AAOS/ABOS Sports Medicine MCQs: Trauma Board Review

Question 1

A 32-year-old amateur bowler has progressive pain in the lateral aspect of the proximal forearm and elbow. Nonsurgical management consisting of a tennis elbow brace, nonsteroidal anti-inflammatory drugs, and activity modification has failed to provide relief. Examination reveals tenderness in the lateral aspect of the proximal forearm and exacerbation of symptoms with resisted finger extension. Radiographs of the elbow reveal no abnormalities. Which of the following studies will aid in diagnosis?

Explanation

It is often difficult to accurately discern between lateral epicondylitis and radial tunnel syndrome. Neither MRI nor a bone scan is likely to reveal abnormalities. Electrodiagnostic studies are often inconclusive, and radial tunnel syndrome often presents without motor weakness. The symptoms of radial tunnel syndrome are expected to improve with an injection of lidocaine into the radial tunnel; therefore, this is the test of choice in this clinical scenario. Radiographs of the wrist will not assist in making the diagnosis. Eversmann WW Jr: Entrapment and compression neuropathies, in Green DP (ed): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingston, 1993, pp 1341-1385.

Question 2

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Explanation

Failure of the scalene block, necessitating general anesthesia or the immediate administration of narcotic medications, is the most common complication, occurring in 3% to 18% of patients. Cardiac arrest or cardiovascular collapse has been reported in anecdotal occurrences. Seizure that is the result of intravascular injection of local anesthetic is a rare complication, with an incidence reported of 0% to 6%. Neurologic complications, including laryngeal and phrenic nerve injuries, are rare although parathesias lasting up to 2 weeks have been reported in up to 3% of patients. Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002;84:775-779.

Question 3

Figure 22 shows the MRI scan of a 20-year-old female basketball player who has pain over the anterior knee that interferes with her performance. Examination reveals phase III Blazina patellar tendinosis. Management should consist of

Explanation

Excision of the affected mucoid degenerative area is considered appropriate management in the Blazina classification system. A finding of phase III indicates persistent pain with or without activities, as well as deterioration of performance. With the appearance of the mucoid degeneration and the vigorous activity level of the intercollegiate basketball player, it is unlikely that nonsurgical management will provide adequate relief. When excising the affected degenerative area, care must be taken to retain normal tendon fibers. The defect in the patellar tendon is closed with absorbable sutures, as is the paratenon. Postoperative rehabilitation involves initial mobilization extension, with progressive range-of-motion and mobilization exercises as tolerated and weight bearing as tolerated. Open chain and isokinetic exercises are delayed until full range of motion and mobility is obtained, generally within 4 weeks. A return to activities is achieved by 80% to 90% of athletes, although there may be occasional activity-related aching for 4 to 6 months after surgery. Blazina ME, et al: Jumper's knee. Orthop Clin North Am 1973;4:665. Kelly DW, Carter VS, Jobe FW, Kerlan RK: Patellar and quadriceps tendon ruptures: Jumper's knee. Am J Sports Med 1984;12:375-380. Krums PE, Ryder B: Operative treatment of patella tendon disorders. Operative Techniques Sports Med 1994;2:303.

Question 4

When comparing the failure load of an evenly tensioned four-stranded hamstring tendon anterior cruciate ligament autograft to a 10-mm bone-patellar tendon-bone autograft, the hamstring graft will fail at a tension

Explanation

The failure load of an evenly tensioned four-stranded hamstring tendon autograft has been reported to be 4,500 Newtons. The failure load of a 10-mm patellar tendon autograft has been estimated at 2,600 Newtons. The intact anterior cruciate ligament failure load has been calculated at 1,725 Newtons. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454. Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.

Question 5

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Explanation

Recent studies have documented that an arthroscopic Bankart repair performed with good technique can produce success rates similar to an open repair. However, the results of an arthroscopic repair deteriorate significantly if there is a 25% or greater anterior-inferior glenoid rim defect (inverted pear configuration) or an engaging Hill-Sachs lesion in which the humeral head defect keys onto the glenoid rim in abduction and external rotation. If either of these entities exist or there is multidirectional instability with pathologic hyperextensible tissue laxity, an open repair is recommended. An associated SLAP lesion would not significantly affect the result of the Bankart procedure. Not infrequently, the anterior glenoid labrum is partially or completely disrupted and, in itself, is not a contraindication to arthroscopic Bankart repair. In almost all patients with predominantly unidirectional instability, some degree of capsular/anterior-inferior glenohumeral ligament attenuation is present and can be addressed during the arthroscopic repair. Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694.

Question 6

A 37-year-old man has had isolated chronic knee swelling for the past 6 months. He denies any history of specific trauma. Examination reveals a large effusion with a stable knee, but the remainder of the examination is normal. Plain radiographs are unremarkable. An MRI scan reveals a large effusion without meniscal injury. An arthroscopic image of the suprapatellar pouch is shown in Figure 23. What is the most likely diagnosis?

Explanation

The history and physical examination are consistent with a monoarticular joint condition but not typical of joint sepsis. The arthroscopic appearance of brownish proliferative synovium is typical of PVNS. PVNS is a monoarticular synovial disease of unknown etiology and is treated with total synovectomy. The proliferative synovitis is not consistent with chondromalacia. Synovial cell sarcoma is an extracapsular disease. Rheumatoid arthritis typically is polyarticular, and the synovial appearance is not associated with hemosiderin deposition. Flandry FC, Hughston JC, Jacobson KE, Barrack RL, McCann SB, Kurtz DM: Surgical treatment of diffuse pigmented villonodular synovitis of the knee. Clin Orthop 1994;300:183-192.

Question 7

A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?

Explanation

Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury. Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.

Question 8

An 18-year-old hockey player sustains an acute anterior shoulder dislocation that requires manual reduction. At arthroscopy, the lesion shown in Figure 24 will be observed in what percent of patients?

Explanation

The clinical photograph shows an acute capsulolabral avulsion from the anterior glenoid, also referred to as a Perthes-Bankart lesion. In patients who sustain an acute dislocation that requires a manual reduction, this pathologic lesion is observed with high frequency. In several research studies, it has been visualized in 80% to 95% of patients at arthroscopy. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.

Question 9

A 22-year-old competitive volleyball player has shoulder pain, and rest and a cortisone injection have failed to provide relief. Examination reveals atrophy along the posterior scapula, but an MRI scan does not reveal a rotator cuff tear or labral cyst. What is the most likely cause for the shoulder weakness?

Explanation

Repetitive overhead slams and serves may produce a traction injury to the distal branch of the suprascapular nerve. Bankart, biceps, and superior labrum anterior and posterior injuries can occur but usually do not produce visible atrophy. Muscle avulsion is uncommon. Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.

