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 1241
Topic: 5. Sports Medicine
A college basketball player is struck in the eye by a player’s hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of
Correct Answer & Explanation
. administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.
Explanation
DISCUSSION: The athlete has a corneal abrasion. Fluorescein staining identifies the break in the epithelium when examined with ultraviolet light. Topical antibiotics are used as prophylaxis against secondary bacterial infection, and the patch, applied with the lid closed, is used for comfort and to promote epithelial healing. The accompanying symptoms, including pain, tearing, and photophobia, are usually too intense to allow a return to play. Surgery is reserved for a corneal laceration with associated loss of the anterior chamber. While a proper fundoscopic examination may be a consideration, increased intraocular pressure is not typically associated with this injury. Traumatic hemorrhage in the anterior chamber (hyphema) necessitates strict bed rest during the early phases of healing; examination will most likely reveal the red fluid level of blood settling inferiorly in the anterior chamber. It is often associated with increased intraocular pressure. REFERENCES: Brucker AJ, Kozart DM, Nichols CW, et al: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby-Year Book, 1991, pp 650-670. Zagelbaum BM: Treating corneal abrasions and lacerations. Phys Sports Med 1997;25:38-44.
Question 1242
Topic: 5. Sports Medicine
Anaerobic weight training has what effect in a prepubescent 10-year-old male athlete? Review Topic
Correct Answer & Explanation
. It can increase efficiency of muscle action.
Explanation
Although anaerobic weight training in this age group does not lead to muscle hypertrophy, it can increase the efficiency of muscle action by increasing muscle memory. There is insufficient testosterone in this patient population to allow for muscle hypertrophy. Proper techniques of weight training have been shown to be safe and do not damage the growth plates or joints in these individuals.
Question 1243
Topic: 5. Sports Medicine
When reconstructing the anterior cruciate ligament (ACL), what is the most common source of potential autograft failure? Review Topic
Correct Answer & Explanation
. Tunnel position
Explanation
Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause for technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. Although graft choice is an important factor when planning an ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position.
Question 1244
Topic: 5. Sports Medicine
Which of the following nerves is most commonly injured during arthroscopy of the ankle?
Correct Answer & Explanation
. Superficial peroneal and its branches
Explanation
Neurological complications of account for approximately 49.1% of all complications in Ankle Arthroscopy. Nerve injuries resulted from direct trauma of portal placement. Nerves affected in order: 1) Superficial peroneal 2) Sural 3) Saphenous 4) Deep peroneal.
Question 1245
Topic: 5. Sports Medicine
Figure 3 shows the clinical photograph of a wrestler who has an acute mass in his ear. He does not wear protective headgear. The area is mildly tender and without erythema. Management should consist of
Correct Answer & Explanation
. aspiration and compression.
Explanation
DISCUSSION: The patient has an auricular hematoma. This injury is typically related to blunt trauma, occurring in wrestlers who do not use protective headgear. The goal of treatment is to remove the fluid, reapproximate the perichondrium to the underlying articular cartilage, and limit reaccumulation of the fluid in attempt to prevent cartilage necrosis. Aspiration and application of a compressive dressing offers the best chance to achieve this goal. There are no signs of infection such as marked tenderness, erythema, or surrounding edema to justify antibiotic use or irrigation and debridement. The mass does not warrant excision. REFERENCES: Kaufman BR, Heckler FR: Sports-related facial injuries. Clin Sports Med 1997;16:543-562. Griffin CS: Wrestler’s ear: Pathophysiology and treatment. Ann Plastic Surg 1992;28:131-139.
Question 1246
Topic: Shoulder & Hip Sports
A 65-year-old woman sustained an axial load on the arm followed by an abduction injury after falling on ice. Treatment in the emergency department consisted of reduction of an anterior dislocation. She now has a positive drop arm sign and a positive lift-off test. An MRI scan is shown in Figure 9. Based on these findings, management should consist of
Correct Answer & Explanation
. repair of the subscapularis tendon and biceps tenodesis.
Explanation
DISCUSSION: Dislocation of the long head of the biceps tendon is the result of a defect in the region of the rotator cuff interval, coracohumeral ligament-superior glenohumeral ligament pulley, or an associated tear of the medial insertion of the subscapularis tendon. In the case of an intra-articular dislocation of the long head of the biceps tendon associated with a tear of the subscapularis tendon, stabilization of the biceps tendon is difficult in this situation; therefore, biceps release or tenodesis and repair of the subscapularis tendon is the treatment of choice. REFERENCES: Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310. Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654. Walch G, Boileau P: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100-108.
Question 1247
Topic: Shoulder & Hip Sports
What phase of overhead throwing puts the rotator cuff at most risk of injury from internal impingement?
