AAOS Sports Medicine MCQs: Knee & Rotator Cuff Injuries

Question 1

Initial repair of the large U-shaped rotator cuff tear shown in Figure 12 consists of closing the tear side-to-side to take advantage of margin convergence. The most significant biomechanical consequence of this repair step results in

Explanation

Margin convergence refers to the phenomenon that occurs with side-to-side closure of large U- or L-shaped rotator cuff tears in which the free margin of the tear converges toward the greater tuberosity as the side-to-side tear progresses. The creation of the converged cuff margin creates decreased strain in the free margin of the repaired cuff, resulting in a decreased strain in the repair sutures. While the size of the humeral head defect is made smaller with side-to-side closure, biomechanically, this is less significant. The mild increase in thickness of the repair at the side-to-side margin is less important than a reduction in stress in the repaired tissue. Stress in the crescent cable region of the cuff actually increases and becomes more physiologic in transmitting force from the cuff to the greater tuberosity. Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 2000;16:82-90.

Question 2

A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?

Explanation

The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death. While the other choices can be the cause of sudden death in an otherwise healthy young athlete, their incidence is even more rare. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647. Maron BJ, Shirani J, Pollac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.

Question 3

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?

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. Lipscomb AB, Thomas ED, Johnston RK: Treatment of myositis ossificans traumatica in athletes. Am J Sports Med 1976;4:111-120. Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.

Question 4

When standing, dorsiflexion of the great toe will accentuate

Explanation

Dorsiflexion of the great toe will accentuate rigidity of the transverse tarsal articulation. Through the windlass mechanism, dorsiflexion of the great toe tightens the plantar fascia, stabilizing the longitudinal arch and placing the foot in supination. Supination makes the talonavicular and calcaneocuboid joints nonparallel, accentuating the rigidity of the transverse tarsal articulation. The heel also tends to go into varus, resulting in obligatory external tibial rotation. Mann RA: Biomechanics of the foot and ankle, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 1-44.

Question 5

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

Explanation

While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at least 1 year. Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112. Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am 1991;73:1561-1566.

Question 6

A 19-year-old soccer player feels a pop in his knee while making a cut and notes the development of an effusion over several hours. Examination reveals medial joint line tenderness, but the knee is stable to manual stress testing of all ligaments. Examination under anesthesia confirms a stable knee. What is the most critical factor in determining healing after repair of the lesion shown in Figure 14?

Explanation

Numerous clinical and basic science investigations have evaluated meniscal tear characteristics to identify factors that either promote or mitigate against meniscal healing. Complex tears have been noted to heal poorly, while longitudinal tears heal more predictably. Tear length, time from injury to repair, medial versus lateral meniscal tears, and the use of a fibrin clot have not been shown to consistently affect meniscal healing. However, rim width, the distance of the tear site from the peripheral meniscocapsular junction (vascular supply), has been shown to have a significant role in the ability of a meniscus repair to heal. DeHaven KE, Arnoczky SP: Meniscus repair: Basic science, indications for repair, and open repair. Instr Course Lect 1994;43:65-76.

Question 7

Which of the following tissues has the highest maximum load to failure?

Explanation

All of the tissues noted above are stronger than 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. Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225. Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110.

Question 8

A 20-year-old basketball player has tenderness and bruising after sustaining a blow to the knee. A radiograph is shown in Figure 15. What is the most likely diagnosis?

Explanation

The patient has a bipartite patella. The line between the fragment and the main patella is smooth and sclerotic, indicating a chronic, not acute, entity. The location is classic for a bipartite patella, not a tumor. Schmidt DR, Henry JH: Stress injuries of the adolescent extensor mechanism. Clin Sports Med 1989;8:343-355.

Question 9

Reconstruction of the posterior cruciate ligament (PCL) via the inlay technique involves exposure of the PCL tibial insertion site by a posterior

Explanation

The posterior medial approach through the semimembranosus/medial gastrocnemius interval is used in the inlay technique for PCL reconstruction. Exposure of the posterior capsule of the knee through this interval provides the greatest margin of safety to avoid injury to the tibial nerve, motor branch of the medial gastrocnemius, and the peroneal nerve. The direct posterior approach using the medial sural cutaneous nerve allows exposure of the popliteal neurovascular structures, but deep dissection through this interval places the motor branch of the medial gastrocnemius at risk. The interval between the semitendinosus and semimembranosus is used in accessory incisions with medial meniscus repairs but does not allow exposure of the PCL insertion. Berg EE: Posterior cruciate tibial inlay reconstruction. Arthroscopy 1995;11:69-76.

Question 10

A 36-year-old recreational tennis player sustains the injury shown in Figure 16. Management should consist of

Explanation

The MRI scan shows a rupture of the patellar tendon. This injury is most appropriately addressed with primary repair. For athletic individuals, the results of nonsurgical management are suboptimal. Reconstructive procedures are not necessary. Matava MJ: Patellar tendon ruptures. J Am Acad Orthop Surg 1996;4:287-296.

Question 11

Figure 17 shows the clinical photograph of a 45-year-old female tennis player who has right arm pain and weakness with elevation after undergoing a cervical biopsy several months ago. The cause of her shoulder weakness is damage to the

Explanation

The patient has primary scapulotrapezius winging caused by surgical damage to the spinal accessory nerve during a lymph node biopsy. Other causes include blunt trauma, traction, and penetrating injuries. With spinal accessory palsy, the shoulder appears depressed and laterally translated because of unopposed serratus anterior muscle function. With primary serratus anterior winging that is the result of long thoracic nerve palsy, the scapula assumes a position of elevation and medial translation with the inferior angle rotated medially. The thoracodorsal nerve innervates the latissimus dorsi and is not associated with scapular winging. Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

Question 12

A collegiate rower reports the sudden onset of right chest pain while rowing. The athlete states that the pain is worse with deep inspiration and coughing. Examination reveals localized tenderness over the posterolateral corner of the eighth rib. What is the most likely diagnosis?