Question 10

An 11-year-old female gymnast has had gradually increasing right wrist pain for the past 6 months. Examination reveals normal range of motion and strength. Moderate tenderness is present over the distal radius. AP radiographs will most likely show

Explanation

Distal radial physeal stress syndrome has been reported in up to 25% of nonelite gymnasts showing premature closure of the distal radial physis and distal ulnar overgrowth, producing positive ulnar variance. The diagnosis should be suspected when there is tenderness at the distal radial physis in a young gymnast. The pathology is thought to be the result of repetitive compressive stresses caused by upper extremity weight-bearing forces. The recommended treatment is 3 to 6 months of rest. Salter-Harris fractures with a distal radial epiphyseal slip are unlikely, especially in the absence of a specific traumatic event. Mandelbaum BR, Bartolozzi AR, Davis CA, Teurlings L, Bragonier B: Wrist pain syndrome in the gymnast: Pathogenetic, diagnostic, and therapeutic consideration. Am J Sports Med 1989;17:305-317.

Question 11

A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees greater than the contralateral side. He has pain associated with abduction and external rotation but no apprehension. Which of the following tests would most likely reveal positive findings?

Explanation

Postoperative subscapularis detachment can be identified with a positive lift-off test that reveals weakness in internal rotation. This complication does not necessarily compromise the anterior capsule repair. The load-and-sift maneuver and articular contrast studies may be normal. Supraspinatus tests for impingement and weakness should be negative. Gerber C, Krushell RJ: Isolated ruptures of the tendon of the subscapularis muscle: Clinical fractures in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

Question 12

Figures 25a and 25b show the clinical photographs of a 19-year-old baseball outfielder who has shoulder pain after sliding headfirst into second base. He reports pain while batting, sliding, and catching. Examination reveals a posterior prominence during midranges of forward elevation, which then disappears with a palpable clunk during terminal elevation and abduction. What is the most likely diagnosis?

Explanation

A headfirst slide with the arm extended can injure the posterior shoulder. Winging of the scapula is dynamic and is considered a compensatory effort to prevent subluxation; it is not related to nerve injury. Posterior glenohumeral subluxation can be present during the initiation of a bat swing. Rotator cuff function, interval tears, and superior labrum tears can be painful but do not produce winging. Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

Question 13

A soccer player who sustained a twisting injury to the right ankle while making a cut is unable to bear weight and has diffuse tenderness over the anterior and lateral aspects of the ankle. Examination also shows a positive squeeze test. Plain radiographs and a stress radiograph are shown in Figures 26a through 26c. Radiographs of the leg and knee are normal. What is the most appropriate management?

Explanation

The mechanism of injury, physical examination, and radiographs indicate a "high" ankle sprain with disruption of the distal tibiofibular ligaments and interosseous membrane. These injuries typically involve pronation and external rotation forces. In addition, recovery is significantly delayed, often requiring 6 to 8 weeks to heal. Radiographs obtained months after recovery often show calcification within the distal syndesmosis, which is not typically symptomatic. This patient has gross instability, resulting in a high incidence of chronic diastasis and subluxation leading to impaired function. Treatment should consist of reduction and stabilization with a transsyndesmotic screw because this injury demonstrates a widened syndesmosis. Boytim MJ, Fisher DA, Neumann L: Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-298.

Question 14

When compared with the normal anterior cruciate ligament (ACL), placement of an anterior cruciate ligament graft in the over-the-top position on the femoral side has what effect on its function?

Explanation

The placement of ACL graft with respect to its femoral and tibial attachments has a significant effect on its function. Evidence has shown that if the graft is placed in the over-the-top position, the graft will become lax in flexion and more taut with extension. Conversely, if the graft is placed too anterior on the femoral side, it will tighten in flexion and become lax in extension. Azar FM: Revision anterior cruciate ligament reconstruction. Instr Course Lect 2002;51:335-342. Draganich LF, Hsieh YF, Sherwin SH, et al: Intra-articular anterior cruciate ligament graft placement on the average most isometric line on the femur: Does it reproducibly restore knee kinematics? Am J Sports Med 1999;27:329-334.

Question 15

An 11-year-old boy has right shoulder pain and has been unwilling to use the arm after throwing a baseball in a Little League game 3 weeks ago. Examination reveals upper arm and shoulder tenderness with swelling. A radiograph and MRI scan are shown in Figures 27a and 27b. Management should consist of

Explanation

The radiograph is consistent with a unicameral (simple) bone cyst. The MRI scan reveals that the cyst is juxtaposed to the physis and therefore can be classified as active (latent cysts are more than 1 cm away from the physis). Active cysts are treated with aspiration and steroid injection, although repeated injections may be necessary. Curettage and bone grafting results in more reliable healing but may lead to growth arrest in active cysts. Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 945-946.

Question 16

A 37-year-old recreational tennis player undergoes surgery for tennis elbow. Following surgery, she describes clicking and popping on the lateral aspect of the elbow. A lateral pivot shift test is positive. What is the most likely cause of her symptoms?

Explanation

The patient has a posterolateral rotatory instability (PLRI) of the elbow that is most likely the result of iatrogenic injury to the lateral ulnar collateral ligament, the main ligament implicated in PLRI. The anterior band of the medial collateral ligament is implicated in valgus instability. Injury to the radial nerve is unlikely, and the lateral radial collateral ligament makes less of a contribution to elbow stability than does the ulnar component. While the origin of the extensor carpi radialis brevis may contribute to elbow stability, it is not as important a stabilizer as the lateral ulnohumeral ligament. O'Driscoll SW, Morrey BF: Surgical reconstruction of the lateral collateral ligament, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 169-182.

Question 17

An 18-year-old football halfback reports that he had immediate right knee pain after being tackled 1 week ago. Examination now reveals moderate tenderness over the proximal medial tibia and lateral joint and normal cruciate stability. In evaluating the integrity of the posterolateral knee structures, what is the most reliable examination finding?

Explanation

The most reliable test for a relatively isolated posterolateral complex (PLC) injury is the asymmetric tibial external rotation or "dial test." It can be performed with the patient prone or supine. When greater than 10 degrees of external rotation at 30 degrees of flexion is present when compared with the opposite knee, it indicates significant damage to the posterolateral structures. Asymmetric external rotation, which is also present at 90 degrees of flexion, indicates injury to the posterior cruciate ligament (PCL) as well. Varus laxity may indicate significant damage to both the PLC and PCL. Approximately 35% of the normal population may have a reverse pivot shift when examined under anesthesia; therefore, it is considered a less specific test. The external rotation/recurvatum and posterolateral drawer tests are adjunctive in assessing isolated posterolateral laxity but are not thought to be as reliable. Veltri DM, Warren RF: Isolated and combined posterior cruciate injuries. J Am Acad Orthop Surg 1993;1:67-75.

