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5. Sports Medicine MCQs

Practice Set 83 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 1641

Topic: 5. Sports Medicine
The mother of a healthy 8-month-old boy reports that her son refuses to use his left arm. Examination reveals that the arm hangs limp at his side in an adducted and internally rotated position, and the affected shoulder subluxates posteriorly. Passive external rotation measures 15 degrees. Management should consist of
. release of the latissimus dorsi and teres major.
. release of the subscapularis and pectoralis major.
. passive range-of-motion exercises.
. exploration of the brachial plexus.
. functional bracing.

Correct Answer & Explanation

. passive range-of-motion exercises.

Explanation

DISCUSSION: Injury to the upper trunk of the brachial plexus during birth (Erb’s palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered.

Question 1642

Topic: 5. Sports Medicine

When comparing arthroscopic and open rotator cuff repairs, which of the following tears shows a decreased recurrent tear rate in the open versus the arthroscopic group? Review Topic

. Partial-thickness tears
. Tears less than 1 cm in width
. Tears between 1 and 2 cm in width
. Tears greater than 3 cm in width
. Tears showing retraction medial to the glenoid

Correct Answer & Explanation

. Partial-thickness tears

Explanation

As a tool for rotator cuff repair, arthroscopy has afforded surgeons the ability to repair tears without causing potential morbidity to the overlying deltoid. Follow-up studies looking at functional recovery have now shown equivalent or slightly better outcomes with arthroscopic procedures versus standard open procedures. However, small tear size may serve as a better predictor of success with arthroscopic approaches. Imaging studies have shown a higher rate of tear recurrence and/or failure of healing when tears greater than 3 cm in size are repaired arthroscopically versus a standard open approach.

Question 1643

Topic: Knee Sports
An 18-year-old football player lands on a flexed knee and ankle after being tackled. Examination reveals increased external rotation and posterior translation and varus at 30° of flexion, which decreases as the knee is flexed to 90°. What is the most likely diagnosis?
. Torn posterolateral corner
. Torn posterior cruciate ligament (PCL) and posterolateral corner
. Torn PCL
. Rupture of the quadriceps tendon
. Rupture of the lateral collateral ligament

Correct Answer & Explanation

. Torn posterolateral corner

Explanation

DISCUSSION: The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury. The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule). This results in increased posterior translation and external rotation, as well as varus that is most notable at 30° of flexion and decreases as the knee is further flexed to 90°. Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90° from 30°, while isolated PCL tears show the greatest degree of instability at 90° of flexion. A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30° of knee flexion without posterior translation.

Question 1644

Topic: Shoulder & Hip Sports

Figure 7 is the MR image of a 43-year-old man who has left shoulder pain with a traumatic rotator cuff tear after a fall. An examination reveals active forward elevation at 120 degrees and positive Yergason and lift-off test results. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

. Rotator cuff repair and biceps tenodesis
. Rotator cuff repair and loose body removal
. Latissimus dorsi transfer
. Bankart repair

Correct Answer & Explanation

. Rotator cuff repair and biceps tenodesis

Explanation

DISCUSSIONVideo 7 for referenceThe MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 1645

Topic: Knee Sports
A 26-year-old man has recurrent right knee pain. Figures 9a and 9b show consecutive sagittal T2-weighted MRI scans, and Figure 9c shows a coronal T1-weighted MRI scan. What is the most likely diagnosis?
. Bucket-handle tear of the lateral meniscus
. Medial meniscus tear
. Discoid lateral meniscus
. Posterior cruciate ligament tear
. Normal MRI of the knee

Correct Answer & Explanation

. Discoid lateral meniscus

Explanation

DISCUSSION: A discoid meniscus is a large disk-like meniscus. It is seen in the lateral meniscus in 3% of the population; a discoid medial meniscus is much less common. It can be identified on the coronal view by noting meniscal tissue extending into the tibial spine at the intercondylar notch. The average width of a normal meniscus is less than 11 mm. A bow-tie appearance should not be seen on more than two consecutive sagittal images because the conventional thickness of the sagittal slices is 3 mm and the interval between two consecutive slices is 1.5 mm. Two sagittal slices will cover a 9-mm thickness. A discoid meniscus can be diagnosed on the sagittal views by noting a bow-tie appearance on more than two consecutive images.

