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 6741
Topic: Shoulder & Hip Sports
A 45-year-old man with a history of seizures presents with a chronic, locked posterior shoulder dislocation. A modified McLaughlin procedure is planned. During this procedure, which anatomic structure is transferred into the reverse Hill-Sachs defect to provide stability?
Correct Answer & Explanation
. Lesser tuberosity with the attached subscapularis tendon
Explanation
The original McLaughlin procedure involves detaching the subscapularis tendon and transferring it into the reverse Hill-Sachs (anteromedial humeral head) defect to prevent it from engaging the posterior glenoid rim. ThemodifiedMcLaughlin procedure, popularized by Neer, involves an osteotomy of the lesser tuberosity with the subscapularis attached, transferring the bone block into the defect for superior bone-to-bone healing.
Question 6742
Topic: 5. Sports Medicine
A lower trapezius tendon transfer is performed in a young laborer for a massive, irreparable posterosuperior rotator cuff tear. What is the primary kinematic function this transfer aims to restore, and what graft is most commonly used to bridge the interval to the greater tuberosity?
Correct Answer & Explanation
. External rotation; Fascia lata or Achilles allograft
Explanation
The lower trapezius transfer was developed by Elhassan to restore active external rotation in patients with irreparable posterosuperior cuff tears (supraspinatus/infraspinatus). Because the lower trapezius tendon cannot reach the greater tuberosity, an interposition graft—most commonly an Achilles tendon allograft or fascia lata—is required to bridge the gap.
Question 6743
Topic: Shoulder & Hip Sports
A 28-year-old elite volleyball player presents with insidious onset of right shoulder weakness. Physical examination reveals normal forward elevation and abduction, but isolated weakness in external rotation. There is prominent atrophy of the infraspinatus fossa, while the supraspinatus fossa is well-preserved. An MRI reveals a paralabral cyst. Where is the cyst most likely located?
Correct Answer & Explanation
. Spinoglenoid notch
Explanation
The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. The motor branch to the supraspinatus takes off after the nerve passes through the suprascapular notch but before it reaches the spinoglenoid notch. Entrapment of the nerve at the spinoglenoid notch (often due to a paralabral cyst associated with a posterior labral tear) results in isolated denervation of the infraspinatus, sparing the supraspinatus.
Question 6744
Topic: Shoulder & Hip Sports
A 45-year-old male presents with anterior shoulder pain characterized by a positive 'coracoid impingement test' (pain elicited with the arm in forward flexion, internal rotation, and adduction). Advanced imaging measures the coracohumeral distance to be 4 mm. Pathology involving which of the following structures is most highly associated with subcoracoid impingement?
Correct Answer & Explanation
. Subscapularis tendon
Explanation
Subcoracoid impingement is a less common cause of anterior shoulder pain that occurs when the coracohumeral distance is pathologically narrowed (typically less than 6 mm). The impingement occurs between the coracoid process and the lesser tuberosity. Because the subscapularis tendon inserts onto the lesser tuberosity, subcoracoid impingement classically results in tearing or tendinopathy of the subscapularis tendon. The long head of the biceps may also be involved, but subscapularis pathology is the hallmark.
Question 6745
Topic: 5. Sports Medicine
A patient with advanced rheumatoid arthritis presents with an inability to actively extend the fingers of the right hand. The surgeon suspects Vaughan-Jackson syndrome. Which of the following best describes the typical sequence of tendon ruptures in this condition?
Correct Answer & Explanation
. Extensor digiti minimi, progressing radially to the extensor digitorum communis of the index finger.
Explanation
Vaughan-Jackson syndrome refers to closed extensor tendon ruptures in rheumatoid arthritis, caused by mechanical attrition over a dorsally subluxated ulnar head (caput ulnae). The ruptures predictably start on the ulnar side (extensor digiti minimi/EDQ) and progress radially toward the index finger.
Question 6746
Topic: 5. Sports Medicine
During early active mobilization rehabilitation following a zone II flexor tendon repair, the risk of gap formation and tendon rupture is greatest during which postoperative period?
Correct Answer & Explanation
. Days 10-21
Explanation
The tensile strength of a repaired tendon drops significantly during the fibroblastic phase (days 10-21) due to collagen degradation before new collagen synthesis predominates. This is the period of maximum vulnerability to elongation and rupture.
Question 6747
Topic: 5. Sports Medicine
A 58-year-old female with long-standing rheumatoid arthritis presents with an inability to actively extend her small and ring fingers. A tenodesis test demonstrates passive extension of these digits upon wrist flexion, but active extension is absent. This presentation is highly characteristic of Vaughan-Jackson syndrome, where tendon ruptures typically begin with which of the following?
Correct Answer & Explanation
. Extensor digiti minimi (EDM)
Explanation
Vaughan-Jackson syndrome involves attritional ruptures of the extensor tendons moving in an ulnar-to-radial direction, typically caused by a dorsally prominent distal ulna (caput ulnae). The extensor digiti minimi (EDM) is the first tendon to rupture.
