5. Sports Medicine MCQs

Discussion: The typical mechanism of injury is a fall where the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance.

Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.

Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances.

The CT scan shows a posterior sternoclavicular joint dislocation. Initial management involves attempted closed reduction in the operating room. This can be performed with a towel clip and anterior translation of the displaced clavicle. However, the orthopaedic surgeon should be prepared to open this injury and reconstruct the joint if necessary. Furthermore, it is recommended that a thoracic surgeon be available prior to beginning these procedures. Open reduction should be done only if closed reduction is unsuccessful.

This scenario describes a chronic, symptomatic pectoralis major tendon rupture in a young laborer. Direct repair is difficult at this time; therefore, allograft reconstruction is a good alternative to recover strength. Tendon transfers, electrical stimulation, shoulder arthrodesis, and arthroscopy are not indicated in this patient. They will not offer proper reconstruction of the lost muscle tendon unit and/or cosmetic repair.

DISCUSSION: The patient has a locked knee that cannot be fully extended. This is most likely the result of the mechanical block of a bucket-handle tear that has flipped into the notch. Also, the pain may be so severe that the muscle spasm prevents the knee from straightening out. When the patient is anesthetized, the muscle spasm relaxes and the meniscus can be reduced out of the notch. Arthroscopy is the treatment of choice. A meniscal repair is usually possible in large bucket-handle tears because the meniscus is torn in the red-red zone where most of the vascular supply is located. If the handle portion is badly frayed or damaged, a partial meniscectomy should be performed. The classic finding on MRI is a “double PCL sign.” This is due to the flipped portion of the meniscus in the notch. REFERENCES: Critchley IJ, Bracey DJ: The acutely locked knee: Is manipulation worthwhile? Injury 1985;16:281-283. Bansal P, Deehan DJ, Gregory RJ: Diagnosing the acutely locked knee. Injury 2002;33:495-498.

DISCUSSION: Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear. REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284. Neviaser RJ, Neviaser TJ, Neviaser JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-106.

Figures A and B show an acute proximal hamstring tendon avulsion. The next best step in management would be open surgical repair of all tendons to their origin at the ischial tuberosity.Athletes participating in sports that require sprinting, jumping, acceleration and deceleration are at increased risk of sustaining a proximal hamstring tendon avulsion. The greatest predictor of this injury is prior hamstring injury. Other risk factors include increasing age, high training demand, increased body mass index and tight hip flexor muscles. MRI is the gold standard imaging to identify these images. Open hamstring tendon repair is recommended in athletes when all of the hamstring tendons have avulsed off their origin or 2 tendons have avulsed and retracted more than 2 cm.Cohen et al. wrote a JAAOS article on acute proximal hamstring rupture. They point out that testing the peroneal branch of the sciatic nerve function is important in the physical examination, as injury to this branch will cause weakness of the short head of the biceps femoris and may slow potential postoperative rehabilitation.Lefevre et al. reviewed the return to sports after surgical repair of acute proximal hamstring ruptures. They performed a prospective observational study that included 34 patients. Patients returned to sports within a mean 5.7 ± 1.6 months, at the same level in 27 patients (79.4 %) and at a lower level in 7 patients (20.6 %). They conclude that surgical repair of acute proximal hamstring ruptures has the potential to significantly improve the functional prognosis of patients with these injuries.Figures A and B shows a significant amount of swelling and hematoma around the hamstring tendon. The whole ischial tuberosity is denuded of tendon, which is consistent with a complete rupture. Illustration A shows a large posterior thigh ecchymosis commonly seen with this injury. The ecchymosis presents approximately 1 week following injury, which is know as latent ecchymosis. Illustration B shows aschematic and intraoperative image of the open tendon repair of an acute injury.Incorrect

A loss of flexion and internal rotation are hallmarks of FAI. With the hip flexed 90 degrees, maximal internal rotation testing is also known as the anterior impingement test, causing deep groin pain and reproduction of symptoms. Occasionally, a posterior impingement test will be positive with extension and external rotation. There are a variety of causes of FAI; however, the pathology limits motion as the femur (cam) and acetabulum (pincer) contact one another. Also, only one location needs to be present, such as cam-type or pincer-type versus both cam-pincer lesions to cause symptoms.

DISCUSSION: Avulsed teeth must be replanted immediately to enhance viability of the periodontal ligament cells on the root. With the tooth in place, the athlete should bite down on a towel to maintain stability. The athlete should be taken emergently to a dentist’s office or emergency room. The avulsed tooth should not be handled by the root or scrubbed to remove debris. If immediate replantation is not possible, the tooth should be transported in saline solution, milk, or saliva on gauze.REFERENCES: Flores MT, Andreasen JO, Bakland LK, et al: Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001; 17:97-102.Ranalli DN, Demas PN: Orofacial injuries from sport preventive measures for sports medicine. Sports Med2002;2:409-418.

