AAOS Sports Medicine MCQs: Knee & Shoulder Injuries

Question 1

Figure 11 shows the radiograph of an 18-year-old soccer player who reports recurrent lateral foot pain after sustaining an inversion injury. History reveals that 6 months ago he had been treated in a non-weight-bearing cast for a fifth metatarsal fracture. Management should consist of

Explanation

Fractures in this area of the fifth metatarsal have a high incidence of delayed union, nonunion, and recurrence with nonsurgical management. In an acute fracture, prolonged casting in a non-weight-bearing cast may allow for healing; however, in the presence of prolonged symptoms, recurrent fracture, and intermedullary sclerosis, surgical treatment is preferred. Surgery most commonly consists of intermedullary fixation or medullary curettage and bone grafting, followed by application of a non-weight-bearing cast. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am 1984;66:209-214.

Question 2

Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?

Explanation

Evidence has shown that PNF is the treatment of choice to increase joint range of motion and flexibility. PNF has the advantage of pushing the patient to stretch a little further when the muscle tendon unit is relaxed by a partner. While isokinetic and eccentric exercises can improve flexibility, and therefore increase range of motion, their main purpose is to increase strength and endurance. Ballistic stretching involves a large load applied rapidly; however, evidence has shown that static stretching, where a low load is applied for a long duration, offers a more significant benefit. Sady SP, Wortman M, Blanke D: Flexibility training: Ballistic, static or proprioceptive neuromuscular facilitation? Arch Phys Med Rehabil 1982;63:261-263. Tanigawa MC: Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Phys Ther 1972;52:725-735.

Question 3

The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

Explanation

The arthroscopic view shows a HAGL lesion. With the arthroscope directed anteroinferiorly, muscular striations of the subscapularis can be visualized through the avulsion site. In vitro strain studies indicate that glenohumeral ligament failure on the humeral side occurs in approximately 25% of patients, while clinically this lesion has been reported in approximately 9% of patients with shoulder instability. Failure to recognize and treat this lesion leads to persistent anterior instability. An ALPSA lesion, a Bankart variant, occurs on the glenoid side and is characterized by a sleeve-like medial retraction and inferior rotation. A Bankart lesion is the classic avulsion of the glenohumeral ligament from the glenoid rim. The subscapularis tendon and the rotator interval are not shown in the figure. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. Bigliani LU, Pollack RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.

Question 4

An 18-year-old football player has intense pain and is unable to bear weight on the right knee after being tackled from the front. A posterior knee dislocation is reduced on the field. Because the game took place in a remote location, the patient is not examined in the emergency department until 5 hours after the injury. Examination now shows a grossly swollen knee with moderate ischemia in the lower leg. Posterior tibial and dorsalis pedis pulses are diminished. The best course of action should be to

Explanation

Vascular injuries occur in approximately 20% to 35% of knee dislocations, of which one third are posterior. Recognition of the vascular injury is essential. Normal pulses or normal capillary refill do not preclude an arterial injury, and arteriography should be considered in all knee dislocations. If the leg is ischemic, the arteriogram should be circumvented and the patient taken directly to the operating room. The risk of muscle fibrosis, contracture, or vascular insufficiency, and the need for amputation increase significantly when ischemia exceeds 6 hours. This patient has ischemia and is considered a vascular emergency. As such, delays for a thorough examination of the ligament, MRI scans, and even an arteriogram are unwarranted. Concurrent ligamentous repair and reconstruction should be deferred until vascular stability has been achieved. Kremchek TE, Welling RE, Kremchek EJ: Traumatic dislocation of the knee. Orthop Rev 1989;18:1051-1057.

Question 5

A 17-year-old football player is unable to flex the distal interphalangeal (DIP) joint of his ring finger. He states that he injured the finger 6 weeks ago while attempting to tackle another player who pulled free from his grip, but he did not inform his coach at the time of the injury. Current radiographs show an observable fleck of bone volar to the base of the proximal phalanx. Treatment should consist of

Explanation

Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury. Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 6

A 48-year-old ski instructor dislocates his nondominant shoulder in a fall. Management consisting of application of a sling for 1 week results in improvement in his pain. Follow-up examination 6 weeks after the injury reveals that the patient continues to have difficulty with shoulder elevation. Management should now include

Explanation

Patients who are older than age 45 years and have initial dislocations are at greater risk for tearing the rotator cuff. Patients who are unable to lift the upper extremity or who have continued pain should undergo further evaluation for potential rotator cuff tears; early diagnosis is preferred. Physical therapy or continued use of a sling will be of little benefit. A corticosteroid injection might delay the diagnosis and compromise subsequent rotator cuff repair. Repairing the labrum generally is not necessary in a patient of this age who has an initial dislocation. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.

Question 7

Figure 13 shows the MRI scan of a 29-year-old rock climber who reports increasing shoulder pain and weakness. Based on these findings, atrophy will most likely occur in which of the following muscles?

Explanation

The MRI scan shows a cyst at the spinoglenoid notch. These cysts are often associated with a labral injury, such as a superior labrum anterior and posterior (SLAP) lesion. The suprascapular nerve passes through the suprascapular notch and sends motor branches to the supraspinatus and sensory branches to the capsule. At the spinoglenoid notch, the infraspinatus branch of the suprascapular nerve is compressed by the cyst, leading to isolated infraspinatus atrophy. The teres minor and the deltoid are innervated by the axillary nerve. Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature. Arthroscopy 1995;11:727-734. Ianotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.

