AAOS Sports Medicine MCQs: Knee & Shoulder Instability

Question 1

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

Explanation

The radial nerve is only 4 mm from the anterolateral portal, while the median nerve is 11 mm away from the anteromedial portal. The ulnar nerve is only at risk on the medial side of the elbow. Anterior and posterior interosseous nerves are more distal within the forearm and are not in danger during portal placement. O'Driscoll SW, Morrey BF: Elbow arthroscopy, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 21-34.

Question 2

A 39-year-old man has anterior shoulder pain after landing on his abducted left shoulder while playing softball. Examination reveals a stable glenohumeral joint, pain on passive external rotation of greater than 25 degrees, and pain and weakness on belly press (Napoleon's) test. An MRI scan is shown in Figure 32. To provide maximum pain relief and return of function, management should include

Explanation

The examination and MRI scan confirm a subscapularis rupture and dislocation of the long head of the biceps tendon. The greatest return of function will result from repair of the subscapularis and tenodesis of the biceps tendon. Physical therapy alone will result in inadequate healing of the subscapularis and will not address the biceps tendon. While biceps tenotomy is an option, it will not provide the same level of pain relief and return of function as a tenodesis in a young, active man. There is no evidence for a supraspinatus tear. Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.

Question 3

A 37-year-old racquet player had dominant shoulder pain for 1 year, and cortisone injections provided only temporary relief. Because MRI findings did not reveal a rotator cuff tear, he underwent arthroscopic treatment including subacromial decompression and spur removal below the distal clavicle. Three years following surgery, he now reports that the pain has returned. What is the most likely cause of his pain?

Explanation

Co-planing the distal clavicle may lead to painful acromioclavicular joints in up to 35% of patients; this is felt to be related to destabilizing the distal clavicle. Intra-articular diagnosis of synovitis, degenerative joint disease, and superior labrum anterior and posterior lesions would have been identified at initial arthroscopy (not necessarily seen in open surgery). Ganglions are seen on MRI. Fischer BW, Gross RM, McCarthy JA: Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15:241-248. Hazel RM, Tasto JP, Klassen J: Arthroscopic subacromial decompression: A 9-year follow-up. Arthroscopy 1998;14:419.

Question 4

Figure 33 shows the radiograph of a 28-year-old avid golfer who has chronic right wrist pain. Management should consist of

Explanation

The patient's chronic symptoms are associated with a fracture of the base of the hook of the hamate; therefore, the treatment of choice is simple excision of the fracture fragment, with reasonable expectations of functional return. Acute fractures may be difficult to treat because of the high incidence of nonunion, but once nonunion is discovered, nonsurgical management usually is unsuccessful. Bone grafting may be a surgical alternative, but successful outcomes with percutaneous fixation or trephination of the fibrous union have not been reported. Geissler WB: Carpal fractures in athletes. Clin Sports Med 2001;20:167-188.

Question 5

A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of

Explanation

The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect. Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.

Question 6

Which of the following best describes athletic pubalgia?

Explanation

Athletic pubalgia refers to a distinct syndrome of lower abdominal and adductor pain that is mostly commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphysis pubis, referred to as osteitis pubis. Symptoms attributable to the iliopsoas tendon are most commonly associated with snapping of the tendon. Stress fracture of the pubic ramus may cause symptoms in this area, but it is usually confirmed by imaging studies. Neurapraxia of the pudendal nerve is associated with pressure from the seat in cycling sports and also as a complication associated with traction during surgical procedures. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.

Question 7

Figures 34a and 34b show the radiographs of a 28-year-old man who fell on his outstretched arm with significant force while mountain biking. The nerve deficit most likely to occur would result in weakness of

Explanation

The patient has a Monteggia fracture-dislocation (proximal ulnar fracture and radial head dislocation). The posterior interosseous nerve branch of the radial nerve is the most likely to be injured and could result in weakness of thumb extension and finger metacarpal extension. Considerably less likely are injuries to the more proximal radial nerve branches supplying the extensor carpi radialis longus and brevis, resulting in weak wrist extension; the ulnar nerve supplying the digital intrinsics, resulting in weak finger abduction; the anterior interosseous branch of the median nerve, resulting in weakness of the flexor pollicis longus; and the distal median nerve, resulting in weakness of thumb opposition. Bado JL: The Monteggia lesion. Clin Orthop 1967;50:71-86.

Question 8

Which of the following activities can improve posterior capsular contractures?

Explanation

Posterior capsule stretching is performed in the cross-chest and behind the back positions. Stretching in internal rotation in the abducted shoulder will further stretch the posterior capsule. Wide grip stretch, and anterior capsule and strengthening exercises will not necessarily stretch the capsule. Ellenbacher TS: Shoulder internal and external rotation strength and range of motion of highly-skilled junior tennis players. Isokinetic Exercise Sci 1992;2:1-8.

Question 9

Figure 35 shows the radiograph of a 35-year-old weightlifter who has had pain with overhead lifts for the past 7 months. Cortisone injections in the acromioclavicular joint provided only temporary relief. A bone scan reveals increased activity of the acromioclavicular joint. Treatment should now consist of

Explanation

Osteolysis of the distal clavicle is common in weightlifters; therefore, distal clavicle excision is the treatment of choice. A subacromial decompression alone would not alleviate the acromioclavicular joint symptoms. Interval closure, biceps degeneration, and superior labrum anterior and posterior repair would limit superior migration but would not explain the abnormal bone scan. Thermal capsular shrinkage does not have a role here. Flatow EL, Cordasco FA, McCluskey GM, Bigliani LU: Arthroscopic resection of the distal clavicle via a superior portal: A critical quantitative radiographic assessment of bone removal. Arthroscopy 1990;6:153-154.

Question 10

Following reconstruction of the anterior cruciate ligament (ACL), which of the following rehabilitation exercises has the greatest potential to harm the graft?

Explanation

Isometric quadriceps contraction between 15 and 30 degrees of flexion creates significant strain in the ACL and potential damage to the reconstructed graft. Isolated quadriceps contraction with knee flexion of greater than 60 degrees, hamstring contraction at any angle of knee flexion, and active knee motion between 35 and 90 degrees of flexion create substantially less strain in the properly implanted ACL graft. Beynnon BD, Gleming BC, Johnson RL, Nichols CE, Renstrom PA, Pope MH: Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 1995;23:24-34.

Question 11

A young active patient with a complete isolated posterior cruciate ligament (PCL) tear undergoes a double bundle PCL reconstruction. The tensioning pattern of the anterolateral (AL) and posteromedial (PM) bundles most likely to reproduce the most normal knee kinematics would be to tension

Explanation

During flexion and extension of the normal knee, the AL bundle of the PCL is taut in flexion, and the PM bundle is taut when the knee is near extension. The AL bundle is approximately two times larger at its midsubstance, stiffer, and has a higher ultimate load than the PM bundle. In vitro testing has demonstrated that by tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 0 degrees of flexion, essentially normal knee kinematics are restored. Tensioning the AL bundle at 45 degrees of flexion and the PM bundle at 0 degrees of flexion would result in increased laxity with flexion at 90+ degrees. Tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 45 degrees of flexion would result in increased laxity near extension. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin T, Woo SL: Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med 2000;28:144-151.

