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5. Sports Medicine MCQs

Practice Set 97 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 1921

Topic: 5. Sports Medicine
The radiographs, MRI, and MR arthrogram were obtained from a 24-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. When counseling patients who have a cam deformity, the orthopaedic surgeon should note that:
. osteoarthritis of the hip is likely to occur later in life.
. correction prevents later development of osteoarthritis.
. most acetabular tears are symptomatic, and surgical treatment will be necessary.
. this is an inherited deformity.

Correct Answer & Explanation

. osteoarthritis of the hip is likely to occur later in life.

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 1922

Topic: Knee Sports
What is the most reproducible landmark for the accurate anatomic placement of the tibial tunnel for an anterior cruciate ligament (ACL) reconstruction?
. Anterior border of the tibia
. Anterior border of the posterior cruciate ligament (PCL)
. Posterior border of the tibia
. Posterior border of the anterior horn of the lateral meniscus
. Posterior border of the anterior horn of the medial meniscus

Correct Answer & Explanation

. Anterior border of the posterior cruciate ligament (PCL)

Explanation

The anterior border of the PCL is the most accurate and reproducible landmark for appropriate placement of the tibial tunnel for an ACL reconstruction. The central sagittal insertion point of the ACL is consistently 10 to 11 mm anterior to the anterior border of the PCL ligament. The anterior border of the tibia is not well visualized and does not serve as a reference point. While the posterior border of the anterior horn of the lateral meniscus could be used as a reference point, it has twice the variability of the PCL reference point. The posterior border of the tibia is difficult to identify and has greater variability than the PCL relative to the AP dimension of the proximal tibial surface. The anterior horn of the medial meniscus is also more variable than the PCL.

Question 1923

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?

. 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 <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 >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 1924

Topic: Shoulder & Hip Sports

A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. He continues to experience instability postoperatively. Examination reveals a positive apprehension test. Radiographs of both shoulders are seen in Figure A. CT scan of his left shoulder is seen in Figure B. What is the best treatment option? Review Topic

. Bankart repair
. Humeral head bone augmentation
. Remplissage
. Coracoid autograft
. Connolly procedure

Correct Answer & Explanation

. Bankart repair

Explanation

This patient has anterior glenoid bone deficiency (inverted pear glenoid) from a large bony Bankart lesion that was not adequately addressed in the index procedure. This is best treated with bony augmentation using the Latarjet vascularized coracoid transfer.Patients with glenoid bone defects >20-30% have a high recurrence rate (>60%) after Bankart repair alone. Bone grafting is necessary to offer containment. Autograft options include coracoid transfer (such as the Latarjet procedure which extends the articular arc and creates a conjoined tendon sling) and iliac crest bone grafting.Burkhart et al. addressed glenohumeral bone defects. They advise that significant bone deficits cannot be adequately addressed via arthroscopic Bankart repair alone. The Latarjet transfer creates an extra-articular platform to extend the articular arc of the glenoid.Hantes et al. assessed Latarjet repairs using CT. They found that there is almostcomplete repair of a 25% to 30% glenoid defect when using the Latarjet procedure.Figure A comprises comparison Bernageau view glenoid profile radiographs of both shoulders. Figure B is a 3D reconstruction CT with showing glenoid bone deficiency (inverted pear deformity) with a large bony Bankart lesion. Illustration A shows the method of obtaining a Bernageau glenoid profile view. Illustration B shows the "cliff sign" of anterior glenoid bone loss. Illustration C depicts the Latarjet procedure. Illustration D depicts reduction in the articular arc with anterior glenoid loss.Incorrect Answers:

Question 1925

Topic: 5. Sports Medicine
What is the most important factor regarding the risk of recurrent instability in a patient with an acute anterior dislocation of the shoulder?
. Age of the patient
. Time from injury to reduction
. Completion of 3 weeks of immobilization
. The degree of athletic participation
. Bilateral instability

Correct Answer & Explanation

. Age of the patient

Explanation

The recurrence rate of anterior dislocation of the shoulder after the first episode in athletes younger than age 20 years is thought to be as high as 90%, making surgery after the initial episode a consideration. The rate drops from 50% to 75% in the 20- to 25-year age group and down to 15% in patients older than age 40 years. An excellent prospective study of 257 patients in Sweden showed that there was no difference in those who did or did not complete 3 weeks of immobilization. The study also showed variability among different age groups in the importance of athletic participation; athletes in the 12- to 22-year age group had a higher recurrence rate, whereas the more sedentary patients in the 23- to 29-year age group had a higher rate.

