. Sports Medicine

A 45-year-old construction worker undergoes a posterolateral approach for a comminuted posterolateral pilon fracture with significant metaphyseal bone loss. After achieving anatomical reduction of the articular fragments, the surgeon notes a substantial underlying metaphyseal defect. According to the case, what is the most appropriate next step in managing this defect?

. Proceed directly to locking plate fixation without addressing the defect, as the plate will provide sufficient support.
. Fill the defect with autograft or allograft to provide structural support and prevent collapse.
. Apply a non-locking 1/3 tubular plate to the posterior aspect of the tibia to buttress the fragments.
. Perform a primary ankle arthrodesis due to the severity of the bone loss.
. Use a syndesmotic screw to compress the articular fragments into the defect.

Correct Answer & Explanation

. Fill the defect with autograft or allograft to provide structural support and prevent collapse.


Explanation

Correct Answer: B - Fill the defect with autograft or allograft to provide structural support and prevent collapse.Under 'Internal Fixation' for 'Posterolateral Pilon Fixation,' the case states: 'If significant metaphyseal bone loss or impaction exists beneath reduced articular fragments, bone graft (autograft or allograft) should be placed to provide structural support and prevent collapse. This is particularly important in high-energy pilon fractures.'Option A (Proceed directly to locking plate fixation without addressing the defect):This is incorrect. Without addressing the metaphyseal defect, the reduced articular fragments lack underlying support and are prone to collapse, leading to malunion and post-traumatic arthritis, even with locking plate fixation.Option C (Apply a non-locking 1/3 tubular plate):While a 1/3 tubular plate can be used for posterior malleolus, for a comminuted pilon fracture with bone loss, locking plates are generally preferred for their stability, and the plate alone does not address the bone defect.Option D (Perform a primary ankle arthrodesis):Primary arthrodesis is a salvage procedure for severe, end-stage arthritis or irreconstructible fractures, not typically the initial treatment for a pilon fracture where reconstruction is possible. The case mentions it as a consideration for 'severe bone loss' but 'rare for primary treatment of posterior malleolus,' implying reconstruction is preferred for pilon fractures if feasible.Option E (Use a syndesmotic screw to compress the articular fragments):A syndesmotic screw is used to stabilize the syndesmosis, not to compress articular fragments into a metaphyseal defect. This would be an inappropriate use of the implant.

Question 644

Topic: 5. Sports Medicine

A 29-year-old, left-hand-dominant male presents to clinic complaining of left arm and shoulder pain for the last three days. The patient is an avid weight-lifter and was doing the bench press when his arm began to bother him. He has been using ice and resting with mild relief but has not been able to use his left arm for anything more than carrying light-weight objects. He is also having difficulty with simple activities such as putting on his shirt. On physical examination, the patient has ecchymosis and a prominent cord-like structure on the anterior left axilla. He has significant weakness with left shoulder adduction and internal rotation. He has a negative Hawkins sign and a negative Yergason sign.

Based on the information obtained thus far, which of the following is the most likely diagnosis?

. Rotator cuff tear
. Pectoralis major muscle rupture
. Ruptured biceps tendon
. Poland syndrome
. Pectoralis minor muscle rupture

Correct Answer & Explanation

. Pectoralis major muscle rupture


Explanation

Correct Answer: BThe patient's presentation is classic for a pectoralis major muscle (PMM) rupture. The mechanism of injury (weight-lifting, bench press), acute onset of pain, ecchymosis, and the presence of a prominent cord-like structure in the anterior axilla (representing the continuous fascia of the PMM) are highly indicative. Significant weakness with shoulder adduction and internal rotation further supports this diagnosis, as these are primary functions of the pectoralis major. The patient's young age makes a rotator cuff tear less likely, and the negative Yergason sign rules out a biceps tendon rupture. Poland syndrome is a congenital absence of the PMM, which would present differently and not as an acute injury. Pectoralis minor muscle rupture is exceedingly rare and would not typically present with these specific findings.

Question 645

Topic: Shoulder & Hip Sports

A 50-year-old, right-hand-dominant female presents to clinic with posterior right shoulder pain and sometimes a loud noise while using her right upper extremity for overhead activities. Her pain is concentrated over the superomedial border of her scapula, but she also says her pain is underneath her shoulder blade. What is most bothersome is the fact that she is unable to brush her hair because of the discomfort she experiences. She reports that it started as only noise several years prior, but over the last several months she has developed debilitating pain with overhead activities. She works as a salon hair stylist and denies a history of trauma to her right upper extremity.