Question 18

Figures 28a through 28d show the radiographs and MRI scans of a 20-year-old basketball player who sustained an inversion injury to his right ankle. Management should consist of

Explanation

Osteochondral fractures involving the talar dome have been classified based on radiographic and MRI findings. A nondisplaced and incomplete fracture may be treated effectively with a short leg cast and no weight bearing for 6 weeks. This patient has a complete, separated, and displaced osteochondral fragment involving the midlateral talar dome that will most likely cause pain, mechanical symptoms, and effusion if treated nonsurgically. In addition, there is very little bone remaining on the fragment, making the likelihood of healing with open reduction and internal fixation problematic. The treatment of choice includes arthroscopy, removal of the loose fragment, curettage or drilling of the base, and a rehabilitation program that emphasizes peroneal strengthening, range of motion, and proprioceptive training. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.

Question 19

A 19-year-old rugby player has severe knee pain after being injured in a game 2 weeks ago. Examination reveals a knee effusion, limited motion, and increased 3+ Lachman's test and anterior drawer. There is also increased external rotation at 30 degrees of knee flexion when the patient is placed in the prone position. Based on these findings, which of the following actions would most likely increase the risk of anterior cruciate ligament (ACL) reconstruction failure?

Explanation

The patient has a combined ACL and posterolateral corner injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. The tibial external rotation test is best performed with the patient in the prone position. A 10-degree side-to-side difference of external rotation at 30 degrees of knee flexion indicates injury to the posterolateral corner. Acute grade III isolated or combined injuries of the posterolateral corner are best treated early by direct repair or by augmentation or reconstruction of all injured ligaments. Postoperative arthrofibrosis after an ACL reconstruction has been observed with preoperative deficiencies of knee motion. Veltri DM, Warren RF: Posterolateral instability of the knee. J Bone Joint Surg Am 1994;76:460-472.

Question 20

The primary function of structure "A" in Figure 29 is to limit

Explanation

The primary function of the popliteofibular ligament is to resist posterolateral rotation of the tibia on the femur, although it also secondarily resists varus angulation and posterior displacement of the tibia on the femur. The posterior cruciate ligament resists posterior tibial displacement, especially at 90 degrees of flexion. The lateral collateral ligament primarily resists varus displacement at 30 degrees of flexion but also resists posterolateral rotatory displacement with flexion that is less than approximately 50 degrees. The anterior and posterior cruciate ligaments resist varus displacement (along with the lateral collateral ligament) at 0 degrees of flexion. The anterior cruciate ligament primarily resists anterolateral displacement of the tibia on the femur. Sugita T, Amis AA: Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 2001;29:466-472.

Question 21

While lifting weights, a patient feels a pop in his arm. He has the deformity shown in Figure 30. If left untreated, the patient will have the greatest deficiency in

Explanation

The patient has a distal biceps rupture. While the distal biceps contributes to elbow flexion, its main function is forearm supination. Baker BE, Bierwagen D: Rupture of the distal tendon of the biceps brachii: Operative versus non-operative treatment. J Bone Joint Surg Am 1985;67:414-417. D'Arco P, Sitler M, Kelly J, et al: Clinical, functional, and radiographic assessments of the conventional and modified Boyd-Anderson surgical procedures for repair of distal biceps tendon ruptures. Am J Sports Med 1998;26:254-261.

Question 22

Myositis ossificans is a recognized complication of contusion to the quadriceps muscle. During early rehabilitation, this condition is most likely to be exacerbated by

Explanation

Passive stretching is contraindicated during rehabilitation as it may potentiate the severity of the myositis ossificans. Electrical stimulation, iontophoresis, isometric exercise, and ice/heat contrast are not known to exacerbate this process. Brunet ME, Hontas RB: The thigh, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112.

Question 23

Which of the following symptoms are most commonly associated with piriformis syndrome?

Explanation

Piriformis syndrome is best characterized by localized posterior hip pain and radicular symptoms in the sciatic distribution because of compression of the piriformis muscle on the sciatic nerve. Weakness in hip extension is not a characteristic finding, nor is pain with hip abduction or flexion. Hypesthesia of the lateral thigh would be more characteristic of a lesion of the lateral femoral cutaneous nerve. Radiating medial thigh pain would suggest hip joint pathology or upper lumbar nerve root irritation. Weakness in internal rotation is not a characteristic feature, and hypesthesia of the perineum would suggest possible involvement of the pudendal nerve. Byrd JWT: Thigh, hip, and pelvis, in Miller MD, Cooper DE, Warner JJP (eds): Review of Sports Medicine and Arthroscopy, ed 2. Philadelphia, PA, WB Saunders, 2002, pp 114-139.

Question 24

A 19-year-old football player who sustained three traumatic anterior shoulder dislocations underwent surgery to repair a Bankart lesion. Nine months after surgery, examination reveals stability, elevation to 150 degrees, external rotation to 0 degrees with the elbow at his side and to 50 degrees at 90 degrees of abduction, and internal rotation to T12. If his range of motion does not improve, he is at most risk for

Explanation

Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure. A tight anterior capsule will prevent internal impingement. Risk of thoracic outlet syndrome should not be increased. Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted. In time, this patient's shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present. Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.

Question 25

A 30-year-old man underwent an open Bankart repair with capsulorrhaphy for recurrent anterior instability 6 months ago. In a recent fall, he described a hyperabduction and external rotation mechanism of injury. He denies dislocating his shoulder. He now has anterior shoulder pain, weakness, and the sensation of instability. Examination reveals tenderness just lateral to the coracoid and bicipital groove. An MRI scan is shown in Figure 31. Management should now consist of

Explanation

Subscapularis tendon tears are being recognized with increasing frequency, and the mechanism of injury involves hyperabduction and external rotation. The patient will have anterior shoulder pain and may report a sensation of instability. Examination will reveal anterior shoulder tenderness over the lesser tuberosity and bicipital groove, and the Gerber lift-off test usually is positive. The MRI scan shown here reveals an intact anterior labrum. The subscapularis tendon is avulsed and retracted, with no evidence of the biceps tendon within the groove; this implies dislocation of the biceps, a common accompanying feature of a subscapularis tear. This injury is also recognized as a complication after open anterior shoulder stabilizations where the subscapularis has been incised as part of the approach. Therefore, the appropriate management involves repair of the subscapularis. The injury does not represent a recurrence so immobilization or revision stabilization, which may be reasonable treatment for recurrent instability, is not indicated. The findings are not consistent with a superior labral tear. Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.

Question 26

A 22-year-old soccer player sustains a twisting injury to his knee. Radiographs reveal a small avulsion fracture of the lateral tibial plateau. What is the most commonly associated ligamentous injury?

Explanation

The clinical scenario describes a Segond fracture, an avulsion of the anterolateral ligament complex from the lateral tibial plateau. It is highly pathognomonic for an anterior cruciate ligament (ACL) tear.

Question 27

A 25-year-old overhead athlete presents with chronic anterior shoulder pain.