Correct Answer & Explanation
. Late cocking
Explanation
Internal impingement occurs when there is repetitive contact of the posterior superior aspect of the glenoid with the humeral head causing damage to the undersurface of the supraspinatus and anterior aspect of the infraspinatus tendons, as well as posterior superior glenoid labrum. This occurs when the arm is in maximum abduction and external rotation such as during the late cocking phase of the normal throwing motion. The 6 phases of throwing are wind up, early cocking, late cocking, deceleration, and follow through. When the arm is repeatedly placed in the abducted externally rotated position, the anterior capsule can become lax and posterior capsular contractures can develop. When there are kinetic chain abnormalities such as scapular internal rotation or muscle fatigue, there is exacerbation of abnormal anterior humeral head translation and increased contact of the rotator cuff on the posterior glenoid rim, with concomitant increased risk of injuryand symptoms.
Question 1248
Topic: Shoulder & Hip Sports
Figure 41 shows the MRI scan of a 38-year-old weightlifter. What does the arrow on the MRI scan indicate? Review Topic
Correct Answer & Explanation
. Pectoralis major tear
Explanation
Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction.
Question 1249
Topic: 5. Sports Medicine
The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor. Correcr answer : C
Correct Answer & Explanation
. Evidence of presurgical elbow instabilityEnd-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability. Retained hardware from prior surgery was not deemed a contraindication.
Explanation
Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?Elbow arthroscopy with debridementImmobilization and rest for 6 weeksCorticosteroid injectionOpen osteochondral autograft transferOsteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patientswith early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?
Question 1250
Topic: 5. Sports Medicine
What portion of the pitching phase creates forces approaching the tensile limit of the medial collateral ligament?
Correct Answer & Explanation
. Late cocking phase
Explanation
DISCUSSION: The late cocking phase of the overhand throw places a marked valgus moment across the medial elbow. This repetitive force reaches the tensile limits of the medial collateral ligament. REFERENCES: Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995;23:233-239. Lynch JR, Waitayawinyu T, Hanel DP, et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg 2008;33:430-437.
Question 1251
Topic: 5. Sports Medicine
A 16-year-old swimmer has right shoulder pain with activity. She describes the continued sensation that her shoulder is “loose.” She has been in physical therapy for 7 months to work on strengthening the muscles around her shoulder and scapula. She denies being able to voluntarily dislocate her shoulder. Upon examination, you can feel the humeral head slide over the glenoid rim both anteriorly and posteriorly with the load and shift test. She has a grade III sulcus sign. What is the most appropriate next step?
Correct Answer & Explanation
. Capsulorrhaphy
Explanation
DISCUSSION: Nonsurgical treatment with activity modification and physical therapy is generally considered the first-line approach for young athletes with multidirectional instability (MDI) of the shoulder. Physical therapy focuses on exercises to strengthen the scapular stabilizers and rotator cuff muscles and restore scapulohumeral rhythm. Although a definitive length of time to assess physical therapy failure is not known, many surgeons believe that a patient with MDI should undergo at least 6 months of physical therapy and activity modification before considering surgery. Although an open inferior capsular shift has historically been considered the gold standard for surgical treatment for MDI, studies have shown good success rates for arthroscopic capsulorrhaphy. Arthroscopy can allow a surgeon to assess all intra-articular structures and address a patient’s particular problem based on arthroscopic findings.
Question 1252
Topic: 5. Sports Medicine
Which of the following factors is most critical to the success of a meniscal allograft transplantation?
Correct Answer & Explanation
. Accurate graft size
Explanation
Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient’s cells (at least peripherally) within several weeks. Thus,cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated.
Question 1253
Topic: Knee Sports
An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?
Correct Answer & Explanation
. Valgus-producing high tibial osteotomy (HTO)
Explanation
The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman test. Physical therapy and bracing will have little effect.
Question 1254
Topic: Shoulder & Hip Sports
A 25-year-old volleyball player reports pain and clicking in his dominant shoulder during overhand serving. Three months of physical therapy fail to provide relief. Radiographs are normal, and an MRI scan is shown in figures 18a and 18b. Atrophy and weakness are most likely to be localized to which of the following muscles?
Correct Answer & Explanation
. Infraspinatus
Explanation
The MRI of the shoulder shows multiple ganglion type cysts of the genoid labrum. These cyst have a correlation with overhead type repeative motion. It has been suggested in the volleyball players that the rapid deceleration after a spike can lead to a SLAP(superior labral) lesion. This in turn can lead to genoid cyst formation. Now remember that the suprascapular nerve comes off the superior trunk of the Brachial plexus, goes under the superortransverse scapular ligament (in the scapular notch, nerve under artery above). It then descends right behind the posterior glenoid/labrum. Therefore, a large cyst in this area will impinge/entrap the nerve. This nerve supplies the infraspinatus muscle and over time will give you atrophy/ pain of this muscle. 87.