Explanation

A rib stress fracture, the most common injury to the thorax in rowing athletes, generally occurs during periods of intense training with a low stroke rate and heavy loads. It is characterized by the sudden onset of sharp, localized chest pain while rowing. The fifth through the ninth rib is generally affected, and the diagnosis is best established with a bone scan. An intercostal muscle strain generally has an insidious onset and may be poorly localized. Costochondritis affects the anterior costochondral junction. A pneumothorax and an empyema can cause nonlocalized chest pain but are associated with respiratory distress and systemic physical findings. Karlson KA: Rib stress fractures in elite rowers. Am J Sports Med 1998;26:516-520.

Question 13

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

Explanation

The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci. Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.

Question 14

Which of the following substances does not have androgenic effects?

Explanation

Growth hormone is the most abundant substance produced by the pituitary gland. Growth hormone has a direct anabolic effect by accelerating the incorporation of amino acids into proteins. It is becoming an increasingly popular anabolic steroid substitute; however, it is expensive and difficult to obtain. Androstenedione is an androgen produced by the adrenal glands and gonads. It acts as a potent anabolic steroid and is converted in the liver directly to testosterone with a resultant increase in levels after administration. DHEA is a naturally occurring hormone made by the adrenal cortex. It is converted to androstenedione, which in turn is converted to testosterone. The beneficial and adverse effects of DHEA can be correlated directly with those of testosterone. Nandrolone is also a potent anabolic steroid. It is commonly taken as 19-norandrostenedione and may be more favored because of its potent anabolic effects with less androgenic effects (no conversion to estrogen compounds). Creatine sales have skyrocketed, and it is a popular nutritional supplement. There is an expectation that creatine can increase strength and power performance; however, direct anabolic effects have not been demonstrated. Creatine serves as a substrate for hydrogen ions and contributes to the resynthesis of ATP (adenosine triphosphate) during maximal exercise. By enhancing ATP production and buffering local pH in muscle, there may be improved tolerance of anaerobic activities. Increases in muscle mass may be related to increased perception of improved training ability or an increase in muscle water content. Silver M: Use of ergogenic aids by athletes. J Am Acad Orthop Surg 2001;9:61-70.

Question 15

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Explanation

A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%. Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.

Question 16

What is the principal advantage of surgical repair for the lesion shown in Figure 19?

Explanation

The MRI scan shows a rupture of the Achilles tendon. The substantiated advantages of repair are less risk of re-rupture and greater plantar flexion strength. Dorsiflexion strength is not influenced. Motion, pain, and period of recovery are not specifically improved as a consequence of surgery. Bhandari M, Guyatt GH, Siddiqui F, et al: Treatment of acute Achilles tendon ruptures: A systematic overview and meta-analysis. Clin Orthop 2002;400:190-200.

Question 17

An 18-year-old high school football player sustains a left posterior hip dislocation that is reduced in the emergency department under IV sedation. Postreduction radiographs reveal a concentric reduction with no evidence of fracture or loose bodies within the joint. What is the most common complication of hip dislocations?

Explanation

Traumatic dislocation of the hip in sports injuries is uncommon, and 85% to 92% occur in a posterior direction. In dislocations without fractures, osteonecrosis is the most common complication occurring in 10% to 20% of patients. MRI should be performed at 3 months postreduction to rule out osteonecrosis. Nerve injuries are rare in this setting, and recurrent dislocations are unusual without acetabular fractures. Chondrolysis has been reported as a rare occurrence. Anderson K, Strickland S, Warren R: Hip and groin injures in athletes. Am J Sports Med 2001;29:521-533.

Question 18

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals lumbar paraspinal spasm and a positive straight leg raising test. Deep tendon reflexes, motor strength, and sensation in the lower extremities are normal. Radiographic findings are normal. If symptoms persist for longer than a few weeks, what is the best course of action?

Explanation

In the adolescent population, a lumbar herniated disk is characterized by a paucity of clinical findings, with a positive straight leg raising test the only consistently positive finding. This may result in a prolonged period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. An adolescent who lifts weights and has a history of back pain that fails to respond to a short period of active rest should undergo MRI evaluation for the diagnosis of a lumber herniated disk. Epstein JA, Epstein NE, Marc J, et al: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.

Question 19

Examination of a 23-year-old female college basketball player who has had anterior knee pain for the past 3 weeks reveals tenderness and fullness over the inferior patella and proximal patellar tendon. There is no patellofemoral crepitus, patella apprehension sign, or anterior or posterior instability. Initial management should include

Explanation

The patient has patellar tendinitis (jumper's knee). It is a common overuse condition seen in runners, volleyball players, soccer players, and jumpers but can be seen in any activity in which repeated extension of the knee is required. In the acute setting, the pain is well localized and there is tenderness and sometimes swelling of the tendon. MRI is recommended for evaluating chronic cases and for surgical planning. In the acute phases, ice, rest, and avoidance of the offending activity are recommended. Weakness of the quadriceps and hamstring muscle are thought to contribute to this problem; therefore, stretching and isometric exercise in a limited range of motion are important. Complete rest and intratendinous injections of steroids are detrimental to tendon physiology. Stanish WD, Rubinovich RM, Curwin S: Eccentric exercise in chronic tendinitis. Clin Orthop 1986;208:65-68.

Question 20

Which of the following findings is likely to be pathologic in a thin, well-conditioned endurance athlete?

Explanation

Left ventricular hypertrophy by voltage is a nonspecific diagnosis, especially in athletes with an asthenic body habitus. High vagal tone in endurance athletes may result in first degree or even type I second degree (ie, Wenckebach) AV block in endurance athletes. High vagal tone results in resting sinus bradycardia in many trained athletes. A I-II/IV systolic ejection murmur is occasionally found in healthy athletes; however, when the murmur increases in intensity with maneuvers that decrease ventricular filling, such as standing or the Valsalva maneuver, dynamic obstruction that is the result of hypertrophic obstructive cardiomyopathy should be suspected. Nonspecific STT wave changes in the lateral leads on ECG are not uncommon in highly trained athletes; thus, they are nonspecific for ischemic heart disease. Pelliccia A, Maron BJ, Culasso F, DiPaolo FM, et al: Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278-284.