Question 8

A 46-year-old man has acute tenderness along the ulnar aspect of the wrist after falling on his outstretched hand while playing basketball. Examination reveals tenderness and mild swelling along the volar ulnar aspect of the wrist. Radiogaphs are shown in Figures 14a through 14c. Management should consist of

Explanation

The PA view of the wrist shows a pisiform fracture. Pisiform fractures constitute 1% to 3% of all carpal bone fractures. This fracture can be further evaluated with a carpal tunnel view or a supination oblique view of the wrist. Initial management should consist of immobilization with a short arm cast. If nonsurgical measures fail, bony excision is warranted. Failla JM, Amadio PC: Recognition and treatment of uncommon carpal fractures. Hand Clin 1988;4:469-476.

Question 9

A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight. He now reports pain in the anterior aspect of the arm that worsens when he opens a door. Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa. The MRI scans are shown in Figures 15a and 15b. If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of

Explanation

A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load. A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination. The treatment of choice is a direct primary repair by a two-incision technique. If left unrepaired, the most disabling consequence is the loss of forearm supination strength. It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated. Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic. D'Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.

Question 10

Figure 16 shows the lateral radiograph of a patient who is scheduled to undergo an anterior cruciate ligament (ACL) reconstruction. If the graft is tensioned at 20 degrees of flexion and the femoral tunnel is created by passing a reamer over the guide wire marked "A," the resulting ligament reconstruction will excessively

Explanation

If the femoral tunnel is created using guide wire A, it will be too far anterior in the intercondylar notch. The distance between a central tibial insertion for the ACL and an anterior femoral tunnel will progressively increase as the knee is flexed. Therefore, if the graft is tensioned near extension, the ligament will excessively tighten as the knee flexes past 90 degrees. This will result in restricted knee flexion or failure of the graft as full flexion is gained. There will be little effect on the ligament as it extends from 20 degrees to 0 degrees of flexion. If the graft is tensioned in significant flexion (greater than 60 degrees), it will be excessively loose as the knee fully extends. Daniel DM, Fritschy D: Anterior cruciate ligament injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, WB Saunders, 1994, pp 1313-1360.

Question 11

Which of the following nerves is most commonly injured during revision surgery following a Bristow procedure?

Explanation

Because of the previously transferred bone block of coracoid and short arm flexors, the musculocutaneous nerve often scars along the anteroinferior glenohumeral capsule. Mobilization of this tissue places the nerve at greatest risk. The axillary nerve is also potentially at risk, but this is nonspecific to prior surgery, particularly the Bristow procedure. Norris TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complications of Shoulder Surgery. Baltimore, MD, Williams and Wilkins, 1993, pp 98-116.

Question 12

A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season. An MRI scan confirms a complete ACL tear with no meniscal injuries. The patient plans an early return to play and would like to avoid surgery. Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in

Explanation

While there are athletes who can function at a full level with an ACL tear, they are in the minority. As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL. Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports. One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season. Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability. Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.

Question 13

A patient underwent anterior stabilization of the shoulder 6 months ago, and examination now reveals lack of external rotation beyond 0 degrees. The patient has a normal apprehension sign and normal strength, and the radiographs are normal. Based on these findings, the patient is at greater risk for the development of

Explanation

Because the patient's shoulders are overtensioned anteriorly, premature osteoarthritis may develop. This may create obligate translation posteriorly and increase the interarticular pressure of the humeral head against the glenoid. Patients should achieve 20 degrees to 30 degrees of external rotation with the elbow at the side. Late degenerative arthritis following a Putti-Platt procedure is associated with significant restriction of external rotation. This patient's shoulder has a reduced risk of anterior instability, rotator cuff tear, and internal impingement because of the limitation of motion. Hawkins RJ, Angelo RL: Glenohumeral osteoarthritis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.

Question 14

A 13-year-old girl who competes in gymnastics reports the insidious onset of lateral left elbow pain over the past 6 months. She also notes occasional catching episodes in the elbow; however, she denies any history of trauma. Examination reveals tenderness over the lateral epicondyle and extensor muscle origin. The elbow is stable and has full flexion, but lacks 10 degrees of full extension. An AP plain radiograph and an MRI scan are shown in Figures 17a and 17b. Management of the elbow should consist of

Explanation

The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient's history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater. Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-530. Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast's elbow. Arthroscopy 1989;5:129-136.

Question 15

A 25-year-old man injures his shoulder while skiing. Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test. What is the most likely diagnosis?

Explanation

A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

Question 16

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

Explanation

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. 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.

Question 17

In patient selection for meniscal allograft transplantation, which of the following variables has the greatest influence on outcome?

Explanation

Many clinical studies to date show that the extent of arthritis is the most common variable that has the greatest influence on outcome. The success rate of allograft transplantation is significantly diminished in patients who have grade IV chondromalacia of the knee or notable flattening and general joint incongruity. Carter TR: Meniscal allograft transplantation. Sports Med Arthroscopy Rev 1999;7:51-63. Garrett JC: Meniscal transplantation: A review of 43 cases with two- to seven-year follow-up. Sports Med Arthroscopy Rev 1993;2:164-167.

Question 18

A 10-year-old boy sustained an injury to the left knee. The radiographic findings shown in Figure 19 are most commonly associated with injury to which of the following structures?

Explanation

The radiograph shows a bony avulsion of the ACL attachment site on the tibial spine in this skeletally immature patient. In this age group, injury often results in failure of the bony attachment site rather than the substance of the ligament. Avulsion of the patellar tendon insertion site can occur, but this structure is located at the apophysis of the tibial tubercle. The attachment site of the PCL is much more posterior. In adults, bony avulsion is more commonly associated with PCL injuries than with ACL injuries. When a small bony avulsion of the lateral capsule from the lateral tibial plateau is seen on the AP view, this finding is considered pathognomonic of an ACL injury (Segond sign) in adults. The area of the pes anserinus is anterior and distal; avulsion would be unusual. Baxter MP, Wiley JJ: Fractures of the tibial spine in children: An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-230. Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.