Which of the following is the most likely diagnosis?

. Impingement syndrome
. Rotator cuff tendinitis
. Suprascapular nerve entrapment
. Supraspinatus muscle tear
. Scapulothoracic bursitis

Correct Answer & Explanation

. Scapulothoracic bursitis


Explanation

Correct Answer: EThe patient's history is highly characteristic of scapulothoracic bursitis, also known as snapping scapula syndrome. Key features include the long-standing history of a 'loud noise' (crepitus) preceding the onset of pain, pain concentrated over the superomedial border of the scapula and underneath the shoulder blade, and exacerbation with overhead activities (e.g., brushing hair, working as a hair stylist). Scapulothoracic crepitus can lead to symptomatic bursitis over time. Impingement syndrome, rotator cuff tendinitis, and supraspinatus tears typically present with pain in the anterior or lateral shoulder, often without the prominent 'snapping' or 'noise' component, and are less likely to localize pain specifically to the superomedial scapular border. Suprascapular nerve entrapment would primarily cause weakness and atrophy of the supraspinatus and infraspinatus muscles, which is not described as the primary complaint in this case.

Question 646

Topic: 5. Sports Medicine

A 22-year-old female collegiate soccer player sustains a non-contact injury to her right knee during a game, reporting a 'pop' and immediate swelling. She is unable to continue playing. On examination, she has a large effusion, limited range of motion due to pain, and a positive Lachman test. Which of the following associated injuries is most commonly seen with this type of injury?

. Posterior cruciate ligament (PCL) tear
. Medial collateral ligament (MCL) sprain
. Meniscal tear (medial or lateral)
. Patellar tendon rupture
. Osteochondral fracture of the femoral condyle

Correct Answer & Explanation

. Meniscal tear (medial or lateral)


Explanation

Correct Answer: CThe patient's history (non-contact 'pop', immediate swelling, inability to play) and physical exam (effusion, positive Lachman) are highly suggestive of an acute anterior cruciate ligament (ACL) rupture. ACL injuries are frequently associated with other intra-articular injuries. Meniscal tears, particularly of the lateral meniscus (e.g., ramp lesion, root tear) or medial meniscus, are the most common associated injuries, occurring in 50-70% of acute ACL ruptures. The 'unhappy triad' (ACL, MCL, medial meniscus) is a classic but less common combination than isolated ACL with meniscal tear. While MCL sprains (B) can occur, meniscal tears are more prevalent. PCL tears (A) are typically from direct posterior trauma. Patellar tendon ruptures (D) are less common and present with a different mechanism and physical exam. Osteochondral fractures (E) can occur but are less frequent than meniscal tears.

Question 647

Topic: Shoulder & Hip Sports

A 21-year-old rugby player undergoes an MR arthrogram after recurrent anterior shoulder dislocations. The MRI demonstrates an anterior labral tear that is medially displaced and healed to the glenoid neck, with an intact anterior periosteum. What is the most likely diagnosis?

. Classic Bankart lesion
. HAGL lesion
. ALPSA lesion
. GLAD lesion
. SLAP tear

Correct Answer & Explanation

. ALPSA lesion


Explanation

An Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion is characterized by medial displacement of the labrum with an intact anterior periosteum. Unlike a classic Bankart lesion, the periosteum is not torn, allowing the labrum to heal in an abnormal medialized position.

Question 648

Topic: Shoulder & Hip Sports

A 22-year-old collegiate football player undergoes a Latarjet procedure for recurrent anterior shoulder instability with significant glenoid bone loss. Postoperatively, he demonstrates weak elbow flexion and decreased sensation along the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

. Axillary nerve
. Musculocutaneous nerve
. Radial nerve
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Musculocutaneous nerve


Explanation

The musculocutaneous nerve is at risk during the Latarjet procedure as it enters the coracobrachialis, typically 3 to 8 cm distal to the coracoid tip. Injury results in weak elbow flexion (biceps/brachialis) and lateral forearm numbness (lateral antebrachial cutaneous nerve).