Question 21

Figure 20 shows the radiograph of a 21-year-old college basketball player who jammed his left index finger on the rim. He reports pain and tenderness over the dorsum of the distal interphalangeal (DIP) joint. Examination reveals that he is unable to actively extend the DIP joint; however, the skin is intact. Management should consist of

Explanation

Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position. Crawford GP: The molded polyethylene splint for mallet finger deformities. J Hand Surg Am 1984;9:231-237.

Question 22

With a full-thickness articular cartilage injury, the body's healing response produces cartilage mainly composed of what type of collagen?

Explanation

With a full-thickness articular cartilage injury, a healing response is initiated with hematoma, stem cell migration, and vascular ingrowth. This response produces type I collagen and resultant fibrous cartilage rather than desired hyaline cartilage as produced by chondrocytes. This repair cartilage has diminished resiliency, stiffness, poor wear characteristics, and the predilection for arthritis. Type I collagen is also found in the annulus of intervertebral disks, tendon, bone, meniscus, and skin. Type II is found in articular cartilage and nucleus pulposus of intervertebral disks. Type III is found in skin and blood vessels, type IV is found in basement membranes, and type X is found in the calcified layer of cartilage. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.

Question 23

A relative contraindication for anteromedial tibial tubercle transfer for patellar instability is arthrosis in what portion of the patella?

Explanation

Anteromedial displacement of the tibial tubercle unloads the distal and lateral facets of the patella and shifts the forces to the proximal and medial facets. Therefore, if findings indicate arthrosis predominately in the medial and proximal areas of the patella, this is considered a relative contraindication because it may accentuate arthritic symptoms. Fulkerson JP: Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop 1983;177:176-181. Bellemans J, Cauwenberghs F, Witvrouw E, et al: Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25:375-381.

Question 24

An 18-year-old lacrosse player sustained a hamstring pull during a game. Examination the next day reveals ecchymosis through the posterior thigh and a palpable defect in the hamstring musculature in the middle third of the thigh. What is the most likely site of anatomic injury?

Explanation

Hamstring strains are common in athletes. Basic science research and clinical data indicate that the majority of these injuries occur at the myotendinous junction, not within the muscle belly. Avulsion of hamstring origin from the ischial tuberosity does occur but is less common. Complete tearing of all hamstring muscles is unlikely to occur. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 17-33.

Question 25

Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of

Explanation

The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicates disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal. Warren LA, Marshall JL, Girgis F: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974;56:665-674.

Question 26

Which of the following statements regarding the biomechanical properties of commonly used anterior cruciate ligament (ACL) grafts is true?

Explanation

A 10-mm bone-patellar tendon-bone (BPTB) graft has an ultimate failure load of roughly 2900 N and stiffness of 300-400 N/mm, both of which are higher than the native ACL (roughly 2100 N and 242 N/mm).

Question 27

During arthroscopic repair of a massive, retracted superior rotator cuff tear, extensive medial mobilization is required. What is the generally accepted "safe zone" distance from the superior glenoid rim to avoid injury to the suprascapular nerve at the suprascapular notch?

Explanation

The suprascapular nerve is located approximately 1.5 cm (15 mm) medial to the superior glenoid rim at the suprascapular notch. Dissection medial to this distance increases the risk of iatrogenic nerve injury.

Question 28

Which bundle of the posterior cruciate ligament (PCL) serves as the primary restraint to posterior tibial translation at 90 degrees of knee flexion?

Explanation

The anterolateral bundle of the PCL is tightest in flexion and is the primary restraint to posterior translation at 90 degrees. The posteromedial bundle is tightest in extension.

Question 29

A 22-year-old football player sustains a valgus blow to the lateral aspect of his knee. Physical examination reveals medial joint line opening at 30 degrees of flexion but a stable knee in full extension. Which anatomical structure is the primary restraint being tested?

Explanation

The superficial MCL is the primary restraint to valgus stress at 30 degrees of knee flexion. Stability in full extension indicates that the secondary stabilizers (like the posterior oblique ligament and posterior capsule) remain intact.

Question 30

In a young, active patient with an irreparable posterosuperior rotator cuff tear (supraspinatus and infraspinatus) but an intact subscapularis, which of the following tendon transfers is biomechanically and clinically most appropriate to restore external rotation and elevation?

Explanation

Latissimus dorsi transfer (or lower trapezius transfer) is indicated for irreparable posterosuperior rotator cuff tears to restore external rotation and forward elevation. Pectoralis major transfers are typically reserved for irreparable subscapularis tears.

Question 31

A 24-year-old athlete sustains a combined ACL and posterolateral corner (PLC) injury. If the surgeon reconstructs only the ACL and fails to address the PLC, what is the most likely biomechanical consequence?

Explanation

Failure to recognize and treat a posterolateral corner injury results in increased varus and external rotation laxity. This subjects an ACL reconstruction graft to excessive forces, predictably leading to early graft failure.

Question 32

Understanding the anatomical "footprint" of the rotator cuff is essential for proper repair. The supraspinatus footprint on the greater tuberosity is best described by which of the following medial-to-lateral dimensions?

Explanation

Anatomical studies demonstrate that the medial-to-lateral dimension of the supraspinatus footprint on the greater tuberosity is approximately 14 to 16 mm. Its anterior-to-posterior dimension is roughly 25 mm.

Question 33

An obese 35-year-old male sustains a low-velocity knee dislocation following a fall. After successful closed reduction, vascular evaluation reveals an Ankle-Brachial Index (ABI) of 0.8. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 following a knee dislocation is highly suspicious for a vascular injury and mandates advanced imaging, typically CT angiography, to evaluate the popliteal artery.

Question 34

Which of the following patient factors has been clinically demonstrated to have the most significant negative impact on tendon-to-bone healing and functional outcomes following arthroscopic rotator cuff repair?

Explanation

Smoking (nicotine) significantly impairs microvascular perfusion and cellular proliferation, leading to higher rates of delayed healing, nonhealing, and re-tears following rotator cuff repair.

Question 35

A 9-year-old male (Tanner stage 1) sustains a midsubstance ACL rupture while playing soccer. He experiences giving way during daily activities. What is the most widely recommended surgical approach to minimize the risk of growth arrest?