Question 12

Accurate evaluation of the upper portion of the subscapularis muscle is best accomplished with active internal rotation

Explanation

Internal rotators of the shoulder include the subscapularis, pectoralis major, teres major, and latissimus dorsi muscles. The subscapularis has two portions, with the upper portion receiving its innervation from the upper subscapular nerve (C5) and the lower portion from the lower subscapular nerve (C5-6). The two tests commonly performed to isolate the internal rotation to the subscapularis muscle are the lift-off test and the belly press test. Electromyographic findings have shown the lift-off test to be more accurate for the lower portion of the subscapularis and the belly press test to be more sensitive for the upper portion. Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ: Electromyographic activity and applied load during shoulder rehabilitation exercises using elastic resistance. Am J Sports Med 1998;26:210-220.

Question 13

During what phase of the throwing motion is the highest torque measured across the glenohumeral joint?

Explanation

Electromyography is used to evaluate muscular firing patterns about the shoulder during the throwing sequence. The rotator cuff muscles and biceps are relatively inactive during the acceleration phase, whereas the pectoralis major, serratus anterior, latissimus dorsi, and subscapularis show highest activity. By contrast, deceleration is accomplished by the rotator cuff musculature and the larger trunk muscles acting in concert to slow down the arm. It is during this phase of follow through that the highest torque is measured secondary to eccentric muscle contraction. Jobe FW, Moynes DR, Tibone JE, Perry J: An EMG analysis of the shoulder in pitching: A second report. Am J Sports Med 1984;12:218-220. Pappas AM, Zawacki RM, Sulliva TJ: Biomechanics of baseball pitching: A preliminary report. Am J Sports Med 1985;13:216-222.

Question 14

Figure 36 shows the radiograph of a 28-year-old man who injured his shoulder in a motocross race. Management should consist of

Explanation

Fractures of the distal one third of the clavicle have a high incidence of delayed union (45% to 67%) and nonunion (22% to 33%) with nonsurgical management. Surgical stabilization with tension band techniques or a combination of plate and screw techniques is indicated, especially in young, active patients. In this patient, significant displacement of the fracture implies injury to the coracoclavicular ligaments with a higher risk of delayed union or nonunion. Various surgical treatments have been recommended, but the use of smooth wires is not indicated because of the potential for hardware migration. Jupiter JB, Ring D: Fractures of the clavicle, in Ianotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott, Williams and Wilkins, 1999, pp 709-736.

Question 15

Figure 37 shows the radiograph of a 21-year-old collegiate basketball player who has had mild midfoot aching for the past 4 months. What is the best course of action?

Explanation

A stress fracture of the navicular is considered a high-risk injury because of the incidence of nonunion. If identified early, cast immobilization with no weight bearing is appropriate. However, this patient is a high-caliber athlete who has had symptoms for 4 months. Therefore, surgery is recommended to expedite recovery and optimize the chance of healing. Meyer SA, Saltaman CL, Albright JP: Stress fractures of the foot and ankle. Clin Sports Med 1993;12:395-413. Kahn JM, Fuller PJ, Burkner PD, et al: Outcome of conservative and surgical management of navicular stress fractures in athletes: Eighty-six cases proven with computerized tomography. Am J Sports Med 1992;20:657-666.

Question 16

A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals an 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of

Explanation

The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis. Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.

Question 17

An active 55-year-old man who felt a sudden pop in the left heel while playing tennis 6 months ago was diagnosed with an ankle sprain around the time of injury. He now reports calf atrophy and severe weakness with running. Examination reveals a palpable defect in the Achilles tendon and only trace passive ankle flexion when the calf is squeezed. At the time of surgery, an Achilles tendon defect of 6 cm cannot be approximated. Surgical management of the Achilles tendon should include

Explanation

Chronic or neglected Achilles tendon ruptures can present a surgical problem. Ideally, end-to-end apposition of tendon should be attempted, but this should be accomplished without placing the foot in marked equinus. A defect of greater than 5 cm requires the use of a tendon transfer either alone or in combination with a V-Y advancement of the gastrocnemius. Because of its proximity to the Achilles tendon and its strength as a plantar flexor, the flexor hallucis longus is an ideal choice for this task. Studies have shown that early active range-of-motion exercises after an Achilles tendon repair is beneficial for tendon healing and improved clinical outcomes. Myerson M: Achilles tendon ruptures. Instr Course Lect 1999;48:219-230.

Question 18

Figures 38a and 38b show the AP and lateral radiographs of a 12-year-old baseball pitcher who has pain in his right dominant elbow. Management should consist of

Explanation

The patient has a stress fracture of the olecranon; therefore, the most appropriate management is modification of activities below the threshold of symptoms to allow for healing. Ultrasound provides no benefit, and immobilization is not necessary. MRI is not necessary because there is no associated ligamentous injury. Arthroscopy is not indicated. Cabanela ME, Morrey BF: Fractures of the olecranon, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 2000, pp 365-379.

Question 19

What is the most reproducible landmark for the accurate anatomic placement of the tibial tunnel for an anterior cruciate ligament (ACL) reconstruction?

Explanation

The anterior border of the PCL is the most accurate and reproducible landmark for appropriate placement of the tibial tunnel for an ACL reconstruction. The central sagittal insertion point of the ACL is consistently 10 to 11 mm anterior to the anterior border of the PCL ligament. The anterior border of the tibia is not well visualized and does not serve as a reference point. While the posterior border of the anterior horn of the lateral meniscus could be used as a reference point, it has twice the variability of the PCL reference point. The posterior border of the tibia is difficult to identify and has greater variability than the PCL relative to the AP dimension of the proximal tibial surface. The anterior horn of the medial meniscus is also more variable than the PCL. Hutchinson MR, Bae TS: Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777-780.

Question 20

A 20-year-old football player sustains a dorsiflexion external rotation injury to his right ankle. During sideline evaluation, which of the following findings best indicates a syndesmosis ankle sprain without diastasis?

Explanation

The inability to single leg hop is considered the best indicator of a syndesmosis ankle sprain without diastasis. Tenderness along the syndesmosis, the deltoid, or over the anterior talofibular ligament or anterior distal tibia/fibula may present later, following the initial injury. The squeeze test and tenderness with dorsiflexion and external rotation may be positive but often are not present initially. The best determinant for prediction of return to play is the amount of tenderness along the syndesmosis, measured from the distal fibula up the syndesmosis. Nussbaum ED, Hosea TM, et al: Prospective evaluation of syndesmosis ankle sprains without diastasis. Am J Sports Med 2001;29:31-35. Miller CD, Shelton WR, Barrett GR, et al: Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med 1985;23:746-750.