Question 649

Topic: Knee Sports
Following the initial clinical assessment, an MRI of the right knee was obtained. Review the provided sagittal T2-weighted image. Which of the following findings is most accurately depicted in this image and is consistent with the patient's presentation?
. Complete rupture of the posterior cruciate ligament with posterior tibial sag.
. A bucket-handle tear of the lateral meniscus with displacement into the intercondylar notch.
. A complete mid-substance rupture of the anterior cruciate ligament with associated bone bruising.
. A Grade III sprain of the medial collateral ligament with significant gapping.
. An osteochondral fracture of the patella with a large hemarthrosis.

Correct Answer & Explanation

. A complete mid-substance rupture of the anterior cruciate ligament with associated bone bruising.


Explanation

The provided sagittal T2-weighted MRI image, combined with the case description, clearly demonstrates a complete rupture of the anterior cruciate ligament (ACL). The ligament fibers are discontinuous, edematous, and appear amorphous. Furthermore, the image shows areas of hyperintensity (bone bruising) in the middle portion of the lateral femoral condyle and the posterior aspect of the lateral tibial plateau, which are characteristic osteochondral impaction injuries resulting from the pivot-shift mechanism.

Question 650

Topic: Knee Sports

Given the patient's age, activity level, and the presence of a high-grade pivot shift with a Segond fracture, the surgical team decided to augment the intra-articular ACL reconstruction with a Lateral Extra-articular Tenodesis (LET). Which of the following best describes the technique for the modified Lemaire LET performed in this case?

. A strip of the semitendinosus tendon is harvested, passed deep to the LCL, and fixed to the lateral femoral epicondyle and Gerdy's tubercle.
. A 1-cm wide strip of the posterior third of the iliotibial band is harvested, leaving its distal attachment at Gerdy's tubercle intact, passed deep to the fibular collateral ligament, and secured into a femoral socket proximal and posterior to the lateral epicondyle.
. The entire iliotibial band is detached proximally and distally, rerouted, and reattached to the lateral femoral condyle and fibular head.
. A synthetic graft is used to reconstruct the anterolateral ligament, fixed to the lateral femoral epicondyle and the anterolateral tibia.
. A portion of the biceps femoris tendon is harvested, passed superficial to the LCL, and fixed to the lateral femoral epicondyle.

Correct Answer & Explanation

. A 1-cm wide strip of the posterior third of the iliotibial band is harvested, leaving its distal attachment at Gerdy's tubercle intact, passed deep to the fibular collateral ligament, and secured into a femoral socket proximal and posterior to the lateral epicondyle.


Explanation

Correct Answer: BThe case explicitly details the technique for the modified Lemaire lateral extra-articular tenodesis: 'A 1-centimeter wide by 8-centimeter long strip of the posterior third of the iliotibial band was harvested, leaving its distal attachment at Gerdy's tubercle intact. The proximal end was whipstitched. The femoral attachment site was identified slightly proximal and posterior to the lateral epicondyle. A guide pin was placed, and a small socket was drilled. The iliotibial band strip was passed deep to the fibular collateral ligament. With the knee held in 30 degrees of flexion and neutral rotation, the graft was tensioned and secured into the femoral socket using a 6-millimeter bioabsorbable interference screw.'Option A is incorrectas it describes using the semitendinosus and an incorrect fixation pattern for a Lemaire.Option C is incorrectas it describes a more extensive and less common ITB tenodesis, not the modified Lemaire.Option D is incorrectas it describes an ALL reconstruction using a synthetic graft, which is not what was performed in this case.Option E is incorrectas it describes using the biceps femoris tendon and an incorrect passage relative to the LCL.

Question 651

Topic: Knee Sports

The patient's postoperative rehabilitation protocol includes specific restrictions due to the combined ACL reconstruction and meniscal repair. In Phase I (Weeks 0 to 4), what is the most critical initial weight-bearing and range of motion restriction, and what is its primary rationale?

. Full weight-bearing as tolerated with the brace locked in extension to promote quadriceps activation.
. Non-weight-bearing with crutches and unrestricted range of motion to prevent arthrofibrosis.
. Touch-down weight-bearing with crutches, brace locked in full extension, and range of motion restricted to 0-90 degrees to protect the healing meniscal repair.
. Partial weight-bearing with crutches, brace unlocked for ambulation, and full range of motion to restore gait mechanics.
. Non-weight-bearing with crutches, brace locked at 30 degrees of flexion, and range of motion restricted to 30-90 degrees to protect the ACL graft.