MRI arthrogram reveals a Type II SLAP lesion. Following arthroscopic repair, which of the following postoperative range of motion restrictions is most critical to protect the repair during the first 4 weeks?

Explanation

Type II SLAP repairs involve reattaching the superior labrum and biceps anchor. Combined abduction and external rotation places maximal peel-back stress on the superior labrum-biceps anchor complex and must be avoided early postoperatively.

Question 28

A 28-year-old professional hockey player sustains an inversion ankle injury. He has tenderness over the anterior inferior tibiofibular ligament (AITFL) and proximal fibula. Which test is most specific for diagnosing a syndesmotic injury in this patient?

Explanation

The external rotation stress test is considered the most reliable and specific clinical test for evaluating the integrity of the distal tibiofibular syndesmosis. The squeeze test has high specificity but lower sensitivity.

Question 29

During knee arthroscopy on a 45-year-old male, a posterior horn medial meniscus root tear is identified. Biomechanical studies indicate that failure to repair this lesion is most equivalent to which of the following?

Explanation

A medial meniscus posterior root tear disrupts the hoop stresses of the meniscus, leading to extrusion. Biomechanically, this results in contact pressures equivalent to a total meniscectomy, accelerating joint degeneration.

Question 30

A 19-year-old collegiate wrestler sustains an acute primary anterior shoulder dislocation. After successful closed reduction, what is the most significant risk factor for recurrent instability in this patient?

Explanation

The patient's age at the time of the initial anterior shoulder dislocation is the single most significant predictor of recurrence. Patients under 20 years old have recurrence rates exceeding 70% with conservative management.

Question 31

A 34-year-old recreational basketball player sustains an acute Achilles tendon rupture. He opts for nonoperative management with a functional rehabilitation protocol. Compared to operative repair, which of the following is true regarding his clinical outcomes?

Explanation

Historically, nonoperative management of Achilles tendon ruptures has a slightly higher re-rupture rate compared to operative repair, though functional rehab protocols have narrowed this gap. Operative management has a higher risk of wound complications.

Question 32

A 26-year-old female skier presents with a multiligamentous knee injury. Physical examination reveals a positive dial test with 15 degrees of increased external rotation at 30 degrees of flexion, but symmetric external rotation at 90 degrees of flexion. What is the most likely diagnosis?

Explanation

An isolated posterolateral corner (PLC) injury presents with increased external rotation at 30 degrees of knee flexion but not at 90 degrees. A combined PCL and PLC injury would show increased external rotation at both 30 and 90 degrees.

Question 33

A 42-year-old bodybuilder feels a pop in his anterior shoulder during a heavy bench press.

Examination shows loss of the axillary fold and weakness in internal rotation. MRI confirms a complete, retracted rupture of the pectoralis major. Which tendon head is most commonly ruptured in this scenario?

Explanation

Pectoralis major ruptures most commonly occur in weightlifters (e.g., bench pressing) and typically involve an avulsion of the sternal head at its humeral insertion. The sternal head is under maximal tension when the arm is extended and externally rotated.

Question 34

A 20-year-old gymnast has persistent anterolateral ankle pain 6 months following a severe inversion injury. MRI reveals a 12-mm osteochondral lesion of the talus (OLT) on the anterolateral dome. Initial management with immobilization and physical therapy has failed. What is the most appropriate next step in management?

Explanation

For symptomatic osteochondral lesions of the talus less than 1.5 cm in diameter that have failed nonoperative management, arthroscopic debridement and bone marrow stimulation (microfracture) is the gold standard primary surgical treatment.

Question 35

A 16-year-old female dancer experiences recurrent lateral patellar instability.

Imaging reveals a tibial tubercle-trochlear groove (TT-TG) distance of 22 mm and a normal patellar height. Which of the following surgical interventions is most appropriate?

Explanation

A TT-TG distance greater than 20 mm is a biomechanical risk factor for lateral patellar dislocation and an indication for a medializing tibial tubercle osteotomy (Fulkerson osteotomy) to correct the abnormal extensor mechanism vector.

Question 36

A 24-year-old male sustains a shoulder injury following a seizure. Examination reveals the arm is locked in internal rotation. Radiographs demonstrate a posterior shoulder dislocation with an anteromedial humeral head defect involving 30% of the articular surface. Which of the following is the most appropriate surgical management?

Explanation

A reverse Hill-Sachs lesion involving 20% to 40% of the articular surface requires defect filling to prevent recurrent posterior instability. The modified McLaughlin procedure (transfer of the lesser tuberosity/subscapularis into the defect) is indicated for these medium-sized defects.

Question 37

Which of the following native structures serves as the primary restraint to lateral patellar translation at 0 to 20 degrees of knee flexion?

Explanation

The medial patellofemoral ligament (MPFL) is the primary passive restraint to lateral patellar translation in early knee flexion (0 to 20 degrees), contributing approximately 50-60% of the restraining force.

Question 38

A 21-year-old collegiate football receiver sustains an acute, non-displaced Jones fracture (zone 2 of the proximal fifth metatarsal). He is eager to return to play this season. What is the most appropriate management?

Explanation

In high-level or elite athletes, acute Jones fractures are typically treated with intramedullary screw fixation to expedite return to play and reduce the risk of nonunion compared to conservative management.

Question 39

During reconstruction of the anterior cruciate ligament (ACL) using a bone-patellar tendon-bone autograft, the femoral tunnel is drilled too anteriorly. What is the most likely clinical consequence of this technical error?

Explanation

An anteriorly placed femoral tunnel in ACL reconstruction causes the graft to be relatively short in flexion and tightens excessively as the knee bends. This leads to a loss of deep flexion and a high risk of graft rupture during flexion.

Question 40

A 29-year-old overhead throwing athlete develops gradual onset of posterior shoulder pain. Examination demonstrates a positive impingement sign and localized tenderness at the posterior joint line when the arm is abducted and externally rotated.

What is the most likely pathophysiologic mechanism for this condition?

Explanation

The scenario describes internal impingement, common in overhead throwers. It is caused by the abutment of the articular surface of the rotator cuff and greater tuberosity against the posterosuperior glenoid labrum during late cocking (abduction and external rotation).

Question 41

A 12-year-old male soccer player with widely open physes sustains an acute, complete tear of the anterior cruciate ligament (ACL). He has recurrent episodes of giving way. To minimize the risk of physeal growth arrest or angular deformity during reconstruction, which of the following techniques is most appropriate?

Explanation

All-epiphyseal ACL reconstruction avoids drilling through the distal femoral and proximal tibial physes, significantly reducing the risk of premature physeal closure and angular deformity in skeletally immature patients with significant growth remaining.

Question 42

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder dislocations. A 3D computed tomography (CT) scan demonstrates 25% anterior glenoid bone loss. Which of the following is the most appropriate surgical management?