Question 21

A 20-year-old college baseball pitcher reports the insidious onset of medial elbow pain. Examination reveals medial elbow tenderness, a normal neurologic examination, and no obvious valgus laxity. Plain radiographs are normal. MRI scans are shown in Figures 39a and 39b. Management should consist of

Explanation

Throwers and in particular, pitchers, are prone to high valgus loads to the elbow. A constellation of medial elbow pathology can develop, including medial epicondylitis, ulnar nerve neuritis, medial ulnar collateral ligament injuries, and posteromedial osteophytes of the olecranon. The MRI scans show significant increases in signal intensing as well as fiber disruption of the medial collateral ligament, indicating a complete tear. The common flexor origin shows a homogeneous signal and normal morphology. Therefore, excision of posterior osteophytes and debridement of the common flexor origin are not indicated. Likewise, this patient's symptoms do not indicate ulnar nerve pathology; therefore ulnar nerve transposition is not indicated. Primary repair of medial collateral ligament tears of the elbow lead to unpredictable results with an unacceptable rate of reoperation. The most predictable result in treating this high-demand athlete is reconstruction of the medial collateral ligament with autogenous tissue. Norris TR (ed): Athletic Injuries of the Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 311-323.

Question 22

What is the most common arthroscopic finding of internal impingement in an overhead athlete?

Explanation

Internal impingement occurs when the articular side of the supraspinatus abrades against the posterior superior glenoid in the cocking position. Damage may include a posterior labral tear where the contact occurs, not anteriorly as in a Bankart lesion. Biceps fraying and acromion spurs are more commonly seen in extrinsic impingement. Loose bodies may occur from multiple lesions associated with instability and articular cartilage disorders but are uncommon in internal impingement. Jobe CM: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.

Question 23

A 16-year-old high school football player who sustained an acute forceful dorsiflexion ankle injury reported that he felt a pop and then noted immediate swelling over the lateral malleolus. Examination 24 hours later reveals moderate swelling and tenderness along the lateral malleolus. The external rotation, squeeze, anterior drawer, and talar tilt tests are negative. Subluxation of the peroneal tendons is palpable over the peroneal groove of the fibula. Radiographs reveal a small cortical avulsion off the distal rim of the fibula. The stress views show no instability. Initial management for this injury should include

Explanation

The patient has an acute peroneal tendon dislocation. The evaluation for syndesmotic injury and lateral ankle instability is negative. The cortical avulsion off the distal tip of the lateral malleolus, a rim fracture, is characteristic of peroneal tendon dislocations. The sensation of apprehension or frank subluxation of the peroneal tendons with active dorsiflexion of the foot while the foot is held in plantar flexion confirms the diagnosis. Based on these findings, initial management should consist of cast immobilization and protected weight bearing. If a recurrent or chronic condition develops, surgery is the most reliable treatment option. Arrowsmith SR, Fleming LL, Allman FL: Traumatic dislocations of the peroneal tendons. Am J Sports Med 1983;11:142-146.

Question 24

The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the

Explanation

Posterolateral rotatory instability (PLRI) of the elbow represents a three-dimensional injury pattern of rotational displacement of the ulna from the trochlea and the radius from the capitellum. The ulna supinates (externally rotates) past its normal limit and the radiocapitellar joint subluxates posterolaterally, permitting the coronoid process to slide beneath the trochlea. In cadaver studies, the lateral ulnar collateral ligament has been shown to be the essential lesion responsible for PLRI. The medial collateral ligament (of which the anterior bundle is the most important) is the primary restraint to valgus instability. The posterolateral capsule and radial collateral ligament may be disrupted in a complete posterolateral dislocation but are not essential injuries for PLRI. The primary function of the annular ligament is to stabilize the proximal radioulnar joint. O'Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF: The unstable elbow. J Bone Joint Surg Am 2000;82:724-738. Olsen BS, Sojbjerg JO, Dalstra M, Sneppen O: Kinematics of the lateral constraints of the elbow. J Shoulder Elbow Surg 1996;5:333-341.

Question 25

When evaluating articular cartilage, what extracellular matrix component is most closely associated with the deep calcified cartilage zone?

Explanation

Collagen type X is produced only by hypertrophic chondrocytes during enchondral ossification (growth plate, fracture callus, heterotopic ossification) and is associated with calcification of cartilage in the deep zone of articular cartilage. Collagen type I is the predominant collagen in bone, ligament, and tendon. Collagen type II is the predominant collagen in articular cartilage. Proteoglycan aggrecan and hyaluronic acid are components of the extracellular matrix and are involved in the compressive strength characteristics of articular cartilage. Buckwalter JA, Mankin HJ: Articular cartilage: Tissue design and chondrocyte matrix interactions. Instr Course Lect 1998;47:477-486.

Question 26

A 22-year-old rugby player undergoes an open Latarjet procedure for recurrent anterior shoulder instability with 25% glenoid bone loss. Postoperatively, he presents with profound weakness in elbow flexion and decreased sensation over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

Explanation

The musculocutaneous nerve is at significant risk during the Latarjet procedure, particularly during medial retraction of the conjoined tendon. Injury results in biceps weakness and numbness in the lateral antebrachial cutaneous nerve distribution.

Question 27

A 28-year-old man sustains a dashboard injury to his knee during a motor vehicle collision. Examination reveals a positive posterior drawer test. The Dial test demonstrates 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the uninjured side, but symmetrical external rotation at 90 degrees. Which structures are most likely injured?

Explanation

An increase in external rotation at 30 degrees of knee flexion with normal rotation at 90 degrees is the classic physical examination finding for an isolated posterolateral corner (PLC) injury. Combined PLC and PCL injuries show increased external rotation at both 30 and 90 degrees.

Question 28

A 13-year-old female soccer player with widely open physes requires surgical management for a complete ACL tear. To minimize the risk of physeal arrest while providing optimal stability, which of the following surgical techniques is most appropriate?

Explanation

For skeletally immature patients with significant remaining growth, physeal-sparing or all-epiphyseal techniques utilizing soft tissue grafts minimize the risk of growth arrest. Crossing open physes with bone blocks or large-diameter tunnels is strictly contraindicated.

Question 29

A 25-year-old male presents with recurrent anterior shoulder dislocations. CT imaging reveals a 22% anterior glenoid bone defect and a large, engaging Hill-Sachs lesion. Which of the following is the most appropriate definitive surgical management?

Explanation

In the setting of critical anterior glenoid bone loss (>20%) combined with an engaging Hill-Sachs lesion, isolated soft tissue repairs have an unacceptably high failure rate. A bony augmentation procedure, such as the Latarjet, is the definitive standard of care.

Question 30

A 30-year-old competitive weightlifter reports vague, deep posterior shoulder pain and a painful clicking sensation during the eccentric phase of the bench press. Examination demonstrates a positive jerk test. What is the most likely pathological finding?