Question 19

What is the single most important nutritional factor affecting athletic performance?

Explanation

Maintenance of adequate hydration is the single most important factor affecting athletic performance. While carbohydrate loading may be beneficial for some endurance athletes, the consumption of carbohydrates during exercise does not appear to be beneficial for athletes engaged in events that last less than 1 hour. In general, athletes consuming a balanced diet do not need electrolyte supplementation. Maughan RJ, Noakes TD: Fluid replacement and exercise stress: A brief review of studies on fluid replacement and some guidelines for the athlete. Sports Med 1991;12:16-31.

Question 20

A right-handed 20-year-old college baseball pitcher has had a 6-month history of vague right elbow pain while pitching. Examination reveals full flexion of the elbow and a loss of only a few degrees of full extension. The elbow is stable, but palpation reveals tenderness over the olecranon. Plain radiographs are inconclusive. MRI and CT scans are shown in Figures 20a and 20b. Management should consist of

Explanation

The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions. If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks. A light throwing program generally can begin at 8 to 12 weeks. Complete recovery may require 3 to 6 months. If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture. Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.

Question 21

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Explanation

It is well known that suprascapular nerve entrapment can be secondary to many entities, and its association with ganglion cysts and SLAP lesions has been well documented. Because of a superior labral tear, synovial fluid will leak out of the joint underneath the labrum, causing the cyst and secondary compression of the nerve. Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature. Arthroscopy 1995;11:727-734. Iannotti JP, Ramesey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.

Question 22

A 27-year-old runner training for his first marathon reports lateral knee pain after an unusually long training run. He states that the most significant pain occurs while running downhill. Examination of the patient while he is laying on the unaffected side reveals increased pain when manual pressure is applied to the lateral femoral epicondylar area during knee range of motion of 30 degrees to 45 degrees. What is the most likely diagnosis?

Explanation

Iliotibial band friction syndrome is one of the most common causes of lateral knee pain in runners. It is caused by increased friction between the iliotibial band and the lateral femoral condyle because of increased tension on the lateral structures. It may be caused by a prominence of the lateral epicondyle or a malalignment of the lower extremity in the runner, including genu varum, tibia vara, heel varus and forefoot supination, or compensating pronation. These structural characteristics can couple with relative muscle imbalance and lead to an altered running gait, enhancing friction between the lateral femoral condyle and the iliotibial band. Management is usually nonsurgical, including stretching of the iliotibial band and strengthening of the hip abductor muscles, with occasional use of cortisone injections or iontophoresis. Noble CA: The treatment of iliotibial band friction syndrome. Br J Sports Med 1979;13:51-54. James SL: Running injuries to the knee. J Am Acad Orthop Surg 1995;3:309-318.

Question 23

A 30-year-old woman who runs approximately 30 miles a week has had right hip and groin pain for the past 3 weeks. Examination reveals an antalgic gait, limited motion of the right hip, and pain, especially with internal and external rotation. Plain radiographs are normal, and an MRI scan is shown in Figure 21. Management should consist of

Explanation

A stress fracture of the hip is a relatively common problem in endurance sports. These fractures are classified as compression-side, tension-side, and displaced femoral neck fractures. The MRI scan shows a compression-side stress fracture. Compression-side fractures usually occur in the inferior or calcar area of the proximal femur, and non-weight-bearing crutch ambulation for 6 to 7 weeks will most likely result in healing. Once the patient is walking without pain or a limp, activities can be slowly increased. Because tension-side fractures have a high risk of displacement, treatment should consist of immediate internal fixation. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 239-253.

Question 24

Which of the following primary prognostic factors best predicts the outcome of the knee lesion shown in Figure 22?

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. Stanitski CL: Osteochondritis dissecans of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 387-405. Cahill B: Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee. Clin Sports Med 1985;4:367-384.

Question 25

Figures 23a and 23b show the AP and lateral radiographs of the elbow of a 30-year-old professional pitcher. The pathology shown in these studies is most consistent with which of the following conditions?

Explanation

The radiographs show the osteophytic build-up of the posteromedial corner of the elbow that occurs with valgus extension overload in the pitching elbow. This is the result of excessive valgus forces during the acceleration and deceleration phases of throwing. These forces, coupled with medial elbow stresses, cause a wedging of the olecranon into the medial wall of the olecranon fossa. Valgus instability of the elbow may further stimulate osteophyte formation. Repetitive impact of a spur within the olecranon fossa may cause fragmentation and eventual formation of loose bodies. Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99. Field LD, Savoie FJ: Common elbow injuries in sport. Sports Med 1988;26:193-205.

Question 26

Anterior cruciate ligament (ACL) reconstruction is planned. When evaluating graft placement, a femoral tunnel positioned too anteriorly (shallow) in the intercondylar notch will result in a graft that is biomechanically:

Explanation

An anteriorly placed femoral tunnel causes the distance between the femoral and tibial attachments to increase during knee flexion. This results in a graft that is tight in flexion and loose in extension.

Question 27

A 22-year-old collegiate football player undergoes anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. During the procedure, the femoral tunnel is drilled too anteriorly. Which of the following complications is most likely to occur?

Explanation

An anterior femoral tunnel placement in ACL reconstruction results in increased graft tension during flexion, limiting knee flexion. Conversely, an excessively posterior femoral tunnel limits extension.

Question 28

A 26-year-old overhead pitcher presents with vague, deep shoulder pain and decreased velocity. Physical examination reveals a positive O'Brien test and pain with resisted supination. An MR arthrogram demonstrates a Type II SLAP tear. If nonoperative management fails, what is the most appropriate surgical intervention?