Question 1646

Topic: 5. Sports Medicine

A 61-year-old right-hand-dominant woman falls down the stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous sedation is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?

. Open reduction internal fixation with transosseous sutures
. Arthroscopic fixation using a suture bridge technique
. Nonsurgical treatment with early passive range of motion
. Nonsurgical treatment with sling immobilization for 4 weeks

Correct Answer & Explanation

. Open reduction internal fixation with transosseous sutures

Explanation

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive rangeof motion is important to avoid stiffness.

Question 1647

Topic: 5. Sports Medicine
Figure 45 shows the lateral radiograph of a 19-year-old swimmer who has had back pain for the past 2 months. What is the most likely diagnosis?
. Disk degeneration
. Limbus fracture
. Degenerative retrolisthesis of L4-5
. Spondylolysis
. Osteoid osteoma

Correct Answer & Explanation

. Spondylolysis

Explanation

The patient has a pars interarticularis defect of L5 without apparent listhesis. The other diagnoses are not present.

Question 1648

Topic: 5. Sports Medicine

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by

. onset most often by age 30.
. a temporary state of neuronal and axonal derangement.
. manifestations of affect such as apathy, irritability, and suicidal ideation.
. absence of gross pathological brain changes upon autopsy.

Correct Answer & Explanation

. onset most often by age 30.

Explanation

CTE is a neurodegenerative disease that occurs years or decades after recovery from acute or postacute effects of head trauma. The exact relationship between concussion and CTE is not entirely clear; however, early behavioral manifestations of CTE have been described by family and providers to include apathy, irritability, and suicidal ideation. For some patients, cognitive difficulty such as poor episodic memory and executive function may be the first signs of CTE. Onset most often occurs in midlife after athletes have completed their sports careers, with mean age of onset at 42 years. The effects on the brain are degenerative, leading to a permanent state of derangement. Autopsy findings demonstrate multiple gross pathological findings. The condition is more common among contact athletes.

Question 1649

Topic: Shoulder & Hip Sports
  • A right-handed 35-year old man who underwent a Putti-Platt repair for recurrent anterior instability 20 years ago now has increasing shoulder pain and stiffness. Examination of the shoulder reveals internal rotation to the posterior superior iliac spine and external rotation to 10 degrees with the shoulder adducted. The supraspinatus and infraspinatus are moderately atrophied. What is the most likely diagnosis?
. C5 radiculopathy
. Subscapularis rupture
. Glenohumeral arthrosis
. Rotator cuff arthropathy
. Suprascapular nerve compression at the spinoglenoid notch

Correct Answer & Explanation

. C5 radiculopathy

Explanation

Osteoarthrosis of the glenohumeral joint is a potential late complication of the anterior Putti-Platt capsulorrhaphy. Disabling pain in the shoulder began an average of 13.2 after a Putti-Platt repair that had been done for recurrent anterior unidirectional instability. Osteoarthrosis of the glenohumeral joint resulted in substantial limitation of motion. Complications of the Putti-Platt surgery include persistent pain, recurrent subluxation or dislocation, or residual weakness of the shoulder; paresthesias of the musculocutaneous nerve, and infection. This late complication develops when the repair is excessively tight, a 20-25 degree limitation of full external rotation is desired and expected after rehabilitation. The most direct correlation with the severity of osteoarthrosis was the degree of limitation of external rotation.

Question 1650

Topic: Shoulder & Hip Sports

A 48-year-old man undergoes arthroscopy to repair a rotator cuff tear. During the arthroscopy, the tear is characterized and found to involve the entire supraspinatus and a majority of the infraspinatus tendons. After mobilization, the posterior rotator cuff can reach the greater tuberosity. However, the supraspinatus tendon cannot reach its insertion point at the greater tuberosity. What is the most appropriate treatment? Review Topic

. Conversion to a latissimus dorsi muscle tendon transfer
. Acromioplasty and coracoacromial ligament release
. Reverse acromioplasty (tuberoplasty)
. Reverse total shoulder arthroplasty
. Partial repair of the rotator cuff