Explanation

The Latarjet procedure (coracoid transfer) is the gold standard for anterior shoulder instability in the presence of critical glenoid bone loss (typically >20-25%), which would otherwise result in a high failure rate if treated with an isolated soft-tissue Bankart repair.

Question 43

A professional American football player sustains a forced external rotation injury to his right ankle. On examination, he has pain over the anterior inferior tibiofibular ligament (AITFL) and a positive squeeze test. Initial radiographs are negative, but a gravity stress radiograph shows a medial clear space of 6 mm. What is the most appropriate definitive management?

Explanation

A medial clear space >4-5 mm on stress radiographs indicates a dynamically unstable syndesmotic injury. Operative reduction and stabilization with screws or suture-button devices is required to restore the mortise and prevent early osteoarthritis.

Question 44

A 24-year-old skier sustains a hyperextension and varus force to her knee. On physical examination, the dial test reveals 15 degrees of increased external rotation compared to the contralateral knee at 30 degrees of flexion, but symmetric external rotation at 90 degrees of flexion. Which injury pattern does this indicate?

Explanation

An increase in external rotation of >10 degrees at 30 degrees of flexion, which normalizes at 90 degrees of flexion, is diagnostic of an isolated posterolateral corner (PLC) injury. Combined PLC and PCL injuries show increased external rotation at both 30 and 90 degrees.

Question 45

A 30-year-old competitive weightlifter feels a "pop" in his chest while performing a heavy bench press. He presents with bruising over the anterior axillary fold and a loss of the normal axillary contour. Regarding the anatomy and pathology of this injury, which of the following statements is true?

Explanation

Pectoralis major ruptures classicly occur during the eccentric (lowering) phase of a bench press. The sternal head is most commonly involved, typically avulsing from its insertion on the proximal humerus.

Question 46

A 35-year-old recreational athlete sustains an acute Achilles tendon rupture. When comparing modern operative repair to modern functional nonoperative management (using strict early weight-bearing and functional bracing protocols), operative intervention is most closely associated with which of the following?

Explanation

Recent high-quality meta-analyses demonstrate that when strict functional rehabilitation protocols are utilized, re-rupture rates are equivalent between operative and nonoperative management. However, operative management carries a higher risk of wound complications and sural nerve injury.

Question 47

A 45-year-old male feels a pop in the back of his knee while squatting. An MRI demonstrates a posterior root tear of the medial meniscus. What is the primary biomechanical consequence of this specific injury?

Explanation

A meniscal root tear completely disrupts the ability of the meniscus to convert axial loads into circumferential hoop stresses. Biomechanically, this results in peak contact pressures equivalent to a total meniscectomy, predisposing the knee to rapid joint degeneration.

Question 48

A 25-year-old professional baseball pitcher presents with a "dead arm" and pain during the late cocking phase of throwing. MRI arthrography reveals a Type II Superior Labrum Anterior to Posterior (SLAP) tear. What is the most widely recommended initial management?

Explanation

In elite overhead throwers, initial management for SLAP tears should emphasize physical therapy to correct GIRD and scapular dyskinesia. Surgical intervention (SLAP repair) in this population often leads to a failure to return to pre-injury levels of play and is reserved for failed conservative treatment.

Question 49

A 20-year-old gymnast complains of persistent deep ankle pain following an injury 6 months ago. MRI reveals a 1.5 cm osteochondral lesion on the posteromedial aspect of the talar dome. What is the classic mechanism of injury associated with this specific lesion location?

Explanation

Osteochondral lesions of the talus follow the "DIAL a PIMP" mnemonic: Dorsiflexion Inversion causes Anterior Lateral lesions, whereas Plantarflexion Inversion causes Medial Posterior lesions. Medial lesions are typically larger, deeper, and more commonly non-traumatic or insidious.

Question 50

A 16-year-old female sustains a first-time lateral patellar dislocation. Radiographs and an MRI confirm a 1.5 cm displaced osteochondral fracture from the lateral femoral condyle. What is the most appropriate surgical management?

Explanation

While first-time patellar dislocations are often treated nonoperatively, the presence of a displaced osteochondral fragment is an absolute indication for early surgical intervention (arthroscopic evaluation, loose body removal or fixation, and potential medial patellofemoral ligament repair/reconstruction).

Question 51

A 28-year-old avid cyclist falls directly on the point of his shoulder. Radiographs demonstrate a Type III acromioclavicular (AC) joint separation (100% to 200% superior displacement of the clavicle). According to current evidence-based guidelines, what is the most appropriate initial management?

Explanation

Acute Type III AC joint separations are generally managed nonoperatively with a sling and early rehabilitation. Multiple studies have shown similar functional outcomes between operative and nonoperative treatment, but higher complication rates and delayed return to work with surgery.

Question 52

A 32-year-old male sustains an isolated, acute Grade III posterior cruciate ligament (PCL) tear in a dashboard injury. Nonoperative management is selected. Which of the following bracing strategies provides the best biomechanical environment for ligament healing?

Explanation

A dynamic anterior drawer brace (e.g., Jack PCL brace) counteracts gravity and hamstring forces, holding the tibia in an anteriorly reduced position. This prevents the posterior sag that can lead to healing of the PCL in an elongated, incompetent position.

Question 53

A 26-year-old downhill skier sustains a forceful dorsiflexion and eversion injury to the right ankle. He now complains of a painful popping sensation over the lateral malleolus when circumducting the foot. Injury to which of the following structures is responsible for his symptoms?

Explanation

The superior peroneal retinaculum (SPR) is the primary restraint against peroneal tendon subluxation. Injury to the SPR, typically via forced dorsiflexion and eversion with reflex peroneal contraction, allows the tendons to snap over the lateral malleolus.

Question 54

A 19-year-old collegiate soccer player sustains a noncontact pivoting injury to her right knee. MRI confirms an isolated ACL rupture. She undergoes anatomic single-bundle ACL reconstruction using a bone-patellar tendon-bone autograft. During graft harvest, the infrapatellar branch of the saphenous nerve is transected. Where is she most likely to experience numbness?

Explanation

The infrapatellar branch of the saphenous nerve courses transversely across the anterior knee and is frequently injured during patellar tendon harvest. This predictably causes numbness over the anterior proximal tibia.

Question 55

A 25-year-old professional baseball pitcher complains of vague deep shoulder pain. On physical exam, he has decreased internal rotation of 25 degrees compared to the contralateral side. A peel-back sign is positive. What is the primary pathologic mechanism contributing to his diagnosis?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is caused by posterior capsular contracture. This leads to a posterosuperior shift of the humeral head during late cocking, resulting in internal impingement and SLAP tears.

Question 56

A 22-year-old football player sustains a high-energy tackle. Exam reveals increased external rotation of the tibia at 30 degrees of knee flexion but symmetric rotation at 90 degrees compared to the uninjured side. Varus stress is positive at 30 degrees. Which of the following structures is definitively injured?