Explanation

In overhead athletes or adults with symptomatic Type II SLAP tears failing conservative management, biceps tenodesis has shown more reliable return to sport and pain relief compared to SLAP repair, which often leads to stiffness.

Question 29

A 45-year-old woman reports an acute pop in the back of her knee while squatting. MRI reveals a medial meniscus posterior root tear with 3 mm of extrusion. Which of the following biomechanical changes occurs in the knee as a result of this injury?

Explanation

A posterior root tear of the medial meniscus completely disrupts the circumferential hoop stresses. This leads to functional total meniscectomy biomechanics with dramatically increased contact pressures and decreased contact area.

Question 30

A 21-year-old rugby player has recurrent anterior shoulder instability. CT scan

reveals 25% anterior glenoid bone loss. Which of the following is the most appropriate definitive management?

Explanation

In the setting of critical anterior glenoid bone loss (>20-25%) in a contact athlete, a coracoid transfer (Latarjet procedure) is the gold standard. Arthroscopic soft tissue stabilization has an unacceptably high failure rate in this scenario.

Question 31

A 30-year-old man sustains a severe varus and hyperextension injury to his knee. Examination shows a positive dial test at 30 degrees of flexion but normal rotation at 90 degrees. What is the primary injured structure?

Explanation

An isolated posterolateral corner (PLC) injury results in increased external rotation (positive dial test) at 30 degrees but not at 90 degrees. If the dial test is positive at both 30 and 90 degrees, a combined PLC and PCL injury is present.

Question 32

A 55-year-old man presents with an inability to actively internally rotate his arm. Physical examination reveals a positive belly-press test and increased external rotation compared to the contralateral side. MRI confirms a full-thickness tear of the subscapularis. During repair, which anatomic landmark reliably helps locate the retracted tendon?

Explanation

The long head of the biceps tendon is a critical landmark; the subscapularis tendon inserts on the lesser tuberosity just medial to the bicipital groove. A subscapularis tear frequently leads to medial subluxation of the biceps tendon.

Question 33

A 28-year-old competitive weightlifter feels a tearing sensation in his anterior chest while performing a heavy bench press. Examination reveals bruising and loss of the anterior axillary fold. If surgical repair is pursued, the sternal head of the pectoralis major should be reattached in which anatomical relationship to the clavicular head?

Explanation

The pectoralis major twists before insertion. The sternal head inserts posterior and distal to the clavicular head on the lateral lip of the bicipital groove.

Question 34

A 16-year-old girl experiences recurrent lateral patellar dislocations. Imaging shows a normal Tibial Tubercle-Trochlear Groove (TT-TG) distance and normal patellar height. She is scheduled for medial patellofemoral ligament (MPFL) reconstruction. The anatomic femoral attachment of the MPFL is located:

Explanation

The Schöttle point, indicating the anatomical femoral origin of the MPFL, is located proximal and posterior to the medial epicondyle, and distal to the adductor tubercle. Non-anatomic placement leads to altered patellofemoral kinematics.

Question 35

A 65-year-old laborer has a massive, irreparable posterosuperior rotator cuff tear with an intact subscapularis, severe pseudoparalysis, and Hamada Grade 2 changes. Superior capsular reconstruction (SCR) is considered. Which structure provides the biomechanical basis for this procedure by keeping the humeral head reduced?

Explanation

The superior capsule is a critical static stabilizer of the glenohumeral joint. SCR utilizes a graft to replace the deficient superior capsule, preventing superior migration of the humeral head and restoring the fulcrum for the deltoid.

Question 36

A 12-year-old Tanner stage 1 male sustains a mid-substance ACL tear. Due to his open physes, a physeal-sparing reconstruction is planned using the iliotibial band (MacIntosh or Micheli procedure). This technique primarily addresses which plane of instability?

Explanation

Physeal-sparing extra-articular reconstructions using the IT band primarily control anterolateral rotatory instability. They do not fully restore central pivot biomechanics but prevent pivot-shift events until skeletal maturity.

Question 37

A 19-year-old female swimmer complains of bilateral shoulder pain and sensations of instability. Physical examination demonstrates generalized ligamentous laxity, positive sulcus sign, and apprehension in multiple planes. After 6 months of dedicated physical therapy, her symptoms persist. What is the surgical procedure of choice?

Explanation

Multidirectional instability (MDI) failing conservative therapy is treated with an inferior capsular shift or arthroscopic capsular plication. Thermal capsulorrhaphy is obsolete due to high failure rates and chondrolysis.

Question 38

A 25-year-old male presents to the trauma bay after a motorcycle accident with a grossly deformed knee. Radiographs confirm an anterior knee dislocation. After prompt closed reduction, the patient has normal, symmetric distal pulses. Ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury, even if palpable pulses are present. CT angiography is urgently required to evaluate for a popliteal artery intimal tear or occlusion.

Question 39

A 23-year-old minor league baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. MRI demonstrates a partial articular-sided supraspinatus tendon avulsion (PASTA) and posterosuperior labral fraying. This pathology is primarily driven by:

Explanation

Internal impingement in throwers is caused by repetitive abutment of the posterosuperior cuff against the posterior labrum during extreme abduction and external rotation. It is strongly associated with GIRD and a tight posterior capsule.

Question 40

A 14-year-old boy presents with vague right knee pain and catching. Radiographs

reveal an osteochondritis dissecans (OCD) lesion. What is the most common anatomic location for an OCD lesion in the knee?

Explanation

The classic location for osteochondritis dissecans (OCD) of the knee is the lateral aspect of the medial femoral condyle, commonly remembered by the mnemonic LAME (Lateral Aspect Medial Epicondyle/Condyle).

Question 41

A 22-year-old rugby player presents with recurrent anterior shoulder instability. Advanced imaging reveals 30% anterior glenoid bone loss.