Correct Answer & Explanation

. Conversion to a latissimus dorsi muscle tendon transfer

Explanation

If a complete rotator cuff repair is not possible, a partial rotator cuff repair should still be considered and is the appropriate treatment for this patient. In patients with an irreparable massive rotator cuff tear, acromioplasty with coracoacromial ligamentrelease, reverse acromioplasty, and tenotomy of the biceps tendon may improve shoulder pain. If these procedures fail, then a muscle transfer procedure can also be considered in select patients. If, however, a portion of the rotator cuff can be repaired, even partial repair can balance the coronal and axial forces about the shoulder to restore the kinematics of the joint. Reverse total shoulder arthroplasty is not appropriate for this relatively young patient.

Question 1651

Topic: 5. Sports Medicine

An 18-year-old collegiate football player injures his right shoulder during a tackle. He reports pain and numbness in the shoulder and numbness radiating to his fingers. His symptoms improve within 15 minutes and he has no residual symptoms. This condition is best known as Review Topic

. acute and transient spinal cord injury.
. central cord syndrome.
. nerve root avulsion.
. Guillain-Barre syndrome.
. stinger/burner.

Correct Answer & Explanation

. acute and transient spinal cord injury.

Explanation

The condition described in this case is known as a stinger or burner. It is caused by stretching the upper trunk of the brachial plexus in the C5 and C6 nerve roots. The symptoms are temporary and last 15 to 20 minutes. There are no residual deficits, unless the patient has had multiple repetitive injuries. Once motor and sensory examination findings and reflexes have normalized, the athlete can return to play. Acute spinal cord injury may cause temporary complete paralysis in the upper and lower extremities with resolution of symptoms within 24 hours. Central cord syndrome affects the upper more than lower extermities and affects mostly elderly patients. Nerve root avulsions lead to permanent deficits and have a poor prognosis for return of function. Guillain-Barre syndrome is an autoimmune disease that presents as an ascending paralysis with weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes.

Question 1652

Topic: 5. Sports Medicine
A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?
. Immobilization in a sling and swathe
. Open capsular shift
. Arthroscopic capsular plication
. Thermal capsulorrhaphy
. Physical therapy and home exercises

Correct Answer & Explanation

. Physical therapy and home exercises

Explanation

Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.

Question 1653

Topic: 5. Sports Medicine
Figures 52c and 52d show the proton density fat-saturated MRI scans. Treatment at this stage includes arthroscopy and
. early functional rehabilitation.
. proximal realignment alone.
. attempted internal fixation.
. medial collateral ligament (MCL) repair.

Correct Answer & Explanation

. attempted internal fixation.

Explanation

This patient’s examination indicates a patellar or peripatellar knee injury. Initial evaluation with radiographs will assess for fracture, subluxation, or osteochondral injury. Examination findings did not demonstrate a need for emergent surgery, an MRI scan, or an ultrasound, so radiographs are the initial diagnostic imaging choice. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of obvious nondisplaced fracture or physeal changes. In suspected patella dislocation or subluxation with loose fragment seen on radiographs, an MRI scan is indicated. Lateral release alone is seldom indicated in a knee that was normal before injury. Acute proximal realignment has not been shown to alter long-term outcomes for first-time dislocators. The examination and MRI scan did not indicate a need for MCL repair. Closed reduction of the osteochondral fragment would not be indicated or appropriate for this injury. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed.

Question 1654

Topic: Knee Sports
What is the most anatomic location for placement of the femoral tunnel in anterior cruciate ligament reconstruction?
. As far superior in the notch as possible
. As far posterior as possible on the lateral femoral condyle
. As far posterior as possible on the medial femoral condyle
. Directly across from the posterior cruciate femoral insertion
. At resident’s ridge

Correct Answer & Explanation

. As far posterior as possible on the lateral femoral condyle

Explanation

It is critical for graft isometry and knee stability that the femoral tunnel be placed as far posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the one o’clock position on the left knee. Resident’s ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement results in a variety of complications, including an unstable knee, early graft failure, and joint stiffness.