Explanation

Increased external rotation at 30 degrees of flexion with symmetric rotation at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If rotation was increased at both 30 and 90 degrees, it would indicate a combined PLC and PCL injury.

Question 57

A 28-year-old rugby player has recurrent anterior shoulder instability. CT scan indicates a 25% anterior glenoid bone loss. Which of the following is the most appropriate surgical management?

Explanation

For anterior glenoid bone loss greater than 20-25%, a soft tissue Bankart repair has an unacceptably high failure rate. A bone-block augmentation, such as the Latarjet procedure (coracoid transfer), is indicated to restore glenoid width and provide a dynamic sling effect.

Question 58

A 30-year-old male recreational hockey player is evaluated for an ankle injury. Exam shows tenderness over the anterior inferior tibiofibular ligament (AITFL) and a positive external rotation stress test. Radiographs show a widened medial clear space. What is the most appropriate next step?

Explanation

A syndesmotic injury with a widened medial clear space indicates dynamic or static instability of the ankle mortise. Operative reduction and stabilization (e.g., screw or suture button fixation) are required to prevent rapid post-traumatic arthritis.

Question 59

A 24-year-old weightlifter feels a sudden 'pop' in his anterior chest during a heavy bench press. He has weakness in internal rotation and a loss of the anterior axillary fold. MRI shows a pectoralis major tendon rupture. Which part of the muscle is most commonly ruptured in this scenario?

Explanation

Pectoralis major ruptures in weightlifters most commonly involve the sternal head near or at the humeral insertion. This typically occurs when the arm is extended and externally rotated during the eccentric phase of a bench press.

Question 60

A 45-year-old weekend warrior sustains an acute Achilles tendon rupture. He elects for non-operative management. What is the most critical component of his rehabilitation to ensure outcomes comparable to surgical repair?

Explanation

Recent studies show that non-operative management with early functional rehabilitation yields re-rupture rates and functional outcomes similar to operative repair. This protocol avoids surgical complications like wound necrosis and nerve injury.

Question 61

A 16-year-old female gymnast presents with recurrent lateral patellar dislocations. MRI reveals a torn medial patellofemoral ligament (MPFL). If reconstruction is planned, where is the precise anatomic femoral attachment (Schöttle's point) of the MPFL?

Explanation

The femoral footprint of the MPFL (Schöttle's point) is located radiographically between the medial epicondyle and the adductor tubercle. It sits slightly anterior to the posterior femoral cortex extension line.

Question 62

A 35-year-old recreational basketball player reports catching and pain in his knee. MRI reveals a medial meniscal root tear. What are the biomechanical consequences of this injury if left untreated?

Explanation

A meniscal root tear biomechanically mimics a total meniscectomy by disrupting hoop stresses. This causes lateral extrusion of the meniscus and significantly increased contact pressures, leading to rapid osteoarthritis.

Question 63

A 21-year-old collegiate quarterback sustains a Grade III acromioclavicular (AC) joint separation on his non-dominant shoulder. He is currently in the middle of the season. What is the best initial management?

Explanation

Uncomplicated Grade III AC joint separations are typically managed non-operatively, especially in athletes mid-season. Sling immobilization followed by early rehabilitation allows most athletes to return to play within a few weeks.

Question 64

A 28-year-old male presents with acute medial sided elbow pain after throwing a javelin. Examination reveals tenderness distal to the medial epicondyle. The moving valgus stress test is positive. Which band of the ulnar collateral ligament is the primary restraint to valgus stress at 90 degrees of flexion?

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress of the elbow between 30 and 120 degrees of flexion. Injury is common in overhead throwing athletes.

Question 65

A 31-year-old professional tennis player undergoes arthroscopic evaluation of his shoulder for chronic pain. A SLAP lesion is suspected. What associated normal anatomic variant is most commonly confused with a type II SLAP tear?

Explanation

A sublabral recess is a normal anatomic variant characterized by an unattached anterosuperior labrum. Unlike a type II SLAP tear, the recess has smooth margins and the biceps anchor remains firmly attached to the superior tubercle.

Question 66

A 15-year-old boy has anterior knee pain after a football injury. Radiographs show a displaced avulsion fracture of the tibial eminence (Meyers and McKeever Type III). What is the most appropriate management?

Explanation

Meyers and McKeever Type III (completely displaced) tibial spine avulsion fractures generally require surgical fixation. Arthroscopic reduction and fixation using sutures or screws is the standard of care to restore ACL tension and knee stability.

Question 67

A 27-year-old female marathon runner complains of progressive anterior knee pain. She is diagnosed with a focal full-thickness articular cartilage defect (2 cm²) on the medial femoral condyle. She has failed conservative management. Which surgical option is most appropriate for a defect of this size?

Explanation

For symptomatic focal full-thickness chondral defects between 1 to 2.5 cm² in young active patients, osteochondral autograft transfer (OATS) provides hyaline cartilage repair. Microfracture is typically reserved for lesions smaller than 2 cm², while ACI is used for larger defects.

Question 68

A 22-year-old gymnast complains of deep, aching posteromedial ankle pain. MRI shows an osteochondral lesion of the talus (OLT) on the posteromedial dome. Which mechanism of injury is most classically associated with this specific lesion location?

Explanation

Posteromedial osteochondral lesions of the talus are classically caused by an inversion and plantarflexion injury. They are typically deeper and cup-shaped compared to anterolateral lesions, which are often shallow and caused by inversion and dorsiflexion.

Question 69

A 20-year-old football lineman is diagnosed with a posterior cruciate ligament (PCL) injury. On physical examination, the posterior drawer test is performed. At what degree of knee flexion is the PCL the primary restraint to posterior tibial translation?

Explanation

The posterior cruciate ligament (PCL), particularly its anterolateral bundle, is the primary restraint to posterior tibial translation. This restraint is greatest and most easily tested at 90 degrees of knee flexion.

Question 70

A 29-year-old rock climber presents with a popping sensation in his shoulder. MRI reveals an isolated tear of the subscapularis tendon. Which physical examination test is most specific for this injury?

Explanation

The Bear hug test, along with the lift-off and belly-press tests, are specific for evaluating the integrity of the subscapularis tendon. Hornblower's sign evaluates the teres minor, while Jobe's test evaluates the supraspinatus.

Question 71

A 17-year-old male hockey player suffers a midshaft clavicle fracture. Radiographs show a completely displaced, comminuted fracture with 2.5 cm of shortening. What is the primary advantage of operative fixation over non-operative management in this patient?

Explanation

Operative fixation of completely displaced midshaft clavicle fractures with greater than 2 cm of shortening significantly reduces the risk of nonunion and symptomatic malunion. This translates to improved functional outcomes in young, active patients.

