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5. Sports Medicine MCQs

Practice Set 49 of 360

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 961

Topic: Knee Sports

A 16-year-old male presents with recurrent lateral patellar dislocations. Clinical examination reveals a positive J-sign, patellar hypermobility, and a positive apprehension test at 20 degrees of knee flexion. Imaging shows significant trochlear dysplasia, a TT-TG distance of 22 mm, and patella alta. The patient has failed conservative management. Which of the following surgical interventions would be MOST appropriate to address the multiple anatomical risk factors in this patient?

. Isolated MPFL reconstruction with hamstring autograft.
. VMO advancement combined with lateral retinacular release.
. Trochleoplasty and combined MPFL reconstruction with tibial tubercle osteotomy for medialization and distalization.
. Tibial tubercle medialization osteotomy alone.
. Proximal realignment with arthroscopic lateral retinacular release.

Correct Answer & Explanation

. Trochleoplasty and combined MPFL reconstruction with tibial tubercle osteotomy for medialization and distalization.

Explanation

Correct Answer: CThis patient presents with a severe form of patellar instability characterized by multiple significant anatomical risk factors: severe trochlear dysplasia, markedly increased TT-TG distance (normal < 15-20 mm), and patella alta. Isolated MPFL reconstruction would address the medial restraint but not the underlying bony deformities. VMO advancement and lateral retinacular release are typically insufficient for severe bony dysplasia. Tibial tubercle medialization alone would only address the TT-TG and not the trochlear dysplasia or patella alta. Therefore, a comprehensive approach involving trochleoplasty (for the severe dysplasia), MPFL reconstruction (for the medial restraint), and a tibial tubercle osteotomy for both medialization (for TT-TG) and distalization (for patella alta) is indicated for optimal outcomes and recurrence prevention. This combination addresses all major identified risk factors.

Question 962

Topic: Knee Sports

Which of the following is considered the MOST significant risk factor for recurrent patellar instability?

. Generalized ligamentous laxity.
. First dislocation occurring after age 25.
. Absence of a torn MPFL on MRI.
. Severe trochlear dysplasia (Type C or D per Dejour classification).
. Q-angle less than 10 degrees.

Correct Answer & Explanation

. Severe trochlear dysplasia (Type C or D per Dejour classification).

Explanation

Correct Answer: DSevere trochlear dysplasia, especially Dejour Types B, C, or D, is consistently identified as the single most significant anatomical risk factor for recurrent patellar instability. The flattened or convex trochlear groove provides inadequate bony constraint against lateral patellar translation. Generalized ligamentous laxity is a risk factor but less potent than severe dysplasia. Dislocation at a younger age (especially under 15) is associated with higher recurrence rates, not older age. A torn MPFL is characteristic of acute dislocation, but its absence doesn't preclude recurrence if other factors exist; its presenceincreasesrecurrence risk if left untreated. A Q-angle less than 10 degrees would typically be protective or normal, not a risk factor; an increased Q-angle is a risk factor.

Question 963

Topic: Knee Sports

A patient with a history of recurrent patellar instability undergoes an MRI. The report indicates a TTPG (Tibial Tubercle-Trochlear Groove) distance of 20 mm. What is the clinical significance of this finding?

. It is within normal limits and unlikely to contribute to instability.
. It suggests a high likelihood of lateral patellar subluxation due to lateralization of the tibial tubercle.
. It is indicative of severe patella alta.
. It primarily correlates with quadriceps muscle imbalance.
. It necessitates immediate surgical intervention, regardless of symptoms.

Correct Answer & Explanation

. It suggests a high likelihood of lateral patellar subluxation due to lateralization of the tibial tubercle.

Explanation

Correct Answer: BA TT-TG distance of 20 mm is considered significantly elevated. Normal values are typically less than 15-20 mm, with values over 20 mm strongly correlating with patellofemoral instability due to a lateralized pull of the patellar tendon and quadriceps mechanism relative to the trochlear groove. It is a key factor indicating bony malalignment. While patella alta can coexist, TT-TG specifically measures the transverse plane relationship, not patellar height. It's a significant risk factor but doesn't necessarily dictate immediate surgery if asymptomatic or if conservative management is successful. Quadriceps imbalance can contribute but isn't directly measured by TT-TG.