Explanation

A positive jerk test is a reliable indicator of posterior shoulder instability. The classic pathoanatomical lesion associated with posterior instability is a reverse Bankart lesion, defined as a detachment of the posterior labrum from the posterior glenoid rim.

Question 31

A 35-year-old patient involved in a motorcycle collision sustains a knee dislocation. After reduction, the patient has a foot drop and lacks sensation over the dorsum of the foot. Which of the following specific ligamentous injury patterns is most highly associated with this neurologic deficit?

Explanation

Common peroneal nerve injuries frequently accompany severe knee trauma, particularly those involving the posterolateral corner (PLC) and posterior cruciate ligament (PCL). The nerve is tethered at the fibular neck, making it highly vulnerable to traction during significant varus and hyperextension mechanisms.

Question 32

A 19-year-old female gymnast complains of bilateral shoulder pain and feeling like her shoulders 'slip out' when reaching overhead. She has a positive sulcus sign bilaterally and generalized ligamentous laxity. After 9 months of dedicated physical therapy, she remains symptomatic. What is the surgical treatment of choice?

Explanation

For multidirectional instability (MDI) that fails prolonged nonoperative management, an arthroscopic or open capsular shift is the procedure of choice. This effectively reduces the capsular redundancy and volume, establishing joint stability without the high complication rates of thermal procedures.

Question 33

A 24-year-old football player is hit on the lateral aspect of his knee. He presents with medial-sided pain. Examination reveals 8 mm of medial joint line opening at 30 degrees of flexion with a firm endpoint, but he is completely stable to valgus stress at full extension. What is the recommended treatment?

Explanation

The examination describes an isolated Grade II MCL tear (valgus laxity at 30 degrees, stability at 0 degrees). Isolated MCL injuries heal reliably with nonoperative management, consisting of a hinged knee brace and early functional rehabilitation.

Question 34

A 28-year-old professional baseball pitcher presents with deep shoulder pain and decreased throwing velocity. O'Brien's active compression test is positive. An MRI arthrogram reveals a superior labral tear with detachment of the biceps anchor from the superior glenoid. What SLAP tear type is this, and what is the optimal management?

Explanation

A Type II SLAP tear involves detachment of the superior labrum and the origin of the long head of the biceps tendon from the superior glenoid. In young overhead athletes, the standard initial surgical management is arthroscopic repair of the superior labrum.

Question 35

A 32-year-old male presents with a ruptured ACL 3 years following a bone-patellar tendon-bone autograft reconstruction. Radiographs and CT demonstrate significant widening of both the femoral and tibial tunnels, measuring 15 mm each. What is the most appropriate surgical plan?

Explanation

Significant tunnel widening (>12-14 mm) in the setting of a failed ACL reconstruction precludes adequate rigid fixation of a new graft. A two-stage revision, starting with bone grafting the tunnels followed by definitive reconstruction 4-6 months later, is the standard of care.

Question 36

During an arthroscopic stabilization for recurrent anterior shoulder instability, you note that the labrum is completely intact, but the anterior band of the inferior glenohumeral ligament (IGHL) is avulsed off the humeral neck. What is the correct terminology for this specific lesion?

Explanation

Humeral Avulsion of the Glenohumeral Ligament (HAGL) represents a tear of the IGHL from its humeral attachment rather than the glenoid labrum. Failure to recognize and address this lesion is a well-documented cause of recurrent postoperative instability.

Question 37

A 26-year-old male sustains an isolated Grade III PCL tear during a soccer match. He is initially treated conservatively but returns 9 months later with continued complaints. Which of the following is the most widely accepted absolute indication for PCL reconstruction in this patient?

Explanation

While the majority of isolated PCL tears are successfully treated nonoperatively, clear indications for reconstruction include persistent functional instability, combined ligamentous injuries, and symptomatic recurrent 'giving way', particularly during deceleration activities.

Question 38

During a Latarjet procedure for anterior shoulder instability, what is the anatomical landmark that dictates the maximum safe proximal osteotomy of the coracoid process to avoid destabilizing the clavicle and endangering the suprascapular nerve?

Explanation

The coracoid osteotomy must be performed just distal to the coracoclavicular ligaments, specifically the conoid ligament, to prevent iatrogenic acromioclavicular instability. Remaining distal to the conoid also keeps the osteotomy well clear of the suprascapular notch and nerve.

Question 39

You are evaluating a 23-year-old patient with a suspected knee injury following a wrestling match. The Dial test is performed. The patient has 20 degrees greater external rotation on the injured side at 30 degrees of flexion, and 25 degrees greater external rotation at 90 degrees of flexion. What is the most accurate diagnosis?

Explanation

Increased external rotation of more than 10 degrees at 30 degrees of flexion indicates a posterolateral corner (PLC) injury. When this asymmetry persists or increases at 90 degrees of flexion, it signifies a combined PLC and posterior cruciate ligament (PCL) injury.

Question 40

A 28-year-old rock climber with recurrent anterior shoulder dislocations is found to have an engaging Hill-Sachs lesion but minimal glenoid bone loss. An arthroscopic Bankart repair with 'remplissage' is planned. Which structure is tenodesed into the humeral defect during this adjunctive procedure?

Explanation

The remplissage (French for 'filling') procedure involves converting an intra-articular Hill-Sachs lesion into an extra-articular defect by tenodesing the infraspinatus tendon and posterior capsule into the bony defect. This prevents the defect from engaging the anterior glenoid rim during external rotation.

Question 41

A 19-year-old female skier sustains a non-contact pivoting injury to her right knee, presenting with an immediate hemarthrosis. An acute ACL rupture is confirmed on MRI. What is the most common associated meniscal injury seen acutely in this specific setting?

Explanation

In the setting of an acute ACL tear, tears of the lateral meniscus (most commonly the posterior horn) are the most frequently associated meniscal injury. Medial meniscal tears are more classically associated with chronic, long-standing ACL deficiency.

Question 42

A 22-year-old collegiate wrestler undergoes an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BPTB) autograft. Postoperatively, what is the most common complication specifically associated with this graft choice compared to a hamstring autograft?

Explanation

The most common complication specific to a bone-patellar tendon-bone (BPTB) autograft is anterior knee pain, particularly with kneeling. Hamstring grafts are more associated with temporary hamstring weakness and slightly higher revision rates in young athletes.

Question 43

A 20-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 25% anterior glenoid bone loss. What is the most appropriate definitive surgical management?

Explanation

A Latarjet procedure is indicated for patients with recurrent anterior instability and greater than 20-25% glenoid bone loss. Soft tissue procedures alone, such as an arthroscopic Bankart repair, have an unacceptably high failure rate in this setting.

Question 44

A 28-year-old man sustains a dashboard injury to his right knee. Physical examination demonstrates a positive posterior sag sign. Which of the following bundles of the primary injured ligament is tightest in knee flexion?