Correct Answer & Explanation

. Touch-down weight-bearing with crutches, brace locked in full extension, and range of motion restricted to 0-90 degrees to protect the healing meniscal repair.


Explanation

Correct Answer: CThe case explicitly states the Phase I rehabilitation goals: 'The primary goals in the immediate postoperative phase are to control inflammation, protect the graft and meniscal repair, and restore terminal extension.' It further specifies: 'Due to the all-inside repair of the posterior horn of the medial meniscus, weight-bearing was restricted. The patient was allowed touch-down weight-bearing with crutches with the brace locked in full extension. Passive and active-assisted range of motion was initiated early but restricted to 0 to 90 degrees for the first four weeks to prevent excessive shear stress on the healing meniscus.' The primary rationale for these restrictions is to protect the delicate meniscal repair during its initial healing phase, as excessive load or motion can disrupt the repair.Option A is incorrectbecause full weight-bearing is contraindicated with a meniscal repair in the early phase.Option B is incorrectbecause unrestricted range of motion would jeopardize the meniscal repair.Option D is incorrectbecause full weight-bearing and an unlocked brace are too aggressive for the initial phase of a meniscal repair.Option E is incorrectbecause locking the brace at 30 degrees of flexion would promote a flexion contracture and is not standard for ACL/meniscal repair. The ROM restriction is also not optimal.

Question 652

Topic: 5. Sports Medicine

The patient's primary goal is to return to elite-level competitive soccer. Considering his age, activity level, and the presence of a repairable medial meniscal tear, what was the most appropriate graft choice for his ACL reconstruction, and what is its key advantage in this scenario?

. Hamstring autograft, due to less anterior knee pain and faster return to sport.
. Allograft, due to reduced surgical morbidity and quicker recovery time.
. Bone-Patellar Tendon-Bone (BTB) autograft, due to rigid bone-to-bone healing and faster graft incorporation.
. Quadriceps tendon autograft, due to its large diameter and low donor site morbidity.
. Synthetic graft, due to immediate strength and elimination of donor site issues.

Correct Answer & Explanation

. Bone-Patellar Tendon-Bone (BTB) autograft, due to rigid bone-to-bone healing and faster graft incorporation.


Explanation

Correct Answer: CThe case clearly states: 'The decision was made to proceed with a Bone-Patellar Tendon-Bone (BTB) autograft. The BTB autograft is often considered the gold standard for high-demand cutting athletes. Its primary biomechanical advantage lies in the rigid bone-to-bone healing within the femoral and tibial tunnels, which allows for faster incorporation (typically 6 to 8 weeks) compared to soft tissue healing (10 to 12 weeks). Furthermore, the structural properties of the central third of the patellar tendon closely match those of the native anterior cruciate ligament.'Option A is incorrectbecause while hamstring autografts have less anterior knee pain, the case notes they 'have been associated with a slightly higher rate of graft elongation and residual laxity in elite athletes,' making BTB preferred for this high-demand patient.Option B is incorrectbecause the case explicitly states: 'For a young, elite collegiate soccer player, allograft tissue is generally contraindicated due to significantly higher failure rates (up to three to four times higher) compared to autografts in the under-25 demographic.'Option D is incorrectbecause while quadriceps tendon is a good alternative, BTB was specifically chosen in this case due to the surgeon's experience and robust outcomes in elite soccer players.Option E is incorrectbecause synthetic grafts are generally not recommended for primary ACL reconstruction due to high failure rates and concerns about synovitis and long-term outcomes.

Question 653

Topic: Knee Sports

During the arthroscopic portion of the surgery, the medial meniscus was addressed. Review the provided arthroscopic image.

Based on the image and the case description, what type of meniscal tear was identified, and what repair technique was utilized?

. A radial tear of the lateral meniscus, treated with partial meniscectomy.
. A horizontal cleavage tear of the medial meniscus, treated with an outside-in repair.
. A complex tear of the medial meniscus, treated with a meniscal root repair.
. A longitudinal vertical tear in the posterior horn of the medial meniscus, treated with an all-inside repair.
. A bucket-handle tear of the medial meniscus, treated with an inside-out repair.