Question 964

Topic: Knee Sports

A 12-year-old male with open physes experiences his second lateral patellar dislocation. X-rays show no fracture. MRI confirms MPFL rupture and normal trochlear morphology. He has no significant patella alta or increased TT-TG distance. What is the most appropriate surgical approach?

. Tibial tubercle distalization osteotomy.
. Trochleoplasty.
. MPFL reconstruction using an all-epiphyseal or transphyseal technique avoiding the growth plate.
. Lateral retinacular release alone.
. Conservative management with bracing and physiotherapy.

Correct Answer & Explanation

. MPFL reconstruction using an all-epiphyseal or transphyseal technique avoiding the growth plate.

Explanation

Correct Answer: CFor skeletally immature patients with recurrent patellar instability, MPFL reconstruction is the preferred procedure. Given the open physes, techniques that avoid or protect the growth plates are critical, such as an all-epiphyseal (transphyseal without violating growth plates) or transphyseal tunnels placed carefully to minimize growth disturbance. Tibial tubercle osteotomies and trochleoplasty are generally avoided in skeletally immature patients due to the risk of growth arrest, unless there are severe underlying bony deformities that supersede this risk (which are explicitly ruled out in this question). Conservative management has failed after the second dislocation, and lateral release alone is insufficient for MPFL rupture.

Question 965

Topic: Knee Sports

A 28-year-old female presents with persistent anterior knee pain and crepitus following an MPFL reconstruction performed 1 year ago for recurrent patellar dislocations. She reports no further dislocations but finds stairs and squatting painful. Physical exam shows no apprehension, but diffuse tenderness around the patellofemoral joint. Patellar height is normal. What is the most likely cause of her symptoms?

. Recurrent patellar instability.
. Infection of the MPFL graft.
. Over-constraining of the patella during MPFL reconstruction.
. Insufficient medialization of the tibial tubercle.
. Rupture of the MPFL graft.

Correct Answer & Explanation

. Over-constraining of the patella during MPFL reconstruction.

Explanation

Correct Answer: CPersistent anterior knee pain, particularly with activities like stairs and squatting, after an MPFL reconstruction that successfully prevented recurrence, strongly suggests patellofemoral overload or over-constraining. This is a common complication if the MPFL graft is tensioned too tightly or fixed in an incorrect position, leading to increased patellofemoral contact pressures. Recurrence is ruled out by the history. Infection would typically present with different symptoms (fever, warmth, redness, systemic signs). Insufficient medialization would lead to continued instability, not just pain without apprehension. Graft rupture would lead to recurrence.

Question 966

Topic: Knee Sports

Which radiographic measurement is used to assess patellar height?

. Q-angle.
. TT-TG distance.
. Dejour classification.
. Insall-Salvati ratio.
. Bisect offset.

Correct Answer & Explanation

. Insall-Salvati ratio.

Explanation

Correct Answer: DThe Insall-Salvati ratio (patellar tendon length to patellar diagonal length on a lateral X-ray) and modified Insall-Salvati ratio are standard measurements for assessing patellar height (patella alta or baja). The Q-angle measures quadriceps alignment, TT-TG measures tibial tubercle lateralization, Dejour classifies trochlear dysplasia, and bisect offset is used for patellar tilt on axial views. Therefore, Insall-Salvati ratio is the correct answer for patellar height.

Question 967

Topic: Knee Sports

A 15-year-old female presents with bilateral recurrent patellar instability. She has generalized joint hypermobility (Beighton score 7/9) and a family history of patellar dislocations. Imaging shows normal trochlear morphology, minimal patella alta, and normal TT-TG distance bilaterally. What is the most appropriate initial management?

. Bilateral MPFL reconstruction.
. Physical therapy focusing on core and quadriceps strengthening, particularly VMO.
. Bilateral tibial tubercle medialization osteotomies.
. Bracing with hinged knee braces for all activities.
. Genetic counseling for a connective tissue disorder.