The most appropriate definitive surgical management is:

Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability associated with critical glenoid bone loss (>20-25%). Soft tissue stabilization alone, such as a Bankart repair, carries an unacceptably high failure rate in this setting.

Question 42

An 18-year-old female soccer player sustains a non-contact valgus and twisting injury to her knee, resulting in an ACL tear. During anatomic single-bundle ACL reconstruction, the surgeon specifically evaluates the femoral footprint. The posterolateral (PL) bundle of the anterior cruciate ligament is under its greatest tension in which of the following positions?

Explanation

The ACL has two main bundles: the anteromedial (AM) and posterolateral (PL). The PL bundle is tightest in full extension and primarily controls rotatory stability, whereas the AM bundle is tightest in flexion and controls anterior translation.

Question 43

A 45-year-old recreational overhead athlete is diagnosed with an isolated Type II SLAP tear that has failed conservative management. When comparing arthroscopic SLAP repair to primary biceps tenodesis in this age demographic, evidence shows that SLAP repair is associated with:

Explanation

In patients older than 40 years, SLAP repair is associated with higher rates of postoperative stiffness, dissatisfaction, and reoperation compared to primary biceps tenodesis. Therefore, tenodesis is often preferred for Type II SLAP tears in this population.

Question 44

A 25-year-old football player sustains a direct blow to the anteromedial aspect of his proximal tibia. Physical examination reveals increased external tibial rotation at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees compared to the contralateral knee. This isolated physical examination finding strongly indicates injury to the:

Explanation

A positive dial test at 30 degrees of flexion that normalizes at 90 degrees of flexion is pathognomonic for an isolated posterolateral corner (PLC) injury. If the test is positive at both 30 and 90 degrees, it indicates combined PLC and PCL injuries.

Question 45

A 28-year-old professional baseball pitcher presents with a loss of throwing velocity and vague late-cocking phase shoulder pain. Examination reveals a 25-degree loss of internal rotation (GIRD) compared to the non-throwing shoulder. The primary pathophysiologic cause of this glenohumeral internal rotation deficit is:

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is primarily driven by repetitive microtrauma leading to contracture and thickening of the posteroinferior capsule. It is a key contributor to internal impingement and superior labral pathology.

Question 46

A 55-year-old woman experiences a sudden popping sensation in the back of her knee while squatting to garden. An MRI reveals a medial meniscus posterior root tear. Biomechanically, this isolated injury is equivalent to which of the following?

Explanation

A posterior root tear disrupts the hoop stresses of the meniscus, leading to radial extrusion under axial load. Biomechanical studies have demonstrated that a root tear results in contact pressures equivalent to a total meniscectomy, predisposing the joint to rapid chondrolysis.

Question 47

A 32-year-old manual laborer falls directly onto the tip of his shoulder. Radiographs demonstrate a 100% superior displacement of the distal clavicle relative to the acromion, with the coracoclavicular distance increased by 50% compared to the uninjured side. The most appropriate initial management is:

Explanation

The patient has a Type III acromioclavicular (AC) joint separation. Despite being a manual laborer, literature supports an initial trial of nonoperative management with a sling and physical therapy, as most patients achieve satisfactory functional outcomes without surgery.

Question 48

A 22-year-old athlete undergoes an anterior cruciate ligament (ACL) reconstruction. At his 3-month postoperative visit, he lacks 15 degrees of full extension. A lateral radiograph demonstrates that the tibial tunnel is placed anterior to the intersection of Blumensaat's line and the tibial plateau. What is the most likely biomechanical consequence of this tunnel malposition?

Explanation

Anterior placement of the tibial tunnel causes the ACL graft to impinge against the intercondylar roof during knee extension. This roof impingement leads to an extension deficit, anterior knee pain, and potential attrition or failure of the graft.

Question 49

A 19-year-old female gymnast presents with bilateral shoulder pain and a sensation of the shoulders 'slipping' during routines. Physical exam reveals a positive sulcus sign, positive apprehension tests with spontaneous relocation, and generalized ligamentous laxity. First-line management should focus on a rehabilitation program emphasizing strengthening of which of the following muscle groups?

Explanation

Multidirectional instability (MDI) is characterized by symptomatic generalized capsular laxity. The mainstay of initial treatment is a prolonged physical therapy program focusing on the dynamic stabilizers, specifically the rotator cuff and periscapular muscles.

Question 50

A 45-year-old active male feels a 'pop' in the posterior aspect of his knee while performing a deep squat. Subsequent MRI reveals a complete tear of the medial meniscus posterior root. Biomechanically, if left untreated, this injury is most equivalent to which of the following?

Explanation

A complete posterior root tear of the medial meniscus disrupts the circumferential hoop stresses of the meniscus. This leads to meniscal extrusion and profoundly alters contact mechanics, making it biomechanically equivalent to a total meniscectomy.

Question 51

A 45-year-old manual laborer presents with persistent shoulder pain and mechanical catching. Nonoperative management has failed, and arthroscopy reveals an isolated Type II SLAP tear. The surgeon elects to perform a primary biceps tenodesis rather than a SLAP repair. What is the primary advantage of biceps tenodesis over SLAP repair in this specific demographic?

Explanation

In patients over age 40, primary SLAP repair is associated with a high rate of postoperative stiffness and residual pain. Biceps tenodesis provides more predictable pain relief, higher satisfaction, and a significantly lower risk of stiffness in this population.

Question 52

A 26-year-old soccer player sustains a twisting injury to his knee. Physical examination reveals a positive posterior sag sign. A Dial test is performed, demonstrating a 15-degree increase in external rotation of the tibia compared to the contralateral leg at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees of knee flexion. These findings indicate an isolated injury to which structure?