Explanation

The posterior cruciate ligament (PCL) is composed of the anterolateral (AL) and posteromedial (PM) bundles. The AL bundle is the larger of the two and is tightest in knee flexion, whereas the PM bundle is tightest in extension.

Question 45

A 30-year-old recreational skier sustains an isolated, acute grade III medial collateral ligament (MCL) tear without meniscus or cruciate ligament involvement. What is the most appropriate initial management?

Explanation

Isolated grade III MCL tears are typically managed non-operatively with a hinged knee brace to protect against valgus stress while allowing early range of motion. Surgical intervention is generally reserved for multi-ligament injuries, intra-articular entrapment of the ligament, or chronic instability.

Question 46

During an arthroscopic anterior stabilization for recurrent shoulder instability, an off-track, engaging Hill-Sachs lesion is identified. Glenoid bone loss is measured at 8%. Which of the following is the most appropriate adjunctive procedure?

Explanation

The remplissage procedure (infraspinatus tenodesis into the defect) is indicated for engaging, off-track Hill-Sachs lesions when glenoid bone loss is subcritical (<15-20%). It effectively converts an intra-articular defect into an extra-articular one, preventing engagement over the anterior glenoid rim.

Question 47

A 35-year-old man sustains an anterior knee dislocation (Schenck KD III) during a motorcycle accident. Following closed reduction in the emergency department, ankle-brachial indices (ABI) are calculated at 0.85. What is the next most appropriate step in management?

Explanation

In cases of knee dislocations, an Ankle-Brachial Index (ABI) less than 0.9 is highly suspicious for a vascular injury. This mandates immediate advanced imaging, typically CT angiography, to evaluate the integrity of the popliteal artery.

Question 48

A 24-year-old athlete undergoes evaluation for a suspected knee injury. Physical examination reveals a positive dial test at 30 degrees of flexion, but symmetric normal external rotation at 90 degrees. This finding indicates an isolated injury to which of the following structures?

Explanation

The dial test evaluates for posterolateral corner (PLC) and PCL injuries. Increased external rotation of >10 degrees compared to the contralateral side at 30 degrees of flexion, but normal rotation at 90 degrees, indicates an isolated injury to the PLC.

Question 49

A 21-year-old collegiate offensive lineman presents with vague posterior shoulder pain exacerbated by bench pressing. Examination reveals increased posterior translation with a load-and-shift test and pain with the jerk test. What is the initial treatment of choice?

Explanation

The initial treatment for isolated, recurrent posterior shoulder instability, particularly in athletes without significant bone loss, is non-operative management. This focuses on physical therapy to strengthen the posterior shoulder musculature and periscapular stabilizers.

Question 50

Following an anterior cruciate ligament (ACL) reconstruction, a patient has persistent rotational instability (positive pivot shift) despite a negative Lachman test. Radiographs show the femoral tunnel placed at the 12 o'clock position in the intercondylar notch. What is the functional consequence of this specific tunnel placement?

Explanation

Placing the femoral tunnel in a strictly vertical position (12 o'clock) during ACL reconstruction fails to restore normal knee kinematics. While it may limit anterior tibial translation, it poorly controls rotational instability, resulting in a persistent pivot shift.

Question 51

A 26-year-old professional baseball pitcher reports a "dead arm" and deep shoulder pain during the late cocking phase of throwing. A type II SLAP tear is suspected. Which of the following pathomechanical processes is most responsible for this specific injury pattern?

Explanation

Type II SLAP tears in overhead throwing athletes are primarily caused by the peel-back mechanism. During the late cocking phase, maximal external rotation and abduction create a torsional force at the base of the biceps, causing the posterosuperior labrum to peel off the glenoid.

Question 52

A 24-year-old male undergoes a Latarjet procedure for recurrent anterior shoulder instability with severe glenoid bone loss. Postoperatively, he demonstrates profound weakness in elbow flexion and decreased sensation over the lateral aspect of his forearm. Which nerve was most likely injured during the surgical approach?

Explanation

The musculocutaneous nerve is at highest risk during a Latarjet procedure due to its proximity to the coracoid process. It typically enters the coracobrachialis muscle 3 to 8 cm distal to the coracoid tip, making careful retraction and dissection critical.

Question 53

During a single-bundle posterior cruciate ligament (PCL) reconstruction using an Achilles tendon allograft aiming to reconstruct the anterolateral bundle, at what degree of knee flexion should the graft typically be tensioned to best restore normal knee kinematics?

Explanation

During a single-bundle PCL reconstruction aiming to recreate the anterolateral bundle, the graft should be tensioned and fixed at 90 degrees of knee flexion. This is because the anterolateral bundle of the native PCL is tightest in flexion.

Question 54

A 30-year-old man continues to have anterior shoulder instability after a seemingly successful arthroscopic Bankart repair. A revision MRI arthrogram is obtained.

The imaging demonstrates contrast extending inferiorly into the axillary pouch with a characteristic "J-sign" at the humeral insertion of the capsule. What is the most likely diagnosis?

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) lesion involves the tearing of the inferior glenohumeral ligament from its humeral insertion. On MRI arthrography, this presents as the characteristic "J-sign" as contrast extends inferiorly into the axillary pouch through the defect.

Question 55

During reconstruction of the posterolateral corner (PLC) of the knee, anatomical landmarks are critical. In an isolated injury to the popliteofibular ligament, what is the expected primary physical exam finding?

Explanation

The popliteofibular ligament is a primary restraint to external rotation. Injury to the PLC, including the popliteofibular ligament, typically presents with increased external tibial rotation at 30 degrees of knee flexion.

Question 56

A 22-year-old male presents with recurrent anterior shoulder instability. Diagnostic arthroscopy reveals the anterior labrum is stripped and displaced medially down the glenoid neck, with the anterior periosteum remaining intact. Which of the following is the most accurate diagnosis?

Explanation

An Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion involves medial displacement of the labrum with an intact periosteal sleeve. This distinguishes it from a standard Bankart lesion, where the periosteum is ruptured, and from a Perthes lesion, where the labrum is stripped but non-displaced.

Question 57

A 19-year-old collegiate soccer player is scheduled for anterior cruciate ligament (ACL) reconstruction. The surgeon discusses using a bone-patellar tendon-bone (BTB) autograft. Compared to hamstring autografts, BTB autograft is most uniquely associated with which of the following postoperative complications?

Explanation

Patella fracture and anterior knee pain are specific complications associated with the harvest of a bone-patellar tendon-bone autograft. Saphenous nerve injury and hamstring weakness are more commonly associated with hamstring autograft harvests.

Question 58

A 25-year-old male presents with recurrent anterior shoulder dislocations. A pre-operative CT scan demonstrates an anterior glenoid bone defect.

At what percentage of anterior glenoid bone loss is a Latarjet procedure or bone grafting generally indicated over an isolated arthroscopic Bankart repair?