Correct Answer & Explanation

. Physical therapy focusing on core and quadriceps strengthening, particularly VMO.

Explanation

Correct Answer: BFor patients with generalized ligamentous laxity and recurrent patellar instability, conservative management, specifically targeted physical therapy, is the cornerstone of initial treatment. Surgical intervention is often less successful in this population and should be considered only after extensive failure of conservative measures. Bony procedures are usually not indicated if bony alignment is normal. While genetic counseling may be relevant for severe generalized laxity, it's not the 'initial management' for the instability itself. Bilateral MPFL reconstruction is an aggressive surgical intervention and should not be the first step, especially with normal bony alignment. Bracing can be an adjunct but not the primary management.

Question 968

Topic: 5. Sports Medicine

In the setting of an acute, first-time traumatic patellar dislocation without osteochondral fragments, what is the most appropriate initial treatment regimen?

. Immediate MPFL reconstruction.
. Closed reduction, protected weight-bearing, bracing in 20-30 degrees flexion, and supervised physiotherapy.
. Diagnostic arthroscopy and lateral retinacular release.
. Immobilization in full extension for 6 weeks.
. Tibial tubercle medialization osteotomy.

Correct Answer & Explanation

. Closed reduction, protected weight-bearing, bracing in 20-30 degrees flexion, and supervised physiotherapy.

Explanation

Correct Answer: BFor a first-time acute patellar dislocation without significant osteochondral injury, the standard of care is non-operative management. This includes closed reduction, often followed by a period of protected weight-bearing, use of a knee brace (often set to limit extension and encourage early flexion to engage the trochlea), and a comprehensive physiotherapy program focusing on quadriceps strengthening (especially VMO) and proprioception. Surgical intervention (MPFL reconstruction, LRR, osteotomy) is generally reserved for recurrent instability or specific concomitant injuries. Immobilization in full extension is outdated and can lead to stiffness.

Question 969

Topic: Knee Sports

Which of the following factors is considered to be a strong predictor of failure after MPFL reconstruction?

. Isolated patella alta with no other bony risk factors.
. Mild trochlear dysplasia (Dejour Type A).
. Concomitant patellofemoral chondral damage.
. Uncorrected severe bony malalignment (e.g., TT-TG > 20mm, severe trochlear dysplasia).
. Age greater than 40 years at the time of surgery.

Correct Answer & Explanation

. Uncorrected severe bony malalignment (e.g., TT-TG > 20mm, severe trochlear dysplasia).

Explanation

Correct Answer: DMPFL reconstruction primarily addresses the soft tissue medial restraint. If significant bony malalignment (such as a severely increased TT-TG distance, or severe trochlear dysplasia like Dejour Type C or D) remains uncorrected, the biomechanical forces predisposing to instability persist, leading to a high risk of failure (re-dislocation or persistent subluxation) even after a technically adequate MPFL reconstruction. Mild patella alta or Type A dysplasia may not always require concomitant bony procedures. Chondral damage is a complication but not a direct cause of MPFL reconstruction failure in terms of recurrence. Age can influence healing but is not as strong a predictor of failure as uncorrected bony malalignment.

Question 970

Topic: Knee Sports
During reconstruction of the medial patellofemoral ligament (MPFL), identifying the correct femoral attachment is critical to prevent graft anisometry. Based on Schöttle's radiographic landmarks, where is the anatomic femoral origin of the MPFL located?
. Anterior to the posterior femoral cortex and distal to Blumensaat's line
. 1 mm anterior to the posterior cortex line, 2.5 mm distal to the posterior articular border, and proximal to Blumensaat's line
. Anterior to the medial epicondyle and distal to the adductor tubercle
. Posterior to the adductor tubercle and proximal to the medial epicondyle
. Centered exactly on the medial epicondyle

Correct Answer & Explanation

. 1 mm anterior to the posterior cortex line, 2.5 mm distal to the posterior articular border, and proximal to Blumensaat's line

Explanation

The MPFL origin (Schöttle's point) is radiographically defined as 1 mm anterior to the posterior cortex line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior point of Blumensaat's line. Accurate placement prevents graft overtensioning in flexion.