Correct Answer & Explanation

. A longitudinal vertical tear in the posterior horn of the medial meniscus, treated with an all-inside repair.


Explanation

Correct Answer: DThe case description states: 'Attention was turned to the medial meniscus. Probing confirmed a 1.5-centimeter longitudinal vertical tear in the posterior horn, situated in the vascularized red-white zone. The tear was unstable, easily displacing anteriorly into the joint space. An all-inside meniscal repair technique was selected. The meniscal edges and the adjacent synovium were aggressively rasped using an arthroscopic rasp and shaver to stimulate a bleeding bed and promote a healing response. Two all-inside meniscal repair devices (suture anchors) were deployed sequentially, capturing the superior and inferior leaflets of the meniscus and reducing the tear anatomically.'Option A is incorrectbecause the tear was in the medial meniscus, not lateral, and was repaired, not partially meniscectomized.Option B is incorrectbecause it was a longitudinal vertical tear, not a horizontal cleavage tear, and an all-inside technique was used.Option C is incorrectbecause it was a longitudinal vertical tear, not described as complex, and not a root tear.Option E is incorrectbecause it was a longitudinal vertical tear, not a bucket-handle tear, and an all-inside technique was used.

Question 654

Topic: Knee Sports

The timing of ACL reconstruction is crucial to optimize outcomes and minimize complications. In this case, surgery was scheduled for four weeks post-injury. What was the primary rationale for delaying the surgical intervention, and how was the concomitant Grade II MCL sprain managed during this period?

. To allow for spontaneous healing of the ACL and MCL, potentially avoiding surgery.
. To reduce the risk of postoperative arthrofibrosis by allowing resolution of acute inflammation and restoration of knee range of motion, while managing the MCL non-operatively with bracing.
. To perform a staged repair of the MCL first, followed by ACL reconstruction.
. To allow for complete resolution of the hemarthrosis and initiation of full weight-bearing before surgery.
. To obtain additional imaging studies to rule out other injuries, while the MCL was surgically repaired.

Correct Answer & Explanation

. To reduce the risk of postoperative arthrofibrosis by allowing resolution of acute inflammation and restoration of knee range of motion, while managing the MCL non-operatively with bracing.


Explanation

Correct Answer: BThe case explicitly addresses the timing of surgery: 'Historically, acute reconstruction within the first few days of injury was associated with a high incidence of postoperative joint stiffness. Current evidence-based protocols advocate for a period of "pre-habilitation." The patient was placed in a hinged knee brace and initiated on a strict physical therapy regimen aimed at resolving the acute effusion, restoring normal gait mechanics, and achieving full, symmetric range of motion, particularly terminal extension. Surgery was scheduled for four weeks post-injury, at which point his knee was quiet, the effusion had resolved, and he had regained full extension and 125 degrees of flexion. The concomitant Grade II medial collateral ligament sprain was managed non-operatively during this waiting period. Grade I and II medial collateral ligament injuries have excellent healing potential with bracing and rarely require surgical intervention, even in the setting of anterior cruciate ligament reconstruction.'Option A is incorrectbecause spontaneous healing of a complete ACL rupture is rare, and the goal was pre-habilitation, not avoiding surgery.Option C is incorrectbecause Grade I/II MCL sprains are typically managed non-operatively, not with staged surgical repair.Option D is incorrectbecause while effusion resolution is a goal, full weight-bearing is not necessarily achieved or required before surgery, especially with a meniscal tear.Option E is incorrectbecause additional imaging was not the primary reason for delay, and the MCL was managed non-operatively.

Question 655

Topic: Knee Sports

During the surgical procedure, anatomic femoral tunnel placement is critical for successful ACL reconstruction. Which of the following describes the approach and key anatomical landmark used for femoral tunnel creation in this case?

. Transtibial drilling, aiming for the anterior aspect of the lateral femoral condyle.
. Accessory anteromedial portal, with the knee in hyperflexion, targeting the lateral bifurcate ridge and lateral intercondylar ridge on the medial wall of the lateral femoral condyle.
. Outside-in drilling, targeting the posterior aspect of the medial femoral condyle.
. Anterolateral portal, with the knee in full extension, aiming for the anterior aspect of the intercondylar notch.
. Posteromedial portal, targeting the PCL footprint on the medial femoral condyle.