Explanation

A critical glenoid bone loss of approximately 20-25% results in unacceptably high failure rates with soft-tissue Bankart repair alone. In these cases, a bony augmentation procedure such as a Latarjet is the recommended surgical management.

Question 59

A 28-year-old male sustains a "dashboard injury" in a motor vehicle collision. Physical examination and MRI confirm an isolated Grade III posterior cruciate ligament (PCL) tear. What is the most appropriate initial management?

Explanation

Isolated PCL injuries, even Grade III, have an excellent capacity for conservative healing. Initial management involves a hinged knee brace locked in full extension for 2 to 4 weeks to reduce posterior tibial sag, followed by progressive range of motion and quadriceps strengthening.

Question 60

A 35-year-old male with a history of a seizure disorder presents with an unrecognized locked posterior shoulder dislocation that occurred 3 weeks ago. CT imaging reveals an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 35% of the articular surface. The glenohumeral cartilage is otherwise preserved. What is the most appropriate surgical treatment?

Explanation

For a reverse Hill-Sachs lesion involving 20% to 40% of the articular surface, transferring the subscapularis tendon (McLaughlin) or the lesser tuberosity (modified McLaughlin) into the defect prevents engagement and restores stability. Defects greater than 40% typically require structural allograft or arthroplasty.

Question 61

A 30-year-old male presents to the trauma bay following a high-speed motorcycle crash with a grossly deformed left knee. The joint is urgently reduced. Post-reduction, the distal pulses are palpable but symmetric, and the Ankle-Brachial Index (ABI) is calculated to be 0.8. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 in the setting of a knee dislocation is highly suspicious for a popliteal artery injury. A CT angiogram is indicated to evaluate the vascular status comprehensively before proceeding with surgical intervention or observation.

Question 62

A 24-year-old professional baseball pitcher complains of deep shoulder pain, decreased throwing velocity, and pain specifically during the late cocking phase. Clinical examination reveals a positive O'Brien test. What pathomechanical process is most commonly responsible for this patient's condition?

Explanation

In overhead throwers, a contracted posteroinferior capsule leads to a posterosuperior shift of the humeral head in maximum abduction and external rotation. This creates a peel-back force on the biceps anchor, resulting in a type II SLAP tear.

Question 63

A 21-year-old football player is struck on the anteromedial aspect of his proximal tibia. On physical examination, he demonstrates 15 degrees of increased external rotation on the Dial test at 30 degrees of knee flexion compared to the contralateral knee, but normal external rotation at 90 degrees of knee flexion. Which structure(s) is/are most likely injured?

Explanation

An isolated injury to the posterolateral corner (PLC) causes increased external rotation at 30 degrees of knee flexion but not at 90 degrees. A combined PLC and PCL injury would demonstrate increased external rotation at both 30 and 90 degrees.

Question 64

A 28-year-old male presents with recurrent apprehension 1 year after undergoing a Latarjet procedure. CT imaging reveals significant resorption of the coracoid graft. What technical error is most commonly associated with graft osteolysis following a Latarjet procedure?

Explanation

Medial placement of the coracoid graft deprives it of mechanical loading from the humeral head. According to Wolff's law, this stress shielding leads to graft resorption and osteolysis, which can result in recurrent instability.

Question 65

A 26-year-old female presents with acute knee pain after a twisting injury while skiing. Plain radiographs demonstrate a small avulsion fracture from the lateral tibial plateau just distal to the articular surface. This radiographic finding is virtually pathognomonic for a concurrent tear of which of the following structures?

Explanation

The Segond fracture is an avulsion fracture of the anterolateral capsule and the anterolateral ligament (ALL) from the proximal lateral tibia. It is highly associated (greater than 75% of cases) with an anterior cruciate ligament (ACL) tear.

Question 66

A 32-year-old rugby player presents after an acute anterior shoulder dislocation.

A coronal T2-weighted MRI reveals a J-sign with extravasation of joint fluid inferiorly into the axillary pouch, without detachment of the labrum. What is the most likely diagnosis?

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) lesion occurs when the inferior glenohumeral ligament complex is avulsed from the humeral neck. The classic MRI finding is the J-sign, representing the droop of the torn ligament and inferior extravasation of fluid.

Question 67

A 40-year-old male suffers a valgus knee injury. An MRI is obtained, revealing a distal avulsion of the superficial medial collateral ligament (MCL). The torn distal end is flipped superficial to the pes anserinus tendons (a Stener-like lesion). What is the recommended management?

Explanation

Unlike proximal and mid-substance MCL tears which generally heal well non-operatively, a distal tibial avulsion of the MCL that is displaced superficial to the pes anserinus cannot spontaneously reattach to its footprint. This Stener-like lesion requires surgical repair.

Question 68

A 22-year-old male presents with recurrent anterior shoulder dislocations. Diagnostic arthroscopy reveals an anterior glenoid bone defect of 15% and a large, engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

Explanation

For patients with subcritical glenoid bone loss (less than 20%) but a substantial, engaging Hill-Sachs lesion (an off-track lesion), an arthroscopic Bankart repair combined with a Remplissage (infraspinatus tenodesis into the defect) effectively prevents engagement and restores stability.

Question 69

During an endoscopic ACL reconstruction, an inexperienced surgeon places the femoral tunnel entirely too far anteriorly (high at the 12 o'clock position in the notch). What abnormal graft tension pattern will this non-anatomical placement cause?

Explanation

A femoral tunnel placed too anteriorly (high in the notch) falls outside the isometric zone. As the knee moves from extension into flexion, the distance between the femoral and tibial tunnels increases, causing the graft to become tight in flexion and loose in extension, often leading to loss of flexion.

Question 70

During a routine diagnostic shoulder arthroscopy for mild non-specific pain, the surgeon visualizes a cord-like middle glenohumeral ligament and an absent anterosuperior labrum. The patient has no history of instability. What is the most appropriate management of these specific intra-articular findings?

Explanation

The findings describe a Buford complex, which is a normal anatomic variant present in approximately 1.5% of shoulders. It should be left alone (observation); attempting to repair the absent labrum or tethering the middle glenohumeral ligament to the glenoid will severely restrict external rotation.

Question 71

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder dislocations. Advanced imaging demonstrates an anteroinferior labral tear and 26% anterior glenoid bone loss. Which of the following is the most appropriate surgical management to minimize the risk of recurrent instability?

Explanation

Glenoid bone loss greater than 20-25% is a classic indication for a bony augmentation procedure, most commonly the Latarjet procedure. Soft tissue repairs (Bankart) have an unacceptably high failure rate in the presence of critical anterior bone loss.

Question 72

A 25-year-old male sustains a twisting injury to his knee. Physical examination reveals an isolated increase in external tibial rotation of 15 degrees compared to the contralateral side when tested at 30 degrees of knee flexion. The external rotation normalizes and is symmetric at 90 degrees of flexion. Which structure is most likely injured?