Explanation

In prepubescent children (Tanner stages 1 and 2) with significant remaining growth, physeal-sparing techniques such as all-epiphyseal reconstruction are recommended to avoid iatrogenic physeal injury and subsequent growth arrest.

Question 36

During clinical examination of a patient with shoulder pain, the examiner places the palm of the patient's hand on the opposite shoulder and attempts to pull the hand anteriorly while the patient resists. This test is highly specific for a tear of which tendon?

Explanation

This describes the "bear-hug" test, which is a highly sensitive and specific clinical examination maneuver for evaluating the integrity and strength of the subscapularis tendon.

Question 37

Which of the following functional criteria is widely accepted as a minimum objective requirement before an athlete is cleared to return to cutting sports following an ACL reconstruction?

Explanation

Return to play criteria typically require an objective Limb Symmetry Index (LSI) > 90% on functional hop testing, as well as > 90% isokinetic quadriceps and hamstring strength compared to the uninjured leg.

Question 38

A 45-year-old tennis player presents with persistent shoulder pain despite conservative management. MRI reveals a Partial Articular-Sided Supraspinatus Tendon Avulsion (PASTA) lesion that involves roughly 60% of the tendon thickness. What is the most appropriate surgical treatment?

Explanation

Articular-sided partial rotator cuff tears involving greater than 50% of the tendon footprint thickness generally require surgical repair, either by completing the tear and repairing it or by performing a transtendon in situ repair.

Question 39

Biomechanical studies have demonstrated that a medial meniscus posterior root tear alters knee joint kinematics in a manner functionally equivalent to which of the following conditions?

Explanation

A complete tear of the medial meniscus posterior root abolishes hoop stresses within the meniscus, causing the meniscus to extrude. Biomechanically, this results in increased contact pressures equivalent to a total medial meniscectomy.

Question 40

The anterolateral ligament (ALL) of the knee originates posterior and proximal to the lateral epicondyle and inserts on the proximal tibia midway between Gerdy's tubercle and the fibular head. What is its primary biomechanical role?

Explanation

The ALL functions as an important secondary stabilizer to the ACL, primarily resisting internal rotation of the tibia, especially at flexion angles greater than 30 degrees. Its compromise contributes to a high-grade pivot shift.

Question 41

A 28-year-old competitive weightlifter feels a sudden pop and tearing sensation in his anterior chest while bench pressing. Examination reveals ecchymosis and loss of the normal axillary fold contour. If surgical repair is performed, the ruptured tendon should be reattached to which anatomical landmark?

Explanation

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

Question 42

A patient with knee instability is examined using the dial test. The examiner notes 15 degrees of increased external rotation of the affected limb compared to the normal limb at 30 degrees of knee flexion, but there is no side-to-side difference at 90 degrees of knee flexion. This finding strongly suggests an isolated injury to which structure?

Explanation

An isolated posterolateral corner (PLC) injury presents with increased external rotation at 30 degrees of flexion but not at 90 degrees. If external rotation is increased at both 30 and 90 degrees, a combined PLC and PCL injury is present.

Question 43

During a massive rotator cuff repair, the surgeon opts to perform an open subpectoral biceps tenodesis. If retractor placement and dissection drift too far medial to the short head of the biceps/coracobrachialis, which nerve is at greatest risk of iatrogenic injury?

Explanation

The musculocutaneous nerve enters the coracobrachialis approximately 5-8 cm distal to the coracoid process. Retractors placed too aggressively medial to the conjoint tendon during a subpectoral biceps tenodesis can easily injure this nerve.

Question 44

Which component of the posterolateral corner (PLC) of the knee is the primary restraint to external rotation of the tibia at 30 degrees of knee flexion?

Explanation

While the LCL is the primary restraint to varus stress, the popliteus complex (specifically the popliteofibular ligament and popliteus tendon) is the primary restraint to external tibial rotation.

Question 45

A 32-year-old elite volleyball player presents with isolated weakness in external rotation of his dominant shoulder. Physical examination reveals atrophy isolated to the infraspinatus fossa, with normal supraspinatus bulk and strength. Magnetic resonance imaging (MRI) is most likely to reveal a paralabral cyst causing nerve compression at which anatomical location?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only its distal motor branch to the infraspinatus, causing isolated external rotation weakness and atrophy. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 46

During an anatomic anterior cruciate ligament (ACL) reconstruction, failure to adequately recreate the posterolateral (PL) bundle will most likely result in a persistent deficit in which of the following biomechanical functions?

Explanation

The ACL consists of the anteromedial (AM) and posterolateral (PL) bundles. The PL bundle is tightest in extension and provides the primary restraint against rotatory loads, so failure to recreate it leads to persistent rotatory instability.

Question 47

The rotator cable is a thick band of capsuloligamentous tissue that transfers forces from the rotator cuff muscles to the humerus. According to the "suspension bridge" model proposed by Burkhart, in which of the following tear patterns is near-normal cuff kinematics most likely maintained?

Explanation

Burkhart described the rotator cable as a suspension bridge that stress-shields the thinner, avascular crescent tissue. Tears confined strictly to the crescent area with an intact cable preserve the force transmission mechanism, often maintaining near-normal function.

Question 48

A 24-year-old professional athlete sustains an acute, isolated grade III posterior cruciate ligament (PCL) injury. If nonoperative management is chosen, which of the following rehabilitation protocols is most appropriate during the first 2 to 4 weeks?

Explanation

Initial nonoperative management for isolated PCL tears involves immobilization in full extension to counteract the posterior pull of the hamstrings and prevent posterior tibial sag. Open kinetic chain hamstring exercises are strictly avoided early on as they exacerbate posterior translation.

Question 49

A 22-year-old collegiate football player sustains a valgus blow to the knee. Physical examination reveals a grade III medial collateral ligament (MCL) sprain with significantly increased valgus laxity at both 0 and 30 degrees of knee flexion. This finding implies a concomitant injury to which of the following structures?