Question 1926

Topic: 5. Sports Medicine
When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surgery would most likely reveal
. significant quadricep weakness in the patellar tendon compared with the hamstring.
. significant quadricep weakness in the hamstring compared with the patellar tendon.
. significant weakness in the hamstring compared with the patellar tendon.
. significant hamstring weakness in the patellar tendon compared with the hamstring.
. no significant difference between the hamstring and the patellar tendon.

Correct Answer & Explanation

. no significant difference between the hamstring and the patellar tendon.

Explanation

Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically. Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength.

Question 1927

Topic: Shoulder & Hip Sports

Figure 23 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain? Review Topic

. Forward elevation in the scapular plane
. External rotation and abduction
. Flexion, adduction, and internal rotation
. Flexion and abduction

Correct Answer & Explanation

. Forward elevation in the scapular plane

Explanation

This patient has a mechanism of injury and MRI consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 1928

Topic: 5. Sports Medicine

A 26-year-old football player develops tachycardia and hot, dry skin during a game. He is found to have a temperature of 41 degrees C, but is not sweating. Further examination reveals the player is not oriented to time or place, and he soon develops convulsions. Which of the following is the most important next step in treatment? Review Topic

. Aggressive administration of IV fluids
. Administer acetaminophen
. Lay him supine with leg elevation
. Rapid cooling with ice immersion
. Administration of IV antibiotics

Correct Answer & Explanation

. Aggressive administration of IV fluids

Explanation

The patient in the vignette has heat stroke; this condition is treated with rapid reduction in core body temperature through the use of ice immersion, cooling blankets, and/or internal cooling for a goal temperature below 39 C.Heat stroke is a medical emergency with a high mortality rate. The hallmark features include central nervous system dysfunction and anhidrosis. Other symptoms include behavioral changes, such as confusion, disorientation, and staggering. Seizures and unconsciousness can also develop. The first modality of treatment is rapid reduction in temperature, which can be accomplished through ice water immersion, cooling blankets, or evaporative cooling methods including fans and cold water sprays. The goal in temperature reduction is 0.2 C per minute for a target temperature of 39 C.Casa et al. reviewed current literature regarding the cause and care of exertional heat stroke. They stated that mortality from heat stroke remained significant, with the highest rates from sports existing between 2005 and 2009. They recommended accurate temperature assessment, prompt aggressive treatment using an efficient cooling modality (i.e. cold water or ice water immersion) prior to transport, and medically supervised return to play/duty as essential to preventing mortality.Illustration A shows some of the visible differences between heat stroke and exhaustion, with the key discriminator being mental status changes present in heat stroke.Incorrect Answers:

Question 1929

Topic: 5. Sports Medicine
A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with
. hamstring strength.
. quadriceps strength.
. a body mass index of less than 30.
. anterior cruciate ligament stability.
. compliance with brace use.

Correct Answer & Explanation

. quadriceps strength.

Explanation

Rehabilitation of the quadriceps muscle following a partial tear of the PCL has been associated with a favorable outcome. The quadriceps acts as an antagonist to the PCL because its contraction results in anterior tibial translation, which reduces the tensile stress on the injured ligament. Strengthening of the hamstring musculature increases posterior tibial translation and is contraindicated during the early rehabilitative phase following a PCL injury. Brace use has not been found to significantly alter the outcome following nonsurgical management of PCL tears.

Question 1930

Topic: 5. Sports Medicine
A 17-year-old football player continues to have discomfort after sustaining a blow to his midthigh during a game 8 weeks ago. A plain radiograph is shown in Figure 13. What is the most appropriate management?
. Immobilization
. Rest with range-of-motion exercises
. Steroid injection
. Excision
. Irradiation

Correct Answer & Explanation

. Rest with range-of-motion exercises

Explanation

The patient has myositis ossificans. Rest of the involved area is important to help limit the continued irritation of the muscle, but range-of-motion exercises are important to limit stiffness. While immobilization for 1 or 2 days following a muscle contusion is appropriate, longer periods of immobilization result in muscle atrophy and fibrosis. Injections and irradiation have not been found to be of benefit for myositis ossificans. Excision is rarely required, and if performed, it should not be performed prior to maturation of the lesion, which is a minimum of 6 months.