Explanation

An increase in external rotation on the Dial test at 30 degrees of knee flexion that reduces to normal at 90 degrees indicates an isolated injury to the posterolateral corner (PLC). Combined PLC and PCL injuries show increased external rotation at both 30 and 90 degrees.

Question 53

A 16-year-old female experiences an acute lateral patellar dislocation while dancing. She is evaluated in the emergency department and reduced. Which of the following describes the most common anatomic location of injury to the medial patellofemoral ligament (MPFL) in this setting?

Explanation

In acute lateral patellar dislocations, the medial patellofemoral ligament (MPFL) most commonly fails at its femoral origin. The femoral origin is located between the medial epicondyle and the adductor tubercle.

Question 54

A 60-year-old man presents with chronic shoulder weakness. MRI demonstrates a massive, retracted rotator cuff tear involving the supraspinatus and infraspinatus. Electromyography (EMG) shows denervation changes specifically isolated to the infraspinatus. Traction neuropathy of which nerve is most likely responsible for this finding?

Explanation

Massive retracted tears of the posterosuperior rotator cuff alter the pull of the remaining muscles, potentially causing traction on the suprascapular nerve at the spinoglenoid notch. This classically results in denervation and isolated atrophy of the infraspinatus.

Question 55

A 65-year-old male sustains an anterior shoulder dislocation after a fall down stairs. Following successful closed reduction in the emergency department, he continues to have profound weakness in external rotation and elevation. Sensation over the lateral deltoid is completely intact. What is the most likely concomitant injury?

Explanation

In patients older than 40 years, anterior shoulder dislocations are highly associated with concomitant rotator cuff tears rather than isolated labral pathology. Persistent weakness after reduction with an intact axillary nerve strongly suggests a massive cuff tear.

Question 56

When comparing bone-patellar tendon-bone (BPTB) autograft to quadrupled hamstring autograft for primary ACL reconstruction, the BPTB graft is most consistently associated with an increased incidence of which of the following postoperative findings?

Explanation

While both grafts yield excellent stability, BPTB autografts are historically and consistently associated with a higher incidence of donor-site morbidity, specifically anterior knee pain and discomfort while kneeling, compared to hamstring autografts.

Question 57

A 22-year-old collegiate baseball pitcher presents with vague dominant shoulder pain. Examination reveals glenohumeral internal rotation of 20 degrees and external rotation of 125 degrees. Total arc of motion is symmetric to the non-throwing shoulder. Nonoperative management for this specific deficit should prioritize stretching of which anatomical structure?

Explanation

This presentation describes Glenohumeral Internal Rotation Deficit (GIRD), common in overhead throwing athletes and primarily caused by posteroinferior capsular contracture. Treatment focuses on stretching the posterior capsule, often utilizing 'sleeper stretches'.

Question 58

A 14-year-old male athlete presents with insidious onset of knee pain and intermittent mechanical catching. Radiographs demonstrate a focal subchondral radiolucency consistent with osteochondritis dissecans (OCD). What is the most common anatomical location for an OCD lesion in the knee?

Explanation

The classic and most frequent location for osteochondritis dissecans (OCD) of the knee is the lateral aspect of the medial femoral condyle, accounting for approximately 70-80% of all knee OCD lesions.

Question 59

A 25-year-old elite javelin thrower complains of posterior shoulder pain during the late cocking phase of throwing. Arthroscopy is performed for suspected internal impingement. Which of the following combined pathological findings is the hallmark of internal impingement of the shoulder?

Explanation

Internal impingement occurs when the greater tuberosity abuts the posterosuperior glenoid during maximum abduction and external rotation. This pinches the rotator cuff, leading to articular-sided, posterosuperior cuff fraying or tearing, along with associated posterosuperior labral (SLAP) pathology.

Question 60

A 55-year-old male with end-stage renal disease falls and presents with sudden swelling and an inability to actively extend his knee. A lateral radiograph demonstrates patella baja. Based on this radiographic finding, which of the following injuries is most likely?

Explanation

Patella baja (a low-riding patella) is indicative of a quadriceps tendon rupture, as the unopposed pull of the intact patellar tendon draws the patella distally. Conversely, a patellar tendon rupture typically results in patella alta.

Question 61

During an anatomic reconstruction of the posterolateral corner (PLC) of the knee, careful dissection is required to protect the common peroneal nerve. To avoid iatrogenic injury, the surgeon must consistently identify the nerve in relation to which primary anatomic landmark?

Explanation

The common peroneal nerve courses posterior to the biceps femoris tendon before wrapping around the fibular neck. Identification and protection of the nerve in this specific location are critical initial steps in posterolateral corner reconstruction.

Question 62

A 30-year-old competitive weightlifter feels a tearing sensation in his anterior chest wall while performing a heavy bench press. Examination shows significant axillary ecchymosis and loss of the anterior axillary fold contour. If surgical repair is indicated, which anatomical portion of the pectoralis major tendon is most commonly ruptured in this scenario?

Explanation

Pectoralis major ruptures in weightlifters most frequently occur at the tendinous insertion onto the humerus. The sternocostal head is placed under maximum tension and stretch during the eccentric phase of the bench press, making it the most vulnerable to avulsion.

Question 63

A 22-year-old athlete presents 6 months after an anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft, complaining of anterior knee pain and a 10-degree extension deficit. Radiographs demonstrate the tibial tunnel is positioned entirely anterior to the Blumensaat line with the knee in full extension. What is the most likely biomechanical cause of his extension deficit?

Explanation

The tibial tunnel in an ACL reconstruction should be positioned posterior to the Blumensaat line when the knee is in full extension. Anterior placement causes the graft to impinge against the intercondylar roof, leading to an extension deficit and potential graft failure.