Explanation

Valgus laxity isolated to 30 degrees of flexion indicates a superficial MCL tear. Additional valgus laxity at 0 degrees of extension strongly implies concomitant injury to the posterior oblique ligament (POL) and the posteromedial capsule.

Question 50

A 65-year-old man presents with severe shoulder pain, pseudoparalysis, and an irreparable massive rotator cuff tear. Radiographs show Hamada grade 3 changes (acetabularization of the acromion). Which of the following is the most appropriate definitive surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for older patients with cuff tear arthropathy and pseudoparalysis. It alters the center of rotation, allowing the deltoid to elevate the arm and restoring function despite the absent rotator cuff.

Question 51

When comparing bone-patellar tendon-bone (BTB) autograft to quadrupled hamstring autograft for ACL reconstruction, which of the following is a recognized characteristic of the BTB autograft?

Explanation

BTB autografts facilitate rapid bone-to-bone healing in the osseous tunnels, typically integrating within 6 to 8 weeks. However, they are associated with a higher incidence of donor-site morbidity, including anterior knee pain and kneeling discomfort.

Question 52

Accurate anatomic restoration is critical during rotator cuff repair. The native footprint of the supraspinatus tendon on the greater tuberosity is best described as having which of the following approximate dimensions?

Explanation

The supraspinatus insertion footprint is roughly triangular, measuring approximately 16 mm in the medial-to-lateral dimension and 25 mm anterior-to-posterior. Understanding this anatomy is critical for achieving adequate footprint coverage during surgical repair.

Question 53

During the evaluation of a suspected posterolateral corner (PLC) knee injury, the dial test is performed. An increase in external rotation of 15 degrees at 30 degrees of knee flexion, but no asymmetry at 90 degrees of flexion, most strongly suggests which of the following injury patterns?

Explanation

An increase in external rotation of greater than 10-15 degrees at 30 degrees of flexion compared to the contralateral side indicates an isolated posterolateral corner (PLC) injury. If the asymmetry persists or increases at 90 degrees, it indicates a combined PCL and PLC injury.

Question 54

In the evaluation of a partial-thickness articular-sided rotator cuff tear (PASTA lesion), surgical repair (either via transtendinous technique or tear completion) is generally indicated over simple arthroscopic debridement when the tear involves what percentage of the native tendon thickness?

Explanation

Surgical repair is generally indicated for partial-thickness rotator cuff tears that involve >50% of the tendon thickness (approximately 7-8 mm of the footprint). Tears involving <50% are typically managed with arthroscopic debridement if nonoperative measures fail.

Question 55

A 28-year-old male is evaluated following a traumatic posterior knee dislocation that was immediately reduced in the emergency department. His foot is warm and well-perfused, but the Ankle-Brachial Index (ABI) of the injured extremity is 0.82. What is the most appropriate next step in management?

Explanation

An ABI < 0.90 after a knee dislocation signifies a high risk for an intimal tear or vascular injury requiring intervention. CT angiography (or traditional arteriography) is urgently indicated to confirm and localize the popliteal artery lesion.

Question 56

The Goutallier classification is utilized on imaging to grade fatty infiltration of the rotator cuff muscles, which correlates with repair prognosis. Which Goutallier grade is specifically defined as having more fat than muscle within the muscle belly?

Explanation

In the Goutallier classification, Grade 3 denotes equal amounts of fat and muscle. Grade 4 is strictly defined as having more fat than muscle within the muscle belly, indicating a poor prognosis for structural healing.

Question 57

A 10-year-old boy (Tanner stage I) sustains a midsubstance ACL rupture and experiences recurrent giving-way episodes despite bracing. What is the most appropriate surgical intervention to stabilize the knee while minimizing the risk of iatrogenic growth arrest?

Explanation

In skeletally immature patients with significant remaining growth (Tanner stage I or II), a physeal-sparing all-epiphyseal ACL reconstruction is recommended. This avoids drilling across the open physes, minimizing the risk of physeal arrest and subsequent angular deformities.

Question 58

Which of the following physical examination maneuvers is considered the most sensitive test for diagnosing a superior partial tear of the subscapularis tendon?

Explanation

The bear-hug test isolates the superior portion of the subscapularis and is highly sensitive and specific for upper subscapularis tears. The lift-off and belly-press tests are less sensitive for superior tears and better at detecting lower or massive complete tendon ruptures.

Question 59

A 24-year-old skier sustains a twisting injury to the knee. A plain radiograph is shown in Figure 1.

The image reveals an avulsion fracture of the lateral tibial plateau (Segond fracture). This pathognomonic finding is most strongly associated with injury to which of the following structures?

Explanation

A Segond fracture is a cortical avulsion of the anterolateral capsular structures from the lateral tibial plateau. It is highly associated (75-100%) with an anterior cruciate ligament (ACL) tear.

Question 60

A 65-year-old man presents with chronic weakness in external rotation and abduction. MRI reveals a massive, retracted tear of the supraspinatus and infraspinatus. Retraction of these tendons medial to the glenoid places which nerve at greatest risk of tethering and subsequent injury?

Explanation

Massive, retracted rotator cuff tears of the supraspinatus and infraspinatus can tether the suprascapular nerve. This most commonly occurs at the suprascapular notch or spinoglenoid notch, leading to denervation and further atrophy.

Question 61

A patient presents with knee pain and instability after a dashboard injury. The dial test shows 15 degrees of increased external rotation of the tibia at 30 degrees of knee flexion compared to the contralateral side, but symmetric external rotation at 90 degrees. What is the most likely diagnosis?

Explanation

The dial test with increased external rotation at 30 degrees but not 90 degrees indicates an isolated posterolateral corner (PLC) injury. If external rotation is increased at both 30 and 90 degrees, it suggests a combined PCL and PLC injury.

Question 62

A 45-year-old weightlifter feels a pop in his anterior shoulder while bench pressing. On examination, he has increased passive external rotation and a positive lift-off test. Which tendon is most likely injured?

Explanation

The subscapularis is the primary internal rotator of the shoulder. Injury results in increased passive external rotation and weakness in internal rotation, which is clinically demonstrated by a positive lift-off, belly-press, or bear-hug test.