Question 1255
Topic: Shoulder & Hip Sports
What is the most likely complication after surgical treatment in this scenario?
Correct Answer & Explanation
. Shoulder stiffness
Explanation
DISCUSSIONPosterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, and internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through as seen in this patient.The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The 4 muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the 4 rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation.This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Brighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion, a posterior opening-wedge osteotomy is appropriate.The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability and degenerative joint disease.
Question 1256
Topic: Shoulder & Hip Sports
A 35-year-old man presents one week after an acute right shoulder posterior dislocation after being electrocuted. He is evaluated in the emergency department and undergoes closed reduction. The patient reports global right shoulder pain and limited active and passive range of motion. He has mild anterior and lateral bruising. He is distally neurovascularly intact. Current radiographs and an MRI scan are shown in Figures 1 through 3. What is the best next step?
Correct Answer & Explanation
. Hemiarthroplasty
Explanation
A 68-year-old man presents with chronic progressive right shoulder pain and loss of motion. He has active shoulder elevation of 120° and 5-/5 shoulder forward flexion strength limited by pain. He has exhausted nonsurgical management over the past year and is now interested in surgical intervention. Figure 1 is the preoperative axial CT scan of his shoulder. During surgical reconstruction, the surgeon should anticipate the location of maximal glenoid erosion to be
Question 1257
Topic: Shoulder & Hip Sports
Which of the following statements best describes labral tears in the hip?
Correct Answer & Explanation
. They commonly occur in the posteroinferior quadrant of the hip.
Explanation
DISCUSSION: Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability.The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.REFERENCES: Beck M, Kalhor M, Leunig M, et al: Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018.Ito K, Leunig M, Ganz R: Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res 2004;429:262-271.Crawford MJ, Dy CJ, Alexander JW, et al: The 2007 Frank Stinchfield Award. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res 2007;465:16-22.
Question 1258
Topic: 5. Sports Medicine
A 10-year-old boy tripped as he was running down a hill, felt a painful pop in his right knee, and was unable to bear weight on the involved lower extremity. Examination reveals a tense effusion and an extensor lag of the right knee. Figures 36a and 36b show AP and lateral radiographs. Management should consist of:
Correct Answer & Explanation
. Open reduction and internal fixation.
Explanation
DISCUSSION: The examination and radiographs are consistent with a sleeve fracture of the patella, which is an avulsion fracture of the distal pole of the patella with a disruption of the extensor mechanism. Treatment is open reduction and internal fixation of the patella, and repair of the extensor mechanism. The distal fragment can be much larger than it appears on the radiographs because it consists largely of cartilage.
Question 1259
Topic: 5. Sports Medicine
Examination of an 18-year-old professional soccer player who was forcefully kicked across the shin while attempting a slide tackle reveals a marked effusion and limited motion of the knee. The tibia translates 12 mm posterior to the femoral condyles when the knee is held in 90 degrees of flexion. There is no posteromedial or posterolateral instability. Management should consist of
Correct Answer & Explanation
. knee immobilization in full extension for 2 to 4 weeks.
Explanation
DISCUSSION: The patient has an acute grade III posterior cruciate ligament injury. The majority of grade I and II injuries can be treated with protected weight bearing and quadriceps rehabilitation, and most patients can return to sports within 2 to 4 weeks. In contrast, grade III injuries require immobilization in full extension for 2 to 4 weeks to protect the posterior cruciate ligament and the other posterolateral structures presumed to be damaged. The mainstay of postinjury rehabilitation for all posterior cruciate ligament injuries is quadriceps strengthening exercises, which have been shown to counteract posterior tibial subluxation. REFERENCES: Miller MD, Bergfeld JA, Fowler PJ, Harner CD, Noyes FR: The posterior cruciate ligament injured knee: Principles of evaluation and treatment. Instr Course Lect 1999;48:199-207. Posterior Cruciate Ligament Injuries in Principles and Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott, Williams and Wilkins, 2000.
Question 1260
Topic: 5. Sports Medicine
Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a gunshot wound to his knee. What is the most appropriate definitive surgical management for his articular cartilage defect?
Correct Answer & Explanation
. Osteochondral allograft transfer
Explanation
The images show a full-thickness cartilage defect with significant bony involvement >4 cm2. Microfracture should be considered for lesions <2 cm2without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm2, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia andwould not be indicated in this case.
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