Question 72

A 32-year-old runner has chronic heel pain localized to the insertion of the Achilles tendon. Conservative treatment has failed. MRI shows a Haglund's deformity and insertional Achilles tendinopathy with calcification. If surgery is performed involving detachment and reattachment of the Achilles, what structure is most at risk during the lateral exposure?

Explanation

The sural nerve courses distally along the posterolateral aspect of the calf and ankle. It is at significant risk of iatrogenic injury during lateral surgical approaches to the Achilles tendon and calcaneal tuberosity.

Question 73

A 26-year-old female dancer has chronic lateral ankle instability despite 6 months of physical therapy. She undergoes a modified Broström-Gould procedure. Which anatomic structure is advanced and attached to the fibula to augment the repair in the Gould modification?

Explanation

The Broström-Gould modification involves mobilizing and advancing the inferior extensor retinaculum to the distal fibula. This reinforces the primary anatomic repair of the anterior talofibular and calcaneofibular ligaments, improving overall stability.

Question 74

A 22-year-old rugby player has recurrent anterior shoulder instability. Computed tomography reveals 25% anterior glenoid bone loss. What is the most appropriate surgical treatment?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for patients with recurrent anterior shoulder instability and significant glenoid bone loss (typically >20-25%). Arthroscopic Bankart repair in this setting carries an unacceptably high failure rate.

Question 75

A 28-year-old soccer player sustains a knee injury. MRI shows an isolated complete posterior cruciate ligament (PCL) tear. Examination reveals a grade III posterior sag, but the patient is asymptomatic with straight-ahead running. What is the most appropriate initial management?

Explanation

Isolated PCL tears are generally treated nonoperatively with a brief period of immobilization in extension to reduce posterior tibial subluxation, followed by aggressive quadriceps strengthening. Hamstring strengthening is avoided initially as it exacerbates posterior tibial translation.

Question 76

A 21-year-old collegiate football player sustains a rotational ankle injury. Examination reveals tenderness over the anterior inferior tibiofibular ligament and a positive squeeze test. Gravity stress radiographs demonstrate 6 mm of medial clear space widening. What is the best management?

Explanation

Medial clear space widening on stress radiographs indicates a dynamically unstable syndesmosis injury. Operative fixation with syndesmotic screws or a flexible suture-button construct is required to restore and maintain the syndesmosis.

Question 77

A posterior root tear of the medial meniscus results in altered knee biomechanics that are most similar to which of the following conditions?

Explanation

A medial meniscus posterior root tear disrupts the crucial hoop stresses of the meniscus, causing it to extrude under physiological load. This effectively leaves the medial compartment functioning biomechanically as if a total meniscectomy had been performed.

Question 78

A 40-year-old manual laborer has deep, aching shoulder pain. MRI arthrogram demonstrates a Type II SLAP tear. After failing a 4-month course of physical therapy, surgery is planned. What is the most reliable surgical treatment to provide pain relief and facilitate return to work?

Explanation

In older patients (typically >35-40 years old), primary biceps tenodesis is highly favored over SLAP repair for Type II SLAP tears. Tenodesis provides higher rates of patient satisfaction, lower complication rates, and a lower incidence of postoperative stiffness.

Question 79

In medial patellofemoral ligament (MPFL) reconstruction for recurrent patellofemoral instability, anatomic femoral tunnel placement is critical to avoid anisometry. Where is the anatomic femoral attachment of the MPFL located?

Explanation

The MPFL femoral origin is located in a bony sulcus between the medial epicondyle (which is distal) and the adductor tubercle (which is proximal). Non-anatomic placement, particularly proximal or anterior, can lead to severe graft tensioning issues during knee flexion.

Question 80

A 25-year-old cyclist falls directly onto his shoulder. Radiographs show 150% superior displacement of the clavicle relative to the acromion (Type III acromioclavicular joint separation). What is the general consensus regarding initial management in this athletic population?

Explanation

Uncomplicated Type III AC joint separations are generally treated nonoperatively with a sling and early physical therapy. Surgical intervention is typically reserved for patients who fail conservative management, those with severe superior displacement (Type V), or those with specific high-demand overhead requirements.

Question 81

A 32-year-old male sustains an acute Achilles tendon rupture. When comparing nonoperative management utilizing early functional rehabilitation to operative repair, which of the following statements is true?

Explanation

Recent high-quality literature demonstrates that with early functional rehabilitation, re-rupture rates are similar between operative and nonoperative management. However, operative repair carries a significantly higher risk of soft-tissue and wound complications.

Question 82

A 22-year-old sustains a KD III-M multiligament knee injury. Which of the following nerve injuries is most commonly associated with disruption of the posterolateral corner (PLC) of the knee?

Explanation

The common peroneal nerve courses directly around the fibular neck and is highly susceptible to traction injuries during the varus and hyperextension mechanisms that typically rupture the posterolateral corner structures.

Question 83

A 30-year-old weightlifter sustains a pectoralis major rupture while performing a heavy bench press. Regarding the anatomy of the pectoralis major tendon, where does the sternocostal head typically insert on the humerus relative to the clavicular head?

Explanation

The bilaminar pectoralis major tendon undergoes a 180-degree twist before inserting onto the humerus. This twist results in the lower sternocostal fibers inserting deep and proximal to the clavicular fibers.

Question 84

A 24-year-old soccer player presents with chronic anterolateral ankle pain. MRI reveals a 1.2 cm osteochondral lesion of the anterolateral talar dome. Nonoperative management has failed. What is the most appropriate initial surgical treatment?

Explanation

For symptomatic osteochondral lesions of the talus that are less than 1.5 cm in diameter and have failed conservative treatment, arthroscopic bone marrow stimulation (microfracture) remains the recommended first-line surgical treatment.

Question 85

A 16-year-old female soccer player undergoes anterior cruciate ligament (ACL) reconstruction. Which of the following graft choices is associated with the highest rate of clinical failure and re-rupture in this specific patient demographic?

Explanation

Multiple studies and registries have conclusively demonstrated that allografts have a significantly higher failure and re-rupture rate compared to autografts when utilized for ACL reconstruction in young, highly active athletes.

Question 86

A 30-year-old man presents with a locked posterior shoulder dislocation following a seizure. A CT scan reveals a reverse Hill-Sachs lesion involving 35% of the anterior articular surface. What is the most appropriate surgical management?

Explanation

For a locked posterior dislocation with an anterior articular defect (reverse Hill-Sachs lesion) involving 20% to 40% of the humeral head, transfer of the lesser tuberosity or subscapularis into the defect (modified McLaughlin or McLaughlin procedure) is indicated to prevent recurrent engagement.

Question 87

A 19-year-old collegiate football player sustains a primary anterior shoulder dislocation.

Imaging demonstrates an anteroinferior labral tear accompanied by 25% glenoid bone loss. What is the most appropriate definitive management for this athlete?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability in the setting of significant glenoid bone loss (>20-25%). Arthroscopic or open Bankart repairs alone have unacceptably high failure rates when critical bone loss is present.