Question 63

When comparing bone-patellar tendon-bone (BPTB) autografts to hamstring autografts for primary ACL reconstruction, BPTB grafts are historically associated with a higher incidence of which of the following complications?

Explanation

BPTB autografts are associated with a higher incidence of anterior knee pain and pain with kneeling compared to hamstring autografts. Rates of overall clinical stability and graft rupture are generally similar.

Question 64

A 28-year-old baseball pitcher undergoes shoulder arthroscopy. A partial articular-sided supraspinatus tendon avulsion (PASTA) involving 60% of the tendon thickness is identified. What is the most appropriate surgical management?

Explanation

For articular-sided partial rotator cuff tears involving greater than 50% of the tendon thickness, completion of the tear and formal repair (or an in situ repair) is recommended. Debridement alone is insufficient for high-grade tears and has higher failure rates.

Question 65

A 25-year-old male is evaluated in the trauma bay following a high-velocity anterior knee dislocation. The knee is reduced, but the ankle-brachial index (ABI) is 0.8. What is the most appropriate next step in management?

Explanation

An ABI of less than 0.9 following a knee dislocation is highly suspicious for a popliteal artery injury. This mandates immediate advanced imaging, typically a CT angiogram, to accurately delineate the vascular injury before potential surgical intervention.

Question 66

Compared to single-row repair, biomechanical studies of double-row rotator cuff repair demonstrate which of the following characteristics?

Explanation

Biomechanical studies show that double-row rotator cuff repairs provide higher construct stiffness, increased footprint contact area, and decreased gap formation compared to single-row repairs. However, demonstrating superior long-term clinical outcomes remains controversial.

Question 67

A 21-year-old football player sustains a valgus blow to the knee. MRI confirms an isolated, acute grade III injury to the medial collateral ligament (MCL) at the femoral attachment. What is the recommended treatment?

Explanation

Isolated grade III MCL injuries, particularly those at the femoral insertion, have excellent healing potential. They are typically treated successfully nonoperatively with a hinged knee brace to protect against valgus stress and early functional rehabilitation.

Question 68

In the evaluation of chronic rotator cuff tears, which of the following MRI findings is the most significant predictor of structural failure after an attempted rotator cuff repair?

Explanation

High-grade fatty infiltration (Goutallier stage 3 or 4) and severe muscle atrophy are strong independent predictors of poor tendon healing, persistent weakness, and structural failure following rotator cuff repair.

Question 69

During surgical reconstruction of the posterolateral corner (PLC) of the knee, the surgeon must reconstruct the primary static stabilizer to varus stress. Which structure inserts on the lateral aspect of the fibular head, anterior to the popliteofibular ligament?

Explanation

The lateral collateral ligament (LCL) is the primary static stabilizer to varus stress. It originates on the lateral femoral epicondyle and inserts on the lateral aspect of the fibular head, anterior to the popliteofibular ligament insertion.

Question 70

A 72-year-old woman with pseudoparalysis and severe rotator cuff arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA). The biomechanical advantage of RTSA relies on shifting the center of rotation in which directions compared to the native shoulder?

Explanation

RTSA medializes and inferiorizes the center of rotation. This increases the lever arm of the deltoid muscle and improves its resting tension, allowing the deltoid to effectively elevate the arm in the absence of a functional rotator cuff.

Question 71

A 9-year-old prepubescent soccer player with wide-open physes sustains a complete ACL tear. Nonoperative management has failed due to recurrent instability. What is the most appropriate surgical technique to minimize the risk of limb length discrepancy and angular deformity?

Explanation

In prepubescent children with significant growth remaining (Tanner stage 1 or 2), physeal-sparing techniques (such as all-epiphyseal or extra-articular ITB reconstruction) are indicated to minimize the risk of physeal arrest. Delaying surgery in unstable knees leads to high rates of meniscal and chondral damage.

Question 72

A 35-year-old man presents with acute, severe shoulder pain that lasted for two weeks, followed by painless weakness in external rotation and forward elevation. MRI shows no rotator cuff tear but diffuse edema in the supraspinatus and infraspinatus muscles. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) is characterized by an acute onset of severe shoulder pain followed by painless weakness and muscle atrophy. MRI typically shows denervation edema in the affected muscles without a mechanical cause.

Question 73

The posterior cruciate ligament (PCL) is composed of two primary bundles. Which statement accurately describes the tensioning pattern of the larger bundle during normal knee range of motion?

Explanation

The PCL consists of the larger anterolateral bundle (ALB) and smaller posteromedial bundle (PMB). The ALB is predominantly tight in knee flexion, while the PMB is tight in knee extension.

Question 74

A patient complains of anterior shoulder pain exacerbated by forward elevation, adduction, and internal rotation ("cross-body" movement). MRI reveals narrowing of the coracohumeral interval to 5 mm and subscapularis tendinosis. This presentation is most consistent with:

Explanation

Subcoracoid impingement classically presents with anterior shoulder pain exacerbated by a cross-body position (adduction and internal rotation). A coracohumeral interval of less than 6 mm on axial MRI supports the diagnosis.

Question 75

A 24-year-old athlete undergoes an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. If the femoral tunnel is inadvertently placed too far anteriorly, what is the most likely biomechanical consequence during range of motion?

Explanation

An anteriorly placed femoral tunnel causes the ACL graft to become excessively tight in flexion. This leads to a significant loss of knee flexion, altered kinematics, and potential graft stretching or failure over time.

Question 76

A 65-year-old man presents with chronic shoulder weakness. Magnetic resonance imaging reveals a massive, retracted tear involving both the supraspinatus and infraspinatus tendons. Medial retraction of the supraspinatus tendon past the glenoid rim places which of the following structures at the greatest risk of tethering or traction injury?

Explanation

Massive, retracted tears of the posterosuperior rotator cuff can cause traction and tethering of the suprascapular nerve at the suprascapular or spinoglenoid notch, potentially leading to further denervation and muscle atrophy.