Question 1655

Topic: Knee Sports

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear? Review Topic

. Failure
. Intra-articular synovitis
. Peroneal nerve injury
. Saphenous nerve injury
. Arthrofibrosis

Correct Answer & Explanation

. Failure

Explanation

All of the answers are possible complications of meniscal repair. There are large volumes of literature evaluating the results of meniscal repair, both for the all-inside technique, as well as the inside-out technique. Failure rates are similar. Intra-articular synovitis occurs with absorbable sutures and absorbable implants. Peroneal nerve injuries are more common with the lateral-sided repairs. Saphenous nerve injuries are more common with medial-sided tears. Because of the incision required and the technique of tying over soft tissue, the risk of a saphenous nerve injury is greater with an inside-out technique than with an all-inside technique.

Question 1656

Topic: 5. Sports Medicine

A 12-year-old boy has a head-on head collision while playing soccer. He had no loss of consciousness but has persistent headaches for 2 weeks. The patient is now back to school and has no headaches. What is the best next step?

. Return to full soccer activity
. Start light aerobic activity
. Obtain baseline neuropsychological testing
. MRI scan of the brain

Correct Answer & Explanation

. Return to full soccer activity

Explanation

Mild traumatic brain injury is common in the adolescent child. Neuropsychological examination is widely used but, in this case, the patient is asymptomatic and has no baseline testing. There is a limited role for MRI in the recovery process of concussions. Furthermore, higher levels of physical/cognitive activity should be avoided due to their potential to increase total recovery time. In this scenario, a graduated return to activity is most appropriate thus, the next appropriate step is to start light aerobic activity.

Question 1657

Topic: Shoulder & Hip Sports

Figure 1 is the MRI scan of a 19-year-old man who has an acute anterior shoulder dislocation. The bony fragment occupies 10% of the glenoid articular surface. What is the most appropriate treatment? Review Topic

. Open structural iliac crest graft
. Open reduction and internal fixation
. Arthroscopic coracoid transfer
. Arthroscopic repair incorporating the bone lesion

Correct Answer & Explanation

. Open structural iliac crest graft

Explanation

The MRI scan shows a bony Bankart lesion involving less than 20% of the glenoid joint surface. A recent series reported high success rates after arthroscopic treatment when the defect is incorporated into the repair. Anterior bony deficiencies occupying more than 25% to 30% of the glenoid joint surface treated with soft-tissue repair only are associated with high recurrence rates. In these patients, an open or arthroscopic coracoid transfer or structural iliac crest graft should be considered. Open reduction and internal fixation has been reported for treatment of large acute glenoid rim fractures but is not recommended for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.

Question 1658

Topic: 5. Sports Medicine
A professional baseball player has had intermittent, mild shoulder pain for the past 2 years. Nonsurgical management has consisted of anti-inflammatory drugs. Examination reveals atrophy of the infraspinatus muscle but not the supraspinatus. There is weakness in external rotation with the arm at his side but not at 90 degrees of abduction. He has no weakness or pain with resisted abduction. Electromyography confirms an isolated lesion of the suprascapular nerve branch to the infraspinatus. He is otherwise neurologically intact. An MRI scan of the shoulder shows no cysts but confirms atrophy of the infraspinatus muscle. What is the next most appropriate step in management?
. Immediate MRI of the brain
. Physical therapy and observation
. Subacromial injection
. Decompression of the suprascapular nerve at the suprascapular notch
. Decompression of the infraspinatus branch of the suprascapular nerve at the spinoglenoid notch

Correct Answer & Explanation

. Physical therapy and observation

Explanation

DISCUSSION: Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered.

Question 1659

Topic: 5. Sports Medicine
A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals a 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of
. a lateral patellar restraining brace for practice and competition.
. arthroscopic lateral retinacular release.
. open medial retinacular plication.
. medial tibial tubercle transfer.
. Maquet tibial tubercle elevation.

Correct Answer & Explanation

. arthroscopic lateral retinacular release.

Explanation

The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis.

Question 1660

Topic: Shoulder & Hip Sports
A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping. What diagnostic test is most appropriate when planning revision surgery?
. CT scan with 3D reconstructions
. Ultrasonography
. MRI scan
. Fluoroscopically-guided arthrogram

Correct Answer & Explanation

. CT scan with 3D reconstructions

Explanation

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting.

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