Question 64

A 20-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan demonstrates a 28% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

Explanation

The Latarjet procedure is indicated for recurrent anterior shoulder instability with critical glenoid bone loss (typically >20-25%). Soft tissue stabilization alone in this setting carries an unacceptably high recurrence rate.

Question 65

A football running back sustains a blow to the anteromedial aspect of his knee. Physical examination reveals 15 degrees of increased external rotation at both 30 and 90 degrees of knee flexion compared to the contralateral side. A posterior sag sign is also present. Which structures are most likely injured?

Explanation

Increased external rotation at both 30 and 90 degrees of knee flexion during the dial test indicates a combined injury to the PCL and the PLC. Isolated PLC injuries typically demonstrate increased external rotation at 30 degrees only.

Question 66

In patients with a massive, retracted rotator cuff tear involving the supraspinatus and infraspinatus tendons, traction neuropathy of the suprascapular nerve is most likely to occur at which of the following anatomic locations?

Explanation

Massive, retracted tears of the supraspinatus and infraspinatus alter the normal medial-lateral excursion of the suprascapular nerve. The tethering effect most commonly causes traction neuropathy at the suprascapular notch due to the fixed transverse scapular ligament.

Question 67

A 45-year-old recreational tennis player feels a sudden "pop" in the posterior aspect of her knee while lunging. MRI reveals a medial meniscus posterior root tear with 4 mm of meniscal extrusion. Which of the following biomechanical consequences is most directly associated with this specific injury?

Explanation

Meniscus root tears disrupt the circumferential hoop stresses of the meniscus, functionally acting like a total meniscectomy. This leads to medial meniscal extrusion and significantly increased tibiofemoral contact pressures, predisposing the knee to early osteoarthritis.

Question 68

An elite baseball pitcher presents with vague, deep shoulder pain and decreased throwing velocity. Physical examination demonstrates a positive O'Brien test and pain with the "peel-back" mechanism in the late cocking phase. Which of the following describes a Type II SLAP lesion?

Explanation

A Type II SLAP lesion involves the detachment of the superior labrum and the origin of the long head of the biceps from the glenoid. It is commonly driven by a peel-back mechanism in overhead throwing athletes.

Question 69

Following a first-time lateral patellar dislocation in a 16-year-old female, the medial patellofemoral ligament (MPFL) is identified on MRI as the primary torn restraint. If surgical reconstruction is planned, where is the normal anatomic femoral origin of the MPFL (Schottle's point) located?

Explanation

The anatomic femoral origin of the MPFL is located in a saddle-shaped region between the medial epicondyle and the adductor tubercle. Non-anatomic reconstruction can lead to abnormal graft tension, stiffness, and altered patellofemoral kinematics.

Question 70

A 28-year-old bodybuilder feels a tearing sensation in his anterior shoulder while performing a heavy bench press. Examination reveals a loss of the anterior axillary fold and weakness in internal rotation. If surgical repair is planned, the sternal head of the pectoralis major must be recognized to insert on the humerus at what position relative to the clavicular head?

Explanation

The pectoralis major tendon twists 180 degrees before its insertion on the lateral lip of the bicipital groove. Due to this twist, the sternal head inserts proximal and deep relative to the clavicular head.

Question 71

A 14-year-old male soccer player presents with vague anterior knee pain and mechanical catching. Radiographs demonstrate an osteochondritis dissecans (OCD) lesion. What is the most common anatomic location for an OCD lesion of the knee?

Explanation

The classic and most common location for osteochondritis dissecans (OCD) of the knee is the lateral aspect of the medial femoral condyle. This area is vulnerable to repetitive microtrauma, particularly in the setting of tibial spine impingement.

Question 72

A 25-year-old cyclist sustains a direct blow to the point of his shoulder. Radiographs demonstrate a Type V acromioclavicular (AC) joint injury. Which of the following correctly describes the fascial disruption distinguishing a Type V from a Type III AC joint injury?

Explanation

A Type V AC joint injury involves disruption of the AC ligaments, CC ligaments, and the deltotrapezial fascia, resulting in >100% superior displacement of the clavicle. Type III injuries have intact deltotrapezial fascia.

Question 73

A 26-year-old male sustains an acute knee dislocation during a football game. The knee was reduced on the field. In the emergency department, his pedal pulses are palpable, but an ankle-brachial index (ABI) is measured at 0.8. What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 or asymmetric pulses is considered a "soft" sign of vascular injury requiring advanced imaging, typically a CT angiogram. Immediate surgical exploration is reserved for "hard" signs of vascular injury, such as absent pulses or active pulsatile hemorrhage.

Question 74

A 22-year-old female collegiate soccer player undergoes anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BPTB) autograft. When comparing this graft choice to a hamstring autograft, what is the most common long-term complication she may face?

Explanation

BPTB autografts are historically associated with a higher incidence of donor-site morbidity, particularly anterior knee pain and kneeling pain, compared to hamstring autografts. Graft rupture rates are comparable or slightly lower for BPTB grafts.

Question 75

A 45-year-old manual laborer presents with chronic anterior shoulder pain.

MRI demonstrates a Type II SLAP tear. Nonoperative management has failed. Which of the following is the most definitive and reliable surgical treatment for this patient?

Explanation

In patients over 35-40 years old, biceps tenodesis provides more reliable pain relief and higher functional satisfaction than SLAP repair. SLAP repairs in older patients are associated with higher rates of postoperative stiffness and failure.

Question 76

A 28-year-old male presents with knee pain and instability after a hyperextension injury. Physical examination demonstrates an abnormal dial test with 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side. At 90 degrees of flexion, external rotation is symmetrical bilaterally. Which structure(s) is/are injured?

Explanation

An isolated posterolateral corner (PLC) injury presents with increased external rotation on the dial test at 30 degrees of knee flexion. If external rotation is increased at both 30 and 90 degrees, it indicates a combined PLC and PCL injury.