Question 1931

Topic: 5. Sports Medicine
A 12-year-old Little League pitcher reports lateral elbow pain and โ€œcatching.โ€ Examination reveals painful pronation and supination and tenderness over the lateral elbow. Radiographs are shown in Figures 22a and 22b. Initial management should consist of
. rest and repeat examination and radiographs until complete healing occurs.
. rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.
. arthroscopic in situ drilling.
. arthroscopic drilling and internal fixation.
. arthroscopy with removal of the loose body, followed by lateral column osteotomy.

Correct Answer & Explanation

. rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.

Explanation

DISCUSSION: Osteochondritis of the capitellum is a common problem in young throwing athletes and gymnasts. The mechanism of injury involves lateral compression and axial loading of the capitellum. Repetitive trauma causes ischemia with resultant osteochondral necrosis and sometimes eventual separation. Initial management includes rest for a minimum of 6 weeks; occasionally bracing is used. At long-term follow-up, there is typically an observed radiographic abnormality indicating incomplete healing even in asymptomatic patients. Arthroscopy with in situ drilling is reserved for symptomatic lesions that have an intact articular surface. Lesions with partial separation often require fixation. Lateral column osteotomy is a new investigational procedure designed to relieve lateral compression forces and may be used in salvage cases.

Question 1932

Topic: 5. Sports Medicine
A 21-year-old collegiate wrestler sustains a blow to his right eye during a match. Examination reveals anisocoria with a dilated right pupil. The globe is properly formed, and extra-ocular movements and the visual field are grossly intact. What is the most likely diagnosis?
. Traumatic mydriasis
. Detached retina
. Dislocated lens
. Corneal abrasion
. Traumatic hyphema

Correct Answer & Explanation

. Traumatic mydriasis

Explanation

DISCUSSION: Traumatic mydriasis occurs from a contusion to the iris sphincter. This is a transient phenomenon during which the iris fails to constrict properly, resulting in a dilated pupil. More severe trauma can result in a tear of the sphincter and permanent pupillary deformity. In association with head injury, traumatic anisocoria would be a concerning indicator of the severity of injury. Retinal detachment, lens dislocation, corneal abrasion, and traumatic hyphema are all potential results of eye injury but are not reflected by this clinical description.

Question 1933

Topic: Shoulder & Hip Sports
A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees greater than the contralateral side. He has pain associated with abduction and external rotation but no apprehension. Which of the following tests would most likely reveal positive findings?
. Impingement injection test
. Lift-off test
. Weakness with โ€œempty-canโ€ abduction test
. Load-and-sift maneuver
. MRI with contrast

Correct Answer & Explanation

. Lift-off test

Explanation

DISCUSSION: Postoperative subscapularis detachment can be identified with a positive lift-off test that reveals weakness in internal rotation. This complication does not necessarily compromise the anterior capsule repair. The load-and-sift maneuver and articular contrast studies may be normal. Supraspinatus tests for impingement and weakness should be negative.

Question 1934

Topic: 5. Sports Medicine
A 40-year-old woman underwent an arthroscopic acromioplasty and mini-open rotator cuff repair 4 weeks ago. At follow-up examination, the incision is painful, erythematous, and draining fluid. The patient is febrile and has an elevated WBC count. What infectious organism should be under high suspicion of causing this outcome?
. Escherichia coli
. Streptococcus viridans
. Oxalophagus oxalicus
. Proprionobacter acnes
. Enterococcus faecalis

Correct Answer & Explanation

. Proprionobacter acnes

Explanation

DISCUSSION: Proprionobacter acnes has been a leading cause of indolent shoulder infections. During shoulder arthroscopy, the arthroscopic fluid may actually dilute the shoulder preparation and lead to a higher rate of infection during subsequent mini-open rotator cuff repair surgery. The remaining bacteria listed are rarely associated with shoulder infections after arthroscopy.

Question 1935

Topic: 5. Sports Medicine
Which of the following primary prognostic factors best predicts the outcome of the knee lesion shown in Figure 22?
. Location
. Size
. Knee stability
. Patient age
. Degree of pain

Correct Answer & Explanation

. Patient age

Explanation

The patient has osteochondritis dissecans. While location, size, and knee stability are all relevant to the overall prognosis, studies have shown that younger patients with open growth plates have a better prognosis of healing when compared with patients who have closed growth plates. The degree of pain is also relevant to treatment, but it is subjective rather than objective and is not as reliable of a prognostic indicator as age.