Question 971

Topic: Knee Sports

A 22-year-old female undergoes a medializing tibial tubercle osteotomy (Fulkerson procedure) for recurrent patellofemoral instability with a TT-TG distance of 24 mm. Postoperatively, what is the most significant risk associated with over-medialization of the tibial tubercle?

. Patella baja
. Medial compartment osteoarthritis
. Recurrent lateral patellar dislocation
. Rupture of the patellar tendon
. Avulsion of the anterior cruciate ligament

Correct Answer & Explanation

. Medial compartment osteoarthritis

Explanation

Over-medialization of the tibial tubercle can significantly increase contact pressures in the medial tibiofemoral compartment, leading to medial compartment overload and early osteoarthritis. Surgeons must carefully titrate medialization to achieve a normal TT-TG distance (10-15 mm).

Question 972

Topic: Knee Sports

When evaluating a patient with patellofemoral instability, the Dejour classification is commonly used to describe trochlear dysplasia on true lateral radiographs. Which of the following radiographic findings defines Dejour Type B dysplasia?

. A shallow trochlear groove with no crossing sign
. A crossing sign with a supratrochlear spur
. A crossing sign with a double contour
. A crossing sign with both a supratrochlear spur and a double contour
. A patella alta with an Insall-Salvati ratio > 1.2

Correct Answer & Explanation

. A crossing sign with a supratrochlear spur

Explanation

In the Dejour classification, Type B dysplasia is characterized by a flat trochlea with a crossing sign and a supratrochlear spur. Type C features a double contour, and Type D features all three (crossing sign, double contour, and supratrochlear spur).

Question 973

Topic: 5. Sports Medicine

A 19-year-old athlete undergoes an isolated medial patellofemoral ligament (MPFL) reconstruction for recurrent lateral patellar instability. During graft fixation on the femoral side, at what knee flexion angle should the graft be tensioned, and what is the consequence of over-tensioning?

. 0 degrees; leads to lateral subluxation in flexion
. 30 degrees; leads to increased medial patellofemoral contact pressures and medial pain
. 60 degrees; leads to patella baja and anterior knee pain
. 90 degrees; leads to early graft failure
. 120 degrees; leads to profound quadriceps weakness

Correct Answer & Explanation

. 30 degrees; leads to increased medial patellofemoral contact pressures and medial pain

Explanation

The MPFL is most taut in full extension and becomes lax as the patella engages the trochlea. The graft should be fixed at 30 degrees of flexion with only enough tension to restore normal lateral translation; over-tensioning risks medial patellofemoral cartilage overload and pain.

Question 974

Topic: Knee Sports

During medial patellofemoral ligament (MPFL) reconstruction, an improperly positioned femoral tunnel that is placed too proximal and anterior to the anatomic footprint will result in which of the following kinematic abnormalities?

. Graft laxity throughout the entire arc of motion
. Graft tightness in knee flexion
. Graft tightness in knee extension
. Recurrent patellar instability in deep flexion
. Excessive lateral patellar tilt in extension

Correct Answer & Explanation

. Graft tightness in knee flexion

Explanation

A femoral tunnel placed too proximal and anterior causes the distance between the femoral and patellar attachments to increase as the knee flexes. This non-isometric placement results in graft overtightening during knee flexion, potentially leading to stiffness and medial cartilage overload.

Question 975

Topic: Knee Sports

A 12-year-old skeletally immature female complains of recurrent patellar instability. MRI reveals a TT-TG (Tibial Tubercle-Trochlear Groove) distance of 24 mm and an intact MPFL. Which of the following surgical interventions is contraindicated in this patient?