Question 77

A 19-year-old collegiate football player sustains a first-time traumatic anterior shoulder dislocation.

What is the single most important risk factor for recurrent instability in this patient if treated nonoperatively?

Explanation

Patient age at the time of the initial dislocation is the most significant predictor of recurrence. Patients under 20 years old have recurrence rates approaching 80-90% with conservative management.

Question 78

A 45-year-old female feels a "pop" in the posterior aspect of her knee while deep squatting. MRI confirms a posterior root tear of the medial meniscus. Left untreated, this injury biomechanically alters the knee in a manner most similar to which of the following?

Explanation

A meniscal root tear completely disrupts the circumferential hoop stresses of the meniscus, leading to radial extrusion. Biomechanically, this results in peak contact pressures equivalent to a total meniscectomy, rapidly accelerating osteoarthritis.

Question 79

A 28-year-old male volleyball player reports vague posterior shoulder pain and profound weakness with external rotation.

MRI demonstrates a large paralabral cyst located strictly within the spinoglenoid notch. Which muscle is primarily affected by this lesion?

Explanation

The spinoglenoid notch transmits the suprascapular nerve after it has already supplied motor branches to the supraspinatus. Compression at this specific location causes isolated denervation and atrophy of the infraspinatus.

Question 80

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the surgeon inadvertently places the femoral tunnel proximal and anterior to the true anatomic insertion (Schottle's point). This malpositioning will cause the graft to be:

Explanation

A femoral tunnel placed too proximal and anterior to the anatomic MPFL footprint increases the distance to the patella as the knee flexes. This results in a graft that is inappropriately loose in extension and excessively tight in flexion.

Question 81

A 22-year-old baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Examination shows 130 degrees of external rotation and 20 degrees of internal rotation. The contralateral non-dominant shoulder has 100 degrees of external rotation and 50 degrees of internal rotation. What is the most appropriate initial treatment?

Explanation

This patient has Glenohumeral Internal Rotation Deficit (GIRD), commonly caused by posterior capsular contracture in overhead athletes. The initial and most effective management is a targeted posterior stretching program (e.g., sleeper stretches).

Question 82

A 30-year-old man presents with chronic knee pain 10 years after sustaining an isolated, untreated Grade III PCL tear. Based on the altered kinematics of a PCL-deficient knee, which compartments are most likely to demonstrate advanced osteoarthritic changes?

Explanation

Chronic PCL deficiency causes posterior tibial translation, which alters knee kinematics and leads to significantly increased contact pressures. This predictably causes premature osteoarthritis in the medial compartment and the patellofemoral joint.

Question 83

A 32-year-old competitive weightlifter feels a sharp tear in his anterior chest wall while bench pressing. Examination reveals loss of the anterior axillary fold and ecchymosis. If surgical repair is planned, where is the precise anatomic insertion of the torn structure?

Explanation

The pectoralis major tendon inserts onto the lateral lip of the bicipital groove of the humerus. Ruptures most commonly occur at the musculotendinous junction or the tendinous insertion during maximal eccentric loading.

Question 84

A 24-year-old professional soccer player presents with a symptomatic, isolated 3.5 cm^2 full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle.

Conservative management has failed. Which of the following is the most appropriate surgical intervention?

Explanation

MACI or osteochondral allograft transplantation are the preferred treatments for large chondral defects (>2-4 cm^2) in young, active patients. Microfracture and standard OATS are typically reserved for smaller lesions (<2 cm^2).

Question 85

A 26-year-old cyclist falls directly onto his right shoulder. Radiographs show superior displacement of the clavicle relative to the acromion, with an 80% increase in the coracoclavicular distance compared to the uninjured side. The deltotrapezial fascia remains structurally intact. This represents which Rockwood classification of acromioclavicular (AC) joint separation?

Explanation

Rockwood Type III injuries involve complete disruption of both the AC and CC ligaments, with 25-100% superior displacement of the clavicle. The deltotrapezial fascia remains intact, unlike in Type V injuries where it is stripped and displacement is >100%.

Question 86

A 25-year-old male sustains a high-energy knee dislocation. Following closed reduction, the patient has absent dorsiflexion of the foot and decreased sensation in the first dorsal web space.

Which nerve is injured, and what is its anatomic course around the knee?

Explanation

The common peroneal nerve is frequently injured in multi-ligament knee injuries and dislocations. It anatomically courses posterior to the biceps femoris tendon before wrapping around the fibular neck.

Question 87

A 65-year-old female presents with pseudoparalysis of the shoulder, severe glenohumeral osteoarthritis, and a massive, retracted, irreparable rotator cuff tear. Her deltoid function is completely intact. What is the most reliable surgical option to restore function and relieve pain?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the gold standard treatment for older patients with cuff tear arthropathy and pseudoparalysis. It constrains the center of rotation and relies on the intact deltoid to elevate the arm.

Question 88

A 14-year-old boy with open physes presents with knee pain. MRI reveals a 1.5 cm osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. The overlying articular cartilage is intact and there is no subchondral fluid line. What is the best initial treatment?

Explanation

In a skeletally immature patient with a stable OCD lesion (intact cartilage, no subchondral fluid on MRI), the initial treatment is nonoperative. A trial of activity modification and restricted weight-bearing allows for a high rate of spontaneous healing.

100 High-Yield Orthopedic MCQs: Shoulder & Elbow | Mock Exam 251

AAOS Sports Medicine MCQs (Set 2): Knee & Shoulder Injuries | ABOS Board Review

Key Takeaway

AAOS Sports Medicine MCQs (Set 2): Knee & Shoulder Injuries | ABOS Board Review

Chapter Index