Correct Answer & Explanation

. Accessory anteromedial portal, with the knee in hyperflexion, targeting the lateral bifurcate ridge and lateral intercondylar ridge on the medial wall of the lateral femoral condyle.


Explanation

Correct Answer: BThe case details the femoral tunnel preparation: 'To achieve independent and anatomic femoral tunnel placement, an accessory anteromedial portal was utilized. The knee was hyperflexed to 120 degrees. A guide pin was placed in the center of the native footprint on the medial wall of the lateral femoral condyle, specifically mentioning the lateral bifurcate ridge and the lateral intercondylar ridge (resident's ridge) as landmarks. A 10-millimeter reamer was used to drill the femoral socket to a depth of 25 millimeters.'Option A is incorrectbecause transtibial drilling often leads to a more vertical femoral tunnel, which is non-anatomic and can compromise rotational stability. The case specifies an accessory anteromedial portal.Option C is incorrectbecause the femoral tunnel is placed on the lateral femoral condyle for ACL reconstruction, not the medial.Option D is incorrectbecause the anterolateral portal is typically used for visualization, and the knee is hyperflexed for anatomic femoral tunnel drilling, not full extension.Option E is incorrectbecause the posteromedial portal is used for posterior compartment pathology or PCL reconstruction, not ACL femoral tunnel placement.

Question 656

Topic: 5. Sports Medicine
A 22-year-old collegiate soccer player presents with acute right knee pain, swelling, and instability following a non-contact pivoting injury. Clinical examination reveals a Grade III Lachman test, a high-grade pivot shift, and mild gapping with valgus stress at 30 degrees of flexion. MRI confirms a complete ACL rupture, a Grade II MCL sprain, and a repairable medial meniscal tear. Which of the following statements regarding the management of the concomitant Grade II MCL sprain is most accurate in this clinical scenario?
. It requires immediate surgical repair prior to ACL reconstruction to prevent chronic instability.
. It is typically managed non-operatively with bracing and physical therapy, even in the setting of ACL reconstruction, due to its excellent healing potential.
. It necessitates a separate surgical procedure for reconstruction using an allograft due to the high demands of the patient's sport.
. It is a contraindication to early ACL reconstruction and requires a prolonged period of non-weight-bearing.
. It indicates a need for a hinged knee brace locked in 30 degrees of flexion for 6 weeks to promote healing.

Correct Answer & Explanation

. It is typically managed non-operatively with bracing and physical therapy, even in the setting of ACL reconstruction, due to its excellent healing potential.


Explanation

Grade I and II medial collateral ligament injuries have excellent healing potential with bracing and rarely require surgical intervention, even in the setting of anterior cruciate ligament reconstruction.

Question 657

Topic: Knee Sports
The patient's clinical presentation, including a high-grade pivot shift and a Segond fracture, strongly suggested profound anterolateral rotatory instability. This finding significantly influenced the surgical decision-making process. What is the primary rationale for adding a Lateral Extra-articular Tenodesis (LET) to the primary ACL reconstruction in this specific patient?
. To provide additional static stability against posterior tibial translation.
. To prevent recurrent patellar dislocation in a high-risk athlete.
. To significantly reduce the risk of graft rupture and persistent rotatory laxity in young, high-risk patients.
. To augment the healing of the medial collateral ligament and prevent valgus instability.
. To address a concomitant lateral meniscal tear and improve meniscal healing.

Correct Answer & Explanation

. To significantly reduce the risk of graft rupture and persistent rotatory laxity in young, high-risk patients.


Explanation

Recent biomechanical and clinical outcome studies, including the STABILITY trial, have demonstrated that adding a LET to a primary anterior cruciate ligament reconstruction in young, high-risk patients significantly reduces the risk of graft rupture and persistent rotatory laxity.

Question 658

Topic: 5. Sports Medicine

The patient's history includes a sudden deceleration with a pivoting motion on a planted foot, followed by a valgus collapse of the knee, and he reported hearing a distinct 'pop.' This mechanism is highly characteristic of an ACL rupture. Which of the following statements accurately describes the biomechanical cascade leading to this injury?