DISCUSSION: The semitendinosus and gracilis tendons lie beneath the superficial fascia and superficial to the medial collateral ligament. The semitendinosus is located more inferior to the gracilis tendon. The sartorius is more posterior and distal as is the medial collateral ligament. The semimembranosus is posterior. REFERENCES: Pagnani MJ, Warner JJ, O’Brien SJ, Warren RF: Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest. Am J Sports Med 1993;21:565-571. Warren LF, Marshall JL: The supporting structures and layers on the medial side of the knee: An anatomical analysis. J Bone Joint Surg Am 1979;61:56-62.

DISCUSSION: The patient has synovial chondromatosis. The MRI scans show multiple small proscribed areas of signal intensity in the gutters and suprapatellar pouch, suggesting very small loose bodies. The arthroscopic view shows the classic appearance of multiple small chondral loose bodies. Synovial chondromatosis is a condition in which the synovium undergoes metaplasia, producing multiple chondral loose bodies that can subsequently ossify. The treatment of choice, removal of the loose bodies and arthroscopic synovectomy, results in a lower incidence of recurrence than other treatment methods. REFERENCES: Coolican MR, Dandy DJ: Arthroscopic management of synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br 1989;71:498-500. Ogilvie-Harris DJ, Saleh K: Generalized synovial chondromatosis of the knee: A comparison of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy 1994;10:166-170.

The patient has multidirectional instability (MDI). A redundant capsular pouch is a consistent and reproducible finding in shoulders with MDI.The first line of treatment for shoulder dislocations in patients with MDI should consist of physical therapy aimed at strengthening the rotator cuff and scapular stabilizers. For those who fail to respond to 3 to 6 months of nonsurgical treatment, surgical intervention can be considered with inferior capsular shift being the procedure of choice for multidirectional instability. Good results have been achieved with surgical procedures for posterior and multidirectional instability, but results have been less predictable than those achieved with procedures for traumatic anterior instability.Ide et al. evaluated the results of an 8-week rehabilitation program with shoulder-strengthening exercises and a novel scapular-stabilizing shoulder orthosis in 46 patients with MDI. There was a significant increase in mean total scores on the modified Rowe grading system and mean torque of internal and external rotation with a normalization of mean external/internal torque ratios at the completion of the program. The authors concluded that shoulder strengthening exercises represent auseful treatment option for patients with MDI.Levine et al. reviewed treatments of multidirectional shoulder instability in athletes. Nonoperative management remains the initial treatment of choice. Open capsular shifts remain the operative treatment of choice, however, arthroscopic electrothermal capsulorrhaphy has become increasingly used as an alternative to an open approach.Beasley et al. reviewed multidirectional instability in the shoulder of female athletes. The authors note that women tend to have greater ligamentous laxity than men and female athletes have a greater risk of converting laxity to symptomatic instability.Figure A demonstrates metacarpophalangeal hyperextension, which is a sign of generalized ligamentous laxity.Incorrect Answers:

DISCUSSION: Symptoms can persist following a rotator cuff repair for a variety of reasons. In the early postoperative period, infection is the primary concern. Stiffness and loss of motion can occur because of postoperative scarring. Complex regional pain syndrome can occur but is rare, and the diagnosis is not made with a plain radiograph. This radiograph shows a superiorly migrated humeral head that articulates with the acromion, indicating that the repair has failed. While large to massive tears may fail more commonly than once thought, the clinical outcome may be satisfactory in many patients.

DISCUSSION: The nerve labeled A is the axillary nerve, a branch from the posterior cord. The posterior cord innervates the subscapularis, latissimus dorsi, teres major and minor, deltoid, triceps, anconeus, brachioradialis, and extensors of the forearm. The axillary nerve innervates the teres minor and deltoid. The pectoralis minor is innervated by the medial cord. The supraspinatus and the subclavius are innervated by the superior trunk. The brachialis is innervated by the lateral cord.

Posterior 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, 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 four 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 four 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 Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure isindicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate.

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

DISCUSSION: All of the tissues noted above are stronger than the native ACL. Although it is often thought that the bone-patellar tendon-bone graft is the strongest when selecting a graft source for ACL reconstruction, biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues listed.

In patients older than age 60 years, over 30% of asymptomatic shoulders show MRI findings of full-thickness rotator cuff tears. Therefore, without significant symptoms, surgical treatment is not warranted.

DISCUSSION: The superficial branch of the peroneal nerve travels subcutaneously anterior to the lateral malleolus at the ankle. It can be easily damaged by deep penetration of the knife blade when making this portal or when passing shavers in and out of the portal. Anesthesia or dysesthesia from laceration or neuroma formation can cause significant postoperative morbidity. The anterior tibialis tendon, anterior tibial artery, and the deep peroneal nerve are located much more anterior and central on the ankle. The sural nerve is posterior lateral to the ankle and is not at risk from this portal.