Question 6748
Topic: 5. Sports Medicine
What is the primary advantage of utilizing an allograft (cadaveric tissue) for lateral ankle ligament reconstruction over an autograft (patient's own tissue)?
Correct Answer & Explanation
. Avoidance of donor site morbidity.
Explanation
The primary advantage of using an allograft for lateral ankle ligament reconstruction is the avoidance of donor site morbidity, as no tissue is harvested from the patient. Autografts, while providing living tissue with potentially better incorporation, carry the risk of pain, weakness, and complications at the harvest site. Allografts do not offer reduced infection risk, faster healing, or inherently superior long-term strength compared to a well-vascularized autograft, and are typically more expensive.
Question 6749
Topic: 5. Sports Medicine
During your consultation for chronic lateral ankle instability, a patient asks about preventing future sprains. What is the most important component of long-term prevention strategies after initial recovery?
Correct Answer & Explanation
. Consistent ankle bracing or taping during at-risk activities.
Explanation
For patients with a history of chronic lateral ankle instability, consistent ankle bracing or taping during at-risk activities (sports, uneven terrain) is the most important and evidence-based component of long-term prevention strategies after initial recovery. This provides external support to limit excessive inversion. While high-top shoes offer some support, they are generally insufficient alone. Avoiding all sports is impractical. Daily anti-inflammatory medication is not a preventive strategy, and prophylactic surgery is usually reserved for those who fail conservative measures and bracing.
Question 6750
Topic: Knee Sports
Which of the following is a potential complication of placing the tibial component with insufficient posterior slope?
Correct Answer & Explanation
. Difficulty achieving full knee flexion
Explanation
Insufficient tibial posterior slope (i.e., the tibial cut being too flat or even anteriorly sloped) can create a relatively 'tight' flexion gap, making it difficult to achieve full knee flexion. It can also cause anterior impingement. Hyperextension instability is associated withexcessiveposterior slope. Increased wear of the anterior polyethylene is less direct. Increased PCL tension can occur, but difficulty with flexion is a more primary functional consequence. Lateral patellar subluxation is usually related to rotational alignment.
Question 6751
Topic: 5. Sports Medicine
What is the consequence of placing the femoral component in an excessively posterior position (e.g., due to insufficient anterior femoral cut)?
Correct Answer & Explanation
. Anterior impingement and restricted flexion
Explanation
Placing the femoral component in an excessively posterior position (effectively 'anteriorizing' the knee) can lead to anterior impingement of the patella or extensor mechanism, restricting full flexion. It can also make the extension gap too tight. A flexion contracture is more associated with an excessively flexed femoral component or posterior condylar over-resection. Hyperextension instability is related to excessive tibial posterior slope. Posterior impingement usually occurs with an oversized femoral component. Patellar tendon rupture is not directly related to femoral AP position.
Question 6752
Topic: Knee Sports
To correct an extension gap that is tight laterally but appropriately balanced medially, what specific soft tissue release might be considered?
Correct Answer & Explanation
. Popliteus tendon release or posterolateral corner release
Explanation
If the extension gap is tight laterally while the medial side is balanced, it indicates tightness of the lateral structures. A popliteus tendon release, or a more comprehensive posterolateral corner release (depending on the degree of tightness and specific structures involved), would be indicated to balance the lateral compartment in extension. MCL releases are for medial tightness. PCL release addresses a tight flexion gap when the PCL is causative. Pes anserinus release primarily affects flexion contracture in some cases.
Question 6753
Topic: Knee Sports
What is the preferred reference for rotational alignment of the tibial component?
Correct Answer & Explanation
. The line connecting the center of the tibial tubercle to the center of the posterior cruciate ligament insertion
Explanation
The preferred reference for rotational alignment of the tibial component is typically a line connecting the center of the tibial tubercle to the center of the posterior cruciate ligament (PCL) insertion (or the middle of the medial third of the tibial tuberosity to the center of the ankle joint). This ensures proper orientation relative to the extensor mechanism and the native knee anatomy. The intermalleolar axis is a valid external reference, but the internal anatomical landmarks are key for component placement.
Question 6754
Topic: Knee Sports
A 14-year-old female presents with her first traumatic lateral patellar dislocation. She has significant knee swelling and pain. Lateral X-ray shows patella alta, and MRI confirms a partial tear of the MPFL at its femoral insertion, extensive bone bruising of the lateral femoral condyle and medial patella, and a small osteochondral fragment off the medial patellar facet. What is the most appropriate initial management strategy?
Correct Answer & Explanation
. Immediate MPFL reconstruction and osteochondral fragment fixation.
Explanation
The presence of a significant osteochondral fragment following a first-time dislocation is an absolute indication for surgical intervention, typically involving fixation or removal of the fragment. Given her age and the acute nature, fixation is preferred if the fragment is salvageable. While conservative management is often appropriate for first-time dislocations without significant concomitant injuries, the osteochondral fragment necessitates surgical intervention. MPFL reconstruction may be considered concurrently or at a later stage depending on residual instability, but the immediate priority is addressing the intra-articular injury. Tibial tubercle osteotomy is too aggressive for a first-time dislocation unless there are severe underlying malalignment issues, and initial conservative management or fragment fixation would precede. Closed reduction is already done, and immobilization in full extension is outdated and detrimental to recovery.