. The foot becomes fixed, and the femur externally rotates over a fixed, internally rotated tibia, applying a varus moment.
. The foot becomes fixed, and the femur internally rotates over a fixed, externally rotated tibia, applying a valgus moment.
. A direct blow to the anterior tibia causes hyperextension and rupture of the ACL.
. A fall onto a flexed knee with the foot plantarflexed causes posterior displacement of the tibia.
. Repetitive microtrauma from chronic overuse leads to gradual degeneration and eventual rupture of the ACL.

Correct Answer & Explanation

. The foot becomes fixed, and the femur internally rotates over a fixed, externally rotated tibia, applying a valgus moment.


Explanation

Correct Answer: BThe case provides a detailed description of the biomechanical cascade: 'The biomechanical cascade typically involves the athlete attempting to change direction rapidly. The foot becomes fixed to the playing surface... As the athlete decelerates and internally rotates the femur over a fixed, externally rotated tibia, a significant valgus moment is applied to the knee joint. This complex loading pattern overwhelms the tensile capacity of the anterior cruciate ligament, often resulting in mid-substance rupture...'Option A is incorrectbecause it describes external rotation of the femur over an internally rotated tibia and a varus moment, which is not the classic ACL mechanism described.Option C is incorrectbecause a direct blow causing hyperextension is a different mechanism, often associated with PCL or multiligamentous injuries, but not the primary non-contact pivoting mechanism.Option D is incorrectbecause a fall onto a flexed knee with the foot plantarflexed is the classic mechanism for a posterior cruciate ligament (PCL) injury.Option E is incorrectbecause this describes a degenerative process, whereas the patient experienced an acute, traumatic injury.

Question 659

Topic: 5. Sports Medicine

A 22-year-old college athlete sustains a complete laceration of the FDP tendon in Zone I of his long finger. During surgical repair, the surgeon plans to use a multi-strand core suture technique to maximize tensile strength and allow for early active mobilization. Which of the following core suture techniques, as described in the case, is known for providing high tensile strength and resistance to gapping, often favored for early active motion protocols?

. Modified Kessler (2-strand)
. Pennington (2-strand)
. Doble-Modified Kessler (4-strand)
. Simple running epitendinous suture only
. Single horizontal mattress suture

Correct Answer & Explanation

. Doble-Modified Kessler (4-strand)


Explanation

Correct Answer: CExplanation:The question asks about core suture techniques known for high tensile strength, suitable for early active motion. The provided image also depicts a multi-strand core suture repair.Option C is correct:The case explicitly states under "Core Suture Techniques" that "Doble-Modified Kessler (4-strand): Two modified Kessler sutures placed 90 degrees apart. This significantly increases strength." It also mentions that modern techniques typically involve 4- to 6-strand repairs, and that a 4- to 6-strand core suture combined with an epitendinous repair is a prerequisite for successful early active motion protocols, achieving strengths of 45-70 N.Option A is incorrect:The Modified Kessler (2-strand) is described as "Historically popular, but often insufficient for early active motion without significant gapping."Option B is incorrect:The Pennington (2-strand) is also described as a 2-strand technique with "similar limitations" to the modified Kessler.Option D is incorrect:An epitendinous suture is appliedafterthe core suture and primarily smooths the repair site and adds 10-50% to tensile strength, but it is not the primary core suture responsible for the majority of tensile strength.Option E is incorrect:A single horizontal mattress suture is a basic suture pattern and would not provide the multi-strand strength required for early active motion protocols.

Question 660

Topic: 5. Sports Medicine

A 24-year-old male is 3 months status post anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. He complains of an inability to fully extend his knee and anterior knee pain during walking. Lateral extension radiographs demonstrate that the tibial tunnel is positioned entirely anterior to the intersection of Blumensaat's line and the tibial plateau. What is the most likely consequence of this tunnel malposition?

. Posterior cruciate ligament impingement in deep flexion
. Graft impingement on the intercondylar notch roof
. Excessive laxity in terminal extension
. Excessive laxity in deep flexion
. Premature degeneration of the medial meniscus

Correct Answer & Explanation

. Graft impingement on the intercondylar notch roof


Explanation

Anterior placement of the tibial tunnel leads to graft impingement against the roof of the intercondylar notch during extension. This commonly results in a loss of terminal extension, anterior knee pain, and potential graft attrition.