Question 77

A 19-year-old soccer player sustains a valgus injury to his left knee. Examination shows 10 mm of medial joint space opening at 30 degrees of flexion with a firm endpoint, but no opening at 0 degrees of flexion. What is the most appropriate initial management?

Explanation

An isolated grade II medial collateral ligament (MCL) sprain (opening at 30 degrees but stable at 0 degrees) is highly responsive to nonoperative management with a hinged knee brace and early functional rehabilitation.

Question 78

A 45-year-old weightlifter feels a sudden pop in his shoulder while performing heavy bench presses. Physical examination reveals significantly increased passive external rotation compared to the contralateral side and a positive belly-press test. Which of the following structures is most likely injured?

Explanation

The subscapularis is the primary internal rotator of the shoulder. A tear typically results in increased passive external rotation, weakness in internal rotation, and a positive belly-press or lift-off test.

Question 79

During an isolated posterior cruciate ligament (PCL) reconstruction using an Achilles tendon allograft, the surgeon utilizes a tibial inlay technique rather than a transtibial tunnel technique. What is the primary biomechanical advantage of the tibial inlay technique?

Explanation

The tibial inlay technique avoids the acute angle (the "killer turn") that the graft must make at the posterior tibial tunnel aperture in a transtibial technique, reducing the risk of graft attenuation and failure.

Question 80

A 70-year-old patient with a chronic rotator cuff tear is evaluated for potential surgical repair. Preoperative MRI demonstrates Goutallier stage 4 fatty infiltration of the infraspinatus muscle. Which of the following best describes this finding and its clinical implications?

Explanation

Goutallier stage 4 signifies there is more fat than muscle in the rotator cuff belly. This high-grade fatty infiltration is largely irreversible and strongly correlates with poor functional outcomes and high re-tear rates following repair.

Question 81

A 30-year-old motorcyclist sustains a traumatic high-velocity knee dislocation. Following emergent closed reduction in the trauma bay, ankle-brachial indices (ABI) are measured at 0.8. What is the next most appropriate step in management?

Explanation

An ABI less than 0.9 following a knee dislocation is highly suspicious for a popliteal artery injury. Emergent CT angiography or immediate vascular surgery consultation is required to evaluate for an intimal flap or complete occlusion.

Question 82

A 55-year-old active manual laborer undergoes arthroscopic repair of a supraspinatus tear and is found to have a concurrent high-grade partial tear of the long head of the biceps tendon. He is heavily reliant on arm strength and explicitly expresses concern regarding postoperative cosmetic deformity and muscle cramping. Which of the following is the most appropriate management for the biceps tendon?

Explanation

Biceps tenodesis maintains the length-tension relationship of the biceps muscle, significantly decreasing the risk of the "Popeye" deformity and biceps cramping that can occur with a simple tenotomy, especially in younger or highly active patients.

Question 83

A 22-year-old collegiate football player sustains a direct blow to the anteromedial aspect of his knee. Examination reveals a positive dial test at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees of flexion. Which structural injury is most consistent with these physical examination findings?

Explanation

An isolated posterolateral corner (PLC) injury results in increased external rotation (a positive dial test) at 30 degrees of flexion but normal rotation at 90 degrees. If the dial test is positive at both 30 and 90 degrees, a combined PLC and PCL injury is present.

Question 84

Incorporating the concept of margin convergence during the repair of a massive, U-shaped rotator cuff tear provides which of the following primary biomechanical benefits?

Explanation

Margin convergence involves the side-to-side suturing of a U-shaped rotator cuff tear. This effectively reduces the overall size of the defect and significantly decreases the strain and tension at the tendon-bone interface when the free margin is ultimately repaired.

Question 85

Compared to a bone-patellar tendon-bone autograft, the use of a non-irradiated tibialis anterior allograft for anterior cruciate ligament reconstruction in a 16-year-old competitive athlete is associated with a significantly higher risk of which of the following complications?

Explanation

The use of allografts in young, highly active competitive athletes has been consistently shown to have a significantly higher rate of clinical failure and graft rupture compared to autografts, likely due to delayed biological incorporation and altered remodeling.

Question 86

A 72-year-old woman presents with severe shoulder pain and pseudoparalysis. Radiographs show significant superior migration of the humeral head with articulation against the acromion. Which of the following is an absolute contraindication to performing a reverse total shoulder arthroplasty in this patient?

Explanation

A functioning deltoid muscle and an intact axillary nerve are absolute prerequisites for a reverse total shoulder arthroplasty. The biomechanics of the reverse implant rely entirely on the deltoid to elevate the arm in the absence of a functioning rotator cuff.

Question 87

In ACL reconstruction utilizing a quadrupled hamstring graft and a cortical suspension button (e.g., Endobutton) for femoral fixation, the "bungee cord effect" and "windshield wiper effect" are established mechanisms that most commonly lead to which of the following postoperative radiographic findings?

Explanation

Cortical suspensory fixation techniques place the fixation point far from the joint line, allowing for micromotion of the graft within the tunnel (the bungee cord and windshield wiper effects). This micromotion is a primary cause of postoperative tunnel widening.

Question 88

A 21-year-old collegiate baseball pitcher presents with chronic posterior shoulder pain primarily occurring during the late cocking phase of throwing. Magnetic resonance arthrography reveals a partial-thickness articular-sided tear of the posterior supraspinatus and anterior infraspinatus, along with posterosuperior labral fraying. What is the most likely diagnosis?

Explanation

Internal impingement occurs in overhead athletes during extreme abduction and external rotation (the late cocking phase). This position causes the articular surface of the posterosuperior rotator cuff to impinge between the greater tuberosity and the posterosuperior glenoid labrum.

Question 89

A 28-year-old recreational skier sustains an acute ACL tear. Concurrent injury to the posterior horn of the medial meniscus root is identified on preoperative MRI. If the medial meniscus root tear is left completely untreated at the time of ACL reconstruction, the knee biomechanics will most closely resemble which of the following states?

Explanation

A posterior root tear of the medial meniscus completely disrupts the meniscal hoop stresses, causing extrusion of the meniscus under load. Biomechanically, this is equivalent to a total medial meniscectomy, predisposing the joint to rapid compartmental osteoarthritis.