. Medial patellofemoral ligament (MPFL) reconstruction with autograft
. Roux-Goldthwait procedure
. Lateral retinacular release
. Tibial tubercle medialization osteotomy
. Medial retinacular imbrication

Correct Answer & Explanation

. Tibial tubercle medialization osteotomy

Explanation

A tibial tubercle osteotomy is absolutely contraindicated in skeletally immature patients due to the high risk of iatrogenic injury to the proximal tibial physis and the tibial tubercle apophysis, which can cause recurvatum deformity.

Question 976

Topic: Knee Sports

A patient with recurrent patellofemoral dislocations has a true lateral knee radiograph demonstrating a "crossing sign" and a prominent "supratrochlear spur." According to the Dejour classification, what type of trochlear dysplasia does this represent?

. Type A
. Type B
. Type C
. Type D
. Type E

Correct Answer & Explanation

. Type B

Explanation

In the Dejour classification, Type B trochlear dysplasia is characterized by a flat trochlea, a crossing sign, and a supratrochlear spur on a true lateral radiograph. Type A has a shallow trochlea, Type C has a convex trochlea with a double contour, and Type D features a cliff pattern.

Question 977

Topic: Knee Sports

When evaluating the anatomic femoral origin of the MPFL on a true lateral radiograph, Schottle's point is best described by which of the following locations?

. 1 mm anterior to the posterior cortical line and just proximal to Blumensaat's line
. 5 mm anterior to the posterior cortical line and distal to Blumensaat's line
. Directly at the center of the adductor tubercle
. Directly at the medial epicondyle
. 10 mm proximal to the adductor tubercle

Correct Answer & Explanation

. 1 mm anterior to the posterior cortical line and just proximal to Blumensaat's line

Explanation

Schottle's point, identifying the radiographic femoral footprint of the MPFL, is located 1 mm anterior to the extension of the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line.

Question 978

Topic: 5. Sports Medicine

A 14-year-old female presents after her first episode of acute lateral patellar dislocation, which spontaneously reduced. MRI shows an intact articular surface without osteochondral loose bodies and a tear of the MPFL at the femoral attachment. What is the most appropriate initial management?

. Immediate MPFL reconstruction with allograft
. Primary repair of the MPFL tear
. Arthroscopic lateral retinacular release
. Short period of immobilization followed by focused physical therapy
. Tibial tubercle medialization

Correct Answer & Explanation

. Short period of immobilization followed by focused physical therapy

Explanation

First-time lateral patellar dislocations without evidence of a massive osteochondral fracture or intra-articular loose bodies are best managed non-operatively with brief immobilization and a rigorous physical therapy program focusing on VMO and core strengthening.

Question 979

Topic: Knee Sports

A 22-year-old female presents with recurrent patellar instability. An axial MRI reveals a TT-TG (Tibial Tubercle-Trochlear Groove) distance of 13 mm. Her patellar height is normal (Caton-Deschamps index = 1.0). Which of the following isolated procedures is the most appropriate surgical option?

. Tibial tubercle medialization (Fulkerson osteotomy)
. Trochleoplasty
. Isolated MPFL reconstruction
. Lateral retinacular release
. Tibial tubercle distalization

Correct Answer & Explanation

. Isolated MPFL reconstruction

Explanation

A TT-TG distance of less than 15-20 mm is considered within the normal to borderline range, indicating that bony malalignment is not the primary driver of instability. In this scenario, an isolated MPFL reconstruction is indicated to restore the primary medial soft tissue restraint.

Question 980

Topic: Knee Sports

Which of the following correctly describes the anatomical femoral attachment of the medial patellofemoral ligament (MPFL)?

. Distal to the adductor tubercle and proximal to the medial epicondyle
. Proximal to the adductor tubercle and distal to the medial epicondyle
. Anterior to the medial epicondyle and proximal to the adductor tubercle
. Directly over the center of the medial epicondyle
. Directly over the center of the adductor tubercle

Correct Answer & Explanation

. Distal to the adductor tubercle and proximal to the medial epicondyle

Explanation

The MPFL femoral origin is located in a saddle-shaped depression between the medial epicondyle and the adductor tubercle. Specifically, it is distal to the adductor tubercle and proximal to the medial epicondyle.

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