Question 6755
Topic: Knee Sports
What is the primary anatomical feature that contributes to the 'J-sign' observed in patients with patellar instability?
Correct Answer & Explanation
. Excessive lateral translation of the patella in terminal knee extension.
Explanation
The J-sign describes the sudden, exaggerated lateral deviation of the patella as the knee approaches full extension during active extension from a flexed position. This phenomenon is a dynamic manifestation of patellar instability and is primarily caused by an underlying trochlear dysplasia (a shallow or flat trochlear groove) that fails to adequately engage and constrain the patella until the very end of extension, leading to a 'jump' laterally. While other factors like lateral retinacular tightness or VMO weakness can contribute to patellar tracking issues, the J-sign itself is most directly linked to the patella failing to engage the trochlear groove early in extension, often due to trochlear dysplasia.
Question 6756
Topic: Knee Sports
When performing a trochleoplasty, what is the primary goal of the procedure?
Correct Answer & Explanation
. To deepen the trochlear groove, creating a more congruent articulation with the patella.
Explanation
Trochleoplasty is a bony procedure specifically designed to address severe trochlear dysplasia. The primary goal is to reshape the distal femur by deepening the trochlear groove and often creating a medial facet, thus improving the bony containment and engagement of the patella, thereby reducing the risk of lateral dislocation. It does not directly affect quadriceps length, patellar tendon insertion point, lateral retinaculum tension (though it indirectly reduces lateral force), or patellar height.
Question 6757
Topic: Knee Sports
A 30-year-old competitive athlete with chronic patellofemoral pain and a history of recurrent patellar subluxation presents. MRI shows mild trochlear dysplasia, increased TT-TG (18mm), and a normal MPFL. She has failed a comprehensive rehabilitation program. Which procedure would be most appropriate?
Correct Answer & Explanation
. Tibial tubercle osteotomy for medialization.
Explanation
This patient has chronic subluxation with an increased TT-TG and failed conservative management, but anormal MPFL. While an MPFL reconstruction would usually be the first-line surgical treatment for patellar instability, the question states the MPFL is normal, implying the instability is due to a primary bony malalignment. With an increased TT-TG of 18mm and mild trochlear dysplasia, a tibial tubercle osteotomy for medialization (e.g., Elmslie-Trillat or modified Fulkerson) would address the primary mechanical driver of her subluxation. Trochleoplasty is generally reserved for more severe dysplasia. Lateral retinacular release is rarely indicated as an isolated procedure. VMO advancement is less effective for bony malalignment. Isolated MPFL reconstruction would be redundant if the MPFL is intact and functional.
Question 6758
Topic: Knee Sports
Which of the following describes the most accurate anatomical reference for the femoral attachment of the MPFL?
Correct Answer & Explanation
. Distal and posterior to the adductor tubercle, between it and the medial epicondyle.
Explanation
The femoral attachment of the MPFL is consistently found in a sulcus located distal and posterior to the adductor tubercle and anterior to the posterior cortex of the femur, between the adductor tubercle and the medial epicondyle. This 'Schottle's Point' or 'Blumensaat's Line' position is critical for isometric reconstruction. Incorrect placement can lead to graft over-tensioning or laxity.
Question 6759
Topic: Knee Sports
Which of the following describes a Type D trochlear dysplasia according to Dejour's classification?
Correct Answer & Explanation
. 'Cliff-like' trochlea with a supratrochlear spur and patellar subluxation.
Explanation
Dejour's classification of trochlear dysplasia is based on axial imaging. Type A is a shallow trochlea, Type B has a supratrochlear spur, Type C has a crossover sign (the medial facet lies lateral to the lateral facet) but no spur, and Type D (the most severe) has both a crossover sign and a supratrochlear spur, often with a 'cliff-like' appearance and clear signs of patellar subluxation. The 'cliff-like' description specifically refers to the combination of these features.
Question 6760
Topic: Knee Sports
Which of the following statements regarding the role of lateral retinacular release in patellar instability surgery is most accurate?
Correct Answer & Explanation
. It is rarely indicated as an isolated procedure and may lead to iatrogenic instability.
Explanation
Lateral retinacular release (LRR) as an isolated procedure is rarely indicated for recurrent patellar instability, especially in the presence of MPFL insufficiency or bony malalignment. Historically, it was overused, leading to medial instability or patellofemoral pain. Its primary indication now is typically for severe lateral patellar tilt without instability or as an adjunct in cases of persistent lateral tracking after comprehensive realignment procedures, where lateral tightness is proven. It does not address trochlear dysplasia, patella alta, or directly MPFL deficiency, and performing it alone for recurrent instability can lead to iatrogenic medial instability. It is generally not performed routinely with MPFL reconstruction unless specific lateral tightness exists.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.