Explanation

An isolated posterolateral corner (PLC) injury typically presents with increased external rotation at 30 degrees of flexion that normalizes at 90 degrees. A combined PLC and PCL injury would demonstrate increased external rotation at both 30 and 90 degrees.

Question 73

During diagnostic arthroscopy for a 28-year-old patient with recurrent anterior shoulder instability, the surgeon notes an intact anteroinferior labrum but observes a U-shaped capsular tear avulsed from the anatomic neck of the humerus in the axillary pouch. What is the diagnosis?

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) presents as a disruption of the inferior glenohumeral ligament from its humeral attachment. It appears as a U-shaped defect in the axillary pouch and is an important cause of instability without a Bankart lesion.

Question 74

A 24-year-old male presents 6 months after an anterior cruciate ligament (ACL) reconstruction complaining of a lack of full terminal extension. Sagittal MRI reveals that the tibial tunnel was placed too anteriorly. The graft is most likely impinging against which of the following structures?

Explanation

A tibial tunnel placed too anteriorly during ACL reconstruction results in graft impingement against the intercondylar roof (Blumensaat's line) during terminal knee extension. This mechanical block leads to an extension deficit and potential graft failure.

Question 75

A 24-year-old male overhead athlete undergoes arthroscopic evaluation for recurrent anterior shoulder instability. Findings include an off-track, engaging Hill-Sachs lesion and 12% anterior glenoid bone loss. Which of the following is the most appropriate management alongside an arthroscopic Bankart repair?

Explanation

For engaging, off-track Hill-Sachs lesions with subcritical glenoid bone loss (typically <20%), an arthroscopic Bankart repair combined with remplissage (infraspinatus tenodesis into the humeral defect) is indicated. This prevents the defect from engaging the anterior glenoid rim.

Question 76

An AP radiograph of a 30-year-old skier's knee following an acute pivoting injury demonstrates a small elliptical avulsion fracture of the lateral tibial plateau, just distal to the joint line. This radiographic finding is most highly associated with an injury to which of the following structures?

Explanation

A Segond fracture is an avulsion of the anterolateral capsule (anterolateral ligament) from the lateral tibial plateau. It is considered highly pathognomonic (up to 75-100% association) for an underlying anterior cruciate ligament (ACL) tear.

Question 77

A 40-year-old man presents to the emergency department with severe shoulder pain and the arm locked in internal rotation after sustaining a severe electrical shock. Radiographs confirm a posterior shoulder dislocation with an anteromedial humeral head impaction fracture involving 25% of the articular surface. Following closed reduction, what is the preferred definitive surgical intervention?

Explanation

Posterior shoulder dislocations commonly cause a reverse Hill-Sachs lesion. For defects involving 20-40% of the articular surface, a McLaughlin procedure (transfer of the lesser tuberosity or subscapularis into the defect) provides excellent stability and prevents engagement.

Question 78

When comparing the tibial inlay technique to the transtibial technique for Posterior Cruciate Ligament (PCL) reconstruction, what is the primary biomechanical advantage of the tibial inlay approach?

Explanation

The tibial inlay technique involves direct fixation of a bone block to the posterior tibia. This eliminates the acute angle (the "killer turn") characteristic of the transtibial technique, reducing graft abrasion and potentially decreasing late graft laxity.

Question 79

A 28-year-old man undergoes a Latarjet procedure for refractory anterior shoulder instability. Postoperatively, he complains of weakness in elbow flexion and numbness over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?

Explanation

The musculocutaneous nerve is at significant risk during the Latarjet procedure when retracting the conjoined tendon or mobilizing the coracoid. It typically penetrates the coracobrachialis 5 to 8 cm distal to the coracoid tip.

Question 80

A 22-year-old collegiate football player sustains an isolated grade III Medial Collateral Ligament (MCL) sprain of the right knee. Examination shows significant valgus laxity at 30 degrees of flexion but a firm endpoint in full extension. What is the most appropriate initial management?

Explanation

Isolated grade III MCL injuries have excellent healing potential due to the ligament's robust blood supply. Non-operative management with a hinged brace and early functional rehabilitation yields outcomes equal to or better than primary surgical repair.

Question 81

A 45-year-old manual laborer presents with deep anterior shoulder pain. Clinical examination reveals a positive O'Brien's test. MRI arthrogram demonstrates a Type II SLAP tear without concomitant rotator cuff pathology. Based on current evidence, what is the most appropriate surgical management for this patient?

Explanation

In patients over the age of 40, especially manual laborers, primary biceps tenodesis is preferred over SLAP repair for Type II SLAP lesions. SLAP repair in this demographic is associated with higher rates of postoperative stiffness, persistent pain, and need for revision.

Question 82

A 30-year-old unrestrained driver is brought to the trauma bay after a motor vehicle collision. He has a grossly deformed knee which is quickly reduced. Post-reduction, distal pulses are palpable, but the Ankle-Brachial Index (ABI) is calculated to be 0.8. What is the most appropriate next step in management?

Explanation

Following a knee dislocation, an ABI less than 0.9 is highly concerning for a popliteal artery injury, even if palpable pulses return. A CT angiogram is urgently indicated to evaluate for an intimal flap, occlusion, or active extravasation.

Question 83

Which of the following factors is most strongly associated with an increased risk of recurrent instability following an isolated arthroscopic Bankart repair for anterior shoulder instability?

Explanation

Significant anterior glenoid bone loss (>20-25%) alters the articular geometry and is the strongest predictor of failure for soft-tissue stabilization alone (Bankart repair). Such bone loss mandates a bony augmentation procedure like the Latarjet.

Question 84

A 10-year-old male soccer player (Tanner stage 1) sustains a complete ACL tear and experiences recurrent giving-way episodes despite physical therapy. To minimize the risk of physeal arrest and angular deformity, which surgical technique is most appropriate?

Explanation

In prepubescent patients with substantial growth remaining (Tanner stage 1 or 2), physeal-sparing techniques, such as an iliotibial band extra-articular reconstruction (e.g., modified MacIntosh or Micheli procedure), are indicated to avoid iatrogenic physeal arrest.

Question 85

A 19-year-old female gymnast complains of bilateral shoulder pain and feeling like her shoulders slip out of place. Examination reveals generalized ligamentous laxity, a positive sulcus sign, and apprehension in anterior, posterior, and inferior directions. What is the most appropriate initial treatment?

Explanation

Multidirectional instability (MDI) typically presents in young females with generalized laxity. The mainstay of initial treatment is a prolonged course (at least 6 months) of physical therapy targeting the dynamic stabilizers (rotator cuff) and periscapular musculature.

Question 86

Six months following an uneventful ACL reconstruction using a hamstring autograft, a patient complains of a painful, audible click and an inability to achieve full terminal extension. MRI demonstrates a rounded, nodular soft tissue mass located anterior to the ACL graft in the intercondylar notch. What is the most likely diagnosis?