Question 1936

Topic: Knee Sports

Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures? Review Topic

. Loose body
. Plica
. Displaced meniscus tear
. Torn retinaculum
. Osteochondral defect

Correct Answer & Explanation

. Loose body

Explanation

Synovial folds or plicae are the result of incomplete or partial resorption of the synovial membranes during fetal development of the knee. The arthroscopic view shows a medial patellar plica, which has been noted in 5% to 55% of all individuals but becomes symptomatic in only a small number of patients. Symptoms may include crepitus, pain, snapping, and swelling and often respond to nonsurgical management.

Question 1937

Topic: Shoulder & Hip Sports
A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of
. Fascia lata graft to restore the coracoacromial arch.
. Immediate subscapularis repair.
. Revision arthroplasty with glenoid reaming to centralize the component.
. Revision arthroplasty with increased retroversion in the humeral component.
. Arthroscopic subacromial decompression.

Correct Answer & Explanation

. Immediate subscapularis repair.

Explanation

DISCUSSION: Results of treatment of subscapularis rupture are best when immediate repair is performed. When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary. Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture.

Question 1938

Topic: 5. Sports Medicine
A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of
. Open anterior acromioplasty and rotator cuff repair.
. Arthroscopic acromioplasty.
. Anterior acromioplasty and distal clavicle excision.
. An open Mumford procedure.
. Immobilization in a sling for 4 weeks followed by additional physical therapy.

Correct Answer & Explanation

. Anterior acromioplasty and distal clavicle excision.

Explanation

DISCUSSION: Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.

Question 1939

Topic: 5. Sports Medicine
Figures 8a through 8c show the lateral radiograph and T1- and T2-weighted MRI scans of a 14-year-old soccer player who reports aching thigh pain. The next most appropriate step in management should consist of
. CT of the chest.
. A bone scan.
. A repeat radiograph in 6 to 8 weeks.
. Repeat MRI in 6 to 8 weeks.
. An open biopsy.

Correct Answer & Explanation

. A repeat radiograph in 6 to 8 weeks.

Explanation

DISCUSSION: Although the MRI findings could be misinterpreted as an aggressive soft-tissue process, the periosteal-based ossification on the radiograph in an athlete most likely suggests myositis ossificans. The radiograph should be repeated to see further maturation of the ossification with a typical โ€œzoningโ€ pattern. The zoning pattern is one of peripheral ossification. This is often best seen on a CT scan.

Question 1940

Topic: 5. Sports Medicine

Figure 48 shows the radiograph of a 17-year-old boy who sustained a gunshot wound to his forearm. There is a small entrance wound on the volar surface. The exit wound is dorsal and more than 15 cm in size, with loss of skin and an extensive amount of devitalized muscle hanging out of the wound. Vascular supply to the hand is excellent, the ulnar and median nerves are intact in the hand, but the radial sensory nerve function is absent. After repeated surgical debridements of the wound and bone, definitive treatment for the fracture would most likely be which of the following? Review Topic

. Spanning external fixation of the radius
. Open reduction and internal fixation of the radius with free fibular flap interposition
. Open reduction and internal fixation of the radius with interposed strut allograft
. Open reduction and internal fixation of the radius with massive cancellous allografting
. Open reduction and internal fixation of the radius with massive cancellous autografting

Correct Answer & Explanation

. Spanning external fixation of the radius

Explanation

The injury needs a very complex traumatic reconstruction. After repeat debridements, there will be a very long segmental loss of the radius, with a significant loss of skin and muscle covering the bone. Spanning external fixation represents a good temporary fixation tool but will not be a definitive solution. The preferred procedure is a vascularized fibular graft with associated skin flap from the lateral leg. This surgical option brings healthy vascularized bone and soft-tissue coverage into an area with significant bone and soft-tissue loss. Placement of large quantities of allograft material, especially strut allograft, is generally contraindicated in the setting of open fractures with soft-tissue compromise because of the risk of infection. Internal fixation and massive cancellous autografting is usually limited to one defect of less than 5 cm with intact soft-tissue covering.

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