Question 90

A 25-year-old athlete undergoes an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. Which of the following is the most common complication associated with this specific graft choice when compared directly to a hamstring autograft?

Explanation

Bone-patellar tendon-bone (BTB) autografts are historically associated with a higher incidence of anterior knee pain and kneeling pain (donor site morbidity) compared to hamstring autografts. Both graft types exhibit similar rates of overall clinical stability and graft survival.

Question 91

A 65-year-old man presents with pseudoparalysis of the right shoulder and a massive, irreparable posterosuperior rotator cuff tear. Anteroposterior radiographs demonstrate an acromiohumeral interval of 3 mm with superior subluxation of the humeral head. Which of the following is the most appropriate definitive surgical treatment?

Explanation

In older patients with a massive irreparable rotator cuff tear, pseudoparalysis, and established rotator cuff arthropathy (evidenced by an acromiohumeral interval <7 mm), a reverse total shoulder arthroplasty provides the most reliable improvement in pain and function. Anatomic total shoulder arthroplasty is contraindicated due to the deficient rotator cuff.

Question 92

When assessing a patient with a suspected multiligamentous knee injury, the 'dial test' is performed. Increased external rotation of the tibia of 15 degrees compared to the contralateral side at 30 degrees of flexion, but equal rotation at 90 degrees of flexion, indicates an isolated injury to which of the following structures?

Explanation

The dial test assesses for posterolateral instability by measuring external rotation of the tibia. Increased rotation at 30 degrees of flexion only indicates an isolated posterolateral corner (PLC) injury. Increased rotation at both 30 and 90 degrees indicates combined injury to the PLC and the posterior cruciate ligament (PCL).

Question 93

A 45-year-old male presents with weakness in internal rotation and a positive 'lift-off' test following a traumatic shoulder dislocation. MRI confirms an isolated, retracted tear of the subscapularis tendon. During arthroscopic repair, which specific anatomical landmark helps identify the superolateral border of the retracted subscapularis tendon?

Explanation

The 'comma sign' is formed by the superior glenohumeral ligament and the coracohumeral ligament, which tear away from their insertion and remain attached to the superolateral corner of the retracted subscapularis tendon. Recognizing this comma-shaped arc of tissue is a critical step in retrieving and repairing retracted subscapularis tears.

Question 94

A 30-year-old female undergoes arthroscopic evaluation for persistent shoulder pain. An articular-sided partial-thickness supraspinatus tear (PASTA lesion) is identified. The tear involves 60% of the tendon footprint depth. What is the most appropriate surgical management?

Explanation

Partial-thickness articular-sided rotator cuff tears involving greater than 50% of the tendon thickness (usually >6mm) are generally treated with surgical repair. Debridement alone is indicated for low-grade tears involving less than 50% of the footprint.

Question 95

During posterior cruciate ligament (PCL) reconstruction, the surgeon targets the primary function of the larger, stronger bundle of the PCL. Which bundle is this, and at what knee position is it most taut?

Explanation

The PCL consists of the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB). The ALB is most taut in flexion, whereas the PMB is taut in extension. Single-bundle PCL reconstructions primarily aim to restore the ALB.

Question 96

A 19-year-old football player sustains a high-energy knee injury resulting in an acute knee dislocation. Following closed reduction, his distal pulses are palpable but seem slightly asymmetric. What is the most appropriate next step in management to rule out a sight-threatening complication?

Explanation

Vascular assessment is critical in the setting of a knee dislocation. If pulses are asymmetric or the ABI is less than 0.9, an immediate CT angiogram or vascular surgery consultation is required to rule out a popliteal artery injury, which carries a high risk of amputation if missed.

Question 97

A 28-year-old skier sustains an isolated Grade III medial collateral ligament (MCL) tear localized entirely to the proximal (femoral) attachment. What is the most appropriate initial management for this injury?

Explanation

Isolated proximal (femoral) and midsubstance Grade III MCL tears typically heal predictably well with nonoperative management, consisting of a hinged knee brace and early functional rehabilitation. Distal (tibial) avulsions have a higher risk of nonhealing (Stener-like lesion) and may occasionally require acute surgical repair.

Question 98

During an arthroscopic anterior cruciate ligament (ACL) reconstruction using an anteromedial portal technique for femoral tunnel drilling, what is the most significant surgical risk associated with this method compared to a traditional transtibial approach?

Explanation

Drilling the femoral tunnel through the anteromedial portal allows for more anatomical placement of the ACL graft compared to the transtibial technique. However, it increases the risk of posterior wall blowout, creating a critically short femoral tunnel, and potentially damaging the medial femoral condyle articular cartilage during drilling.

Question 99

A 55-year-old male with a massive rotator cuff tear is being evaluated for surgical repair. The surgeon assesses muscle quality on the preoperative MRI. According to the Goutallier classification, Grade 3 fatty infiltration of the rotator cuff muscles is defined as:

Explanation

The Goutallier classification grades fatty infiltration of the rotator cuff muscles. Grade 1 is some fatty streaks, Grade 2 is more muscle than fat, Grade 3 is equal amounts of fat and muscle, and Grade 4 is more fat than muscle. Higher grades correlate with a higher risk of structural failure after repair.

Question 100

A 24-year-old athlete undergoes evaluation for a revision anterior cruciate ligament (ACL) reconstruction. Preoperative computed tomography (CT) reveals significant widening of the previous tibial and femoral tunnels, both measuring 17 mm in diameter. What is the most appropriate surgical strategy?

Explanation

In revision ACL reconstruction, severe tunnel widening (typically greater than 14-15 mm) or malpositioned tunnels that intersect with the planned anatomic tunnels mandate a two-stage approach. The first stage involves bone grafting the enlarged tunnels, followed by a second-stage ACL reconstruction 4 to 6 months later.

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

AAOS Sports Medicine MCQs (Set 2): Knee Ligament & Rotator Cuff Injuries | Board Review

Key Takeaway

AAOS Sports Medicine MCQs (Set 2): Knee Ligament & Rotator Cuff Injuries | Board Review

Chapter Index