Explanation

A Cyclops lesion is a localized form of anterior arthrofibrosis that creates a fibrovascular nodule anterior to the ACL graft. It typically causes a loss of terminal extension and can present with an audible or palpable click.

Question 87

A 22-year-old elite baseball pitcher complains of posterior shoulder pain exclusively during the late cocking phase of throwing. Arthroscopic evaluation reveals undersurface fraying of the posterior supraspinatus tendon and a peel-back lesion of the posterosuperior labrum. What is the primary diagnosis?

Explanation

Internal impingement occurs in overhead athletes during the late cocking phase (maximum abduction and external rotation). The greater tuberosity impinges against the posterosuperior glenoid, leading to characteristic articular-sided rotator cuff tears and posterosuperior labral pathology.

Question 88

A patient presents with a knee injury sustained from a blow to the anterolateral aspect of the flexed knee. Clinical examination reveals anteromedial rotatory instability (AMRI), characterized by valgus laxity and anterior subluxation of the medial tibial plateau. Which primary structure of the posteromedial corner is injured?

Explanation

Anteromedial rotatory instability (AMRI) is the clinical hallmark of a posteromedial corner injury. The posterior oblique ligament (POL) and the superficial MCL are the primary restraints to valgus and external rotation forces in this quadrant.

Question 89

A 22-year-old collegiate rugby player with a history of recurrent anterior shoulder instability presents for definitive management. A 3D computed tomography (CT) scan reveals a 27% anterior glenoid bone loss with an associated engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical intervention?

Explanation

Anterior glenoid bone loss greater than 20-25% is a strict contraindication for isolated soft-tissue stabilization (Bankart repair). The Latarjet procedure (coracoid transfer) is the gold standard for restoring glenohumeral stability in the setting of critical bone loss.

Question 90

A 24-year-old male sustains a traumatic knee injury. On physical examination, the dial test reveals 15 degrees of increased external rotation on the injured side compared to the normal side when tested at 30 degrees of knee flexion. However, at 90 degrees of knee flexion, the external rotation is symmetric bilaterally. What is the most likely injured structure?

Explanation

A positive dial test (greater than 10 degrees of asymmetry) at 30 degrees of flexion that normalizes at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If the asymmetry is present at both 30 and 90 degrees, it indicates a combined PLC and PCL injury.

Question 91

A 42-year-old male presents with a locked posterior shoulder dislocation following a witnessed seizure. Imaging reveals a reverse Hill-Sachs lesion comprising 30% of the anterior humeral head articular surface. After successful open reduction, the shoulder remains unstable in internal rotation. What is the most appropriate treatment for the humeral head defect?

Explanation

A reverse Hill-Sachs lesion involving 20% to 40% of the articular surface is optimally managed with a modified McLaughlin procedure, which involves transferring the subscapularis tendon or lesser tuberosity into the defect. Defects greater than 40-50% typically require arthroplasty.

Question 92

A 21-year-old female recreational skier felt a "pop" in her knee during a twisting fall. An AP radiograph in the emergency department reveals a small, elliptical bony avulsion fragment just lateral to the lateral tibial plateau.

This radiographic finding is most highly associated with an injury to which of the following structures?

Explanation

The Segond fracture is an avulsion of the anterolateral ligament and lateral capsule from the lateral tibia. It is pathognomonic for an anterior cruciate ligament (ACL) tear and represents significant anterolateral rotatory instability.

Question 93

A 25-year-old professional baseball pitcher complains of deep shoulder pain during the late cocking phase of throwing. Magnetic resonance arthrography demonstrates a superior labral tear extending from anterior to posterior (Type II SLAP lesion). Which of the following mechanisms is considered the primary etiology for this specific injury in overhead throwing athletes?

Explanation

In overhead throwers, Type II SLAP tears often occur due to the "peel-back" mechanism during the late cocking phase (maximum abduction and external rotation). The biceps vector shifts posteriorly, transmitting severe torsional stress to the superior labral anchor.

Question 94

A 30-year-old male is brought to the trauma bay after a high-speed motorcycle collision. Examination of his right lower extremity reveals a grossly unstable knee with positive anterior, posterior, and valgus stress testing. The foot is warm, and dorsalis pedis pulses are palpable. The Ankle-Brachial Index (ABI) is measured at 0.8. What is the most appropriate next step in management?

Explanation

In the setting of a multiligament knee injury (knee dislocation), an ABI less than 0.9 mandates further advanced vascular imaging, such as a CT angiogram, to rule out a popliteal artery injury. Palpable pulses alone do not reliably exclude an intimal tear or evolving occlusion.

Question 95

A 26-year-old male presents with recurrent anterior shoulder instability. Diagnostic imaging reveals a Bankart lesion, 10% anterior glenoid bone loss, and a large Hill-Sachs lesion that engages the anterior glenoid rim on dynamic 3D CT modeling. Which of the following is the most appropriate surgical management?

Explanation

An engaging Hill-Sachs lesion in the setting of subcritical glenoid bone loss (<20%) is best managed with a Bankart repair combined with a Remplissage procedure (infraspinatus tenodesis into the defect). This converts an intra-articular defect to an extra-articular one, preventing engagement.

Question 96

A 19-year-old collegiate football player is struck on the lateral aspect of his left knee. Physical examination reveals 8 mm of medial joint line opening without a firm endpoint when valgus stress is applied at 30 degrees of flexion, but the knee is stable to valgus stress at 0 degrees of flexion. MRI confirms an isolated, complete proximal tear of the medial collateral ligament (MCL). What is the recommended treatment?

Explanation

Isolated grade III MCL tears, particularly those located at the proximal or mid-substance level, have an excellent healing potential with non-operative management. A hinged knee brace protects against valgus stress while permitting early range of motion to prevent stiffness.

Question 97

A 55-year-old man presents to the emergency department after falling on his outstretched hand. Radiographs confirm an anteroinferior shoulder dislocation. After successful closed reduction, he notes decreased sensation over the lateral aspect of his shoulder. If this neurologic deficit persists, weakness in which of the following muscles is most likely to be observed?

Explanation

The axillary nerve is the most commonly injured nerve during an anterior shoulder dislocation, leading to numbness over the lateral shoulder (regimental badge area). The axillary nerve innervates both the deltoid and the teres minor muscles.

Question 98

A 28-year-old athlete is undergoing a complex multi-ligament knee reconstruction. The surgeon is reviewing the anatomy of the native posterior cruciate ligament (PCL) to optimize tunnel placement. Which of the following accurately describes the anatomy and biomechanics of the primary functional bundle of the PCL?

Explanation

The PCL is composed of two main bundles: the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The anterolateral bundle becomes tight in knee flexion, whereas the posteromedial bundle tightens in extension.

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

AAOS Sports Medicine MCQs (Set 4): Knee Ligament & Shoulder Instability | ABOS Board Review

Key Takeaway

AAOS Sports Medicine MCQs (Set 4): Knee Ligament & Shoulder Instability | ABOS Board Review

Chapter Index