Question 88

A 22-year-old female soccer player sustains a noncontact twisting injury to her knee, feeling a "pop."

MRI confirms an isolated anterior cruciate ligament (ACL) tear. Which of the following is an established intrinsic anatomic risk factor for this injury?

Explanation

A decreased (narrow) intercondylar notch width is a well-established anatomic risk factor for ACL tears. Increased posterior tibial slope and a decreased hamstring-to-quadriceps strength ratio are also known risk factors.

Question 89

A 24-year-old hockey player sustains an external rotation injury to his right ankle and complains of pain extending proximally from the joint.

Radiographs show no fracture and a normal clear space. Which physical examination test is most reliable and specific for diagnosing a syndesmotic injury?

Explanation

The external rotation stress test has the highest reliability and specificity for diagnosing syndesmotic ankle sprains clinically. It exacerbates the separation of the distal tibiofibular joint, reproducing the patient's pain.

Question 90

A 25-year-old professional baseball pitcher complains of deep shoulder pain primarily occurring during the late cocking phase of throwing.

An MR arthrogram reveals a Type II SLAP lesion. What is the primary pathomechanical basis for his symptoms during this specific throwing phase?

Explanation

In the late cocking phase (abduction and maximal external rotation), the biceps vector shifts posteriorly, creating a "peel-back" force on the superior labrum. This mechanism is the classic cause of Type II SLAP lesions in overhead athletes.

Question 91

A 30-year-old skier sustains a traumatic knee dislocation.

The knee is urgently reduced in the emergency department. The ankle-brachial index (ABI) is subsequently measured at 0.8. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 following a knee dislocation is highly suggestive of a vascular injury. CT angiography is the standard of care to accurately diagnose and localize popliteal artery injuries before potential surgical intervention.

Question 92

A 42-year-old recreational tennis player feels a sharp "pop" in his posterior heel.

The Thompson test is positive. He elects for nonoperative management of his acute Achilles tendon rupture. Which rehabilitation protocol yields re-rupture rates most comparable to surgical repair?

Explanation

Recent studies demonstrate that early functional rehabilitation protocols (including early protected weight-bearing and range of motion) for nonoperatively managed Achilles ruptures result in re-rupture rates comparable to surgical repair. Traditional prolonged immobilization carries higher re-rupture and complication rates.

Question 93

A 21-year-old collegiate hockey player sustains a direct blow to the superior aspect of the shoulder.

Radiographs demonstrate a Type III acromioclavicular (AC) joint separation (100% to 200% displacement). What is the most appropriate initial management for this in-season athlete?

Explanation

Initial management for an acute Type III AC joint separation in most athletes is nonoperative, focusing on brief sling immobilization for comfort followed by early range of motion. Surgery is generally reserved for chronic symptomatic cases or severe higher-grade (IV-VI) injuries.

Question 94

A 26-year-old rugby player presents with posterior knee pain and a positive posterior drawer test.

The dial test demonstrates 15 degrees of increased external rotation at 30 degrees of flexion and 15 degrees of increased external rotation at 90 degrees of flexion compared to the contralateral side. Which structures are injured?

Explanation

A dial test showing increased external rotation at both 30 and 90 degrees of knee flexion indicates a combined injury to the posterior cruciate ligament (PCL) and the posterolateral corner (PLC). An isolated PLC injury would show asymmetry only at 30 degrees.

Question 95

A 19-year-old gymnast presents with chronic anterolateral ankle pain unresponsive to bracing and therapy.

MRI reveals a 9 mm x 9 mm uncontained osteochondral lesion of the anterolateral talar dome. What is the surgical treatment of choice?

Explanation

Arthroscopic bone marrow stimulation (microfracture/drilling) is the first-line surgical treatment for symptomatic, small osteochondral lesions of the talus (typically less than 1.5 cm^2). Larger lesions (>1.5 cm^2) or cystic lesions often require OATS or allograft.

Question 96

A 35-year-old active manual laborer is diagnosed with a massive, retracted, and irreparable posterosuperior rotator cuff tear.

Glenohumeral cartilage is intact without arthropathy. Which of the following is a biomechanically sound, joint-preserving surgical option for restoring external rotation?

Explanation

Latissimus dorsi (or lower trapezius) tendon transfer is indicated for younger, active patients with irreparable posterosuperior rotator cuff tears and intact cartilage to restore external rotation and elevation. Reverse total shoulder arthroplasty is reserved for older patients or those with pseudoparalysis and cuff tear arthropathy.

Question 97

A 45-year-old marathon runner feels a sharp pain in the posteromedial knee.

MRI demonstrates a complete radial tear of the medial meniscus posterior root. If left untreated, the biomechanical consequences are most similar to which of the following?

Explanation

A complete tear of the medial meniscus root disrupts the hoop stresses of the meniscus, causing it to extrude. Biomechanically, this results in increased contact pressures identical to a total medial meniscectomy, rapidly leading to osteoarthritis.

Question 98

A 22-year-old collegiate pitcher complains of posterior shoulder pain and decreased velocity.

Physical examination reveals 20 degrees of internal rotation and 130 degrees of external rotation in the dominant arm (contralateral internal rotation is 60 degrees). Initial treatment should emphasize which of the following?

Explanation

The patient has Glenohumeral Internal Rotation Deficit (GIRD), characterized by a loss of internal rotation due to posteroinferior capsular contracture. The first-line treatment is posteroinferior capsular stretching (e.g., "sleeper" stretches).

Question 99

A 20-year-old elite collegiate basketball player sustains an acute Zone II proximal fifth metatarsal fracture (Jones fracture).

To minimize the time lost to sport and reduce the risk of nonunion, what is the most appropriate treatment?

Explanation

In elite athletes, acute Zone II (Jones) fractures of the fifth metatarsal are treated with early intramedullary screw fixation. This approach significantly reduces the time to return to play and lowers the incidence of nonunion compared to nonoperative management.

Question 100

A 17-year-old female experiences recurrent lateral patellar instability and fails conservative management.

Surgery is planned to reconstruct the medial patellofemoral ligament (MPFL). During reconstruction, where should the femoral tunnel be placed anatomically to avoid non-isometric graft tension?

Explanation

The anatomic femoral attachment of the MPFL (often described radiographically by the Schöttle point) lies in a saddle-like depression between the medial epicondyle and the adductor tubercle. Accurate placement is critical to ensure isometry of the graft throughout knee flexion.

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

AAOS/ABOS Sports Medicine MCQs (Set 3): Knee, Shoulder & Ankle Trauma | OITE & Board Review

Key Takeaway

AAOS/ABOS Sports Medicine MCQs (Set 3): Knee, Shoulder & Ankle Trauma | OITE & Board Review

Chapter Index