ABOS Sports Med MCQs (Set 3): Knee & Shoulder Injuries

Question 1

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of

Explanation

The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T1-weighted MRI scans and with high signal intensity on T2-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient. Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 2

A 21-year-old collegiate scholarship football player has an episode of transient quadriplegia. An MRI scan of the cervical spine reveals cord edema and severe congenital spinal stenosis. The athlete has aspirations of playing on a professional level and demands that he be allowed to play. The team physician should give what recommendation to the college?

Explanation

Federal courts have ruled that a student-athlete does not have a constitutional right to participate in athletics against medical advice. As long as the student retains his scholarship, the college is under no legal or ethical obligation to allow the student to participate in sports. A waiver would not hold up in court and would not indemnify the college or the team physician against suit. No equipment has been shown to be effective in preventing transient quadriplegia. Mathias MB: The competing demands of sport and health: An essay on the history of ethics in sports medicine. Clin Sports Med 2004;23:195-214.

Question 3

When performing a posterior cruciate ligament reconstruction with a tibial inlay-type approach, what is the approximate anatomic distance of the popliteal artery from the screws used for fixation of the bone block?

Explanation

Miller and associates reported the results of a cadaveric study of the vascular risk of a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. The average distance from the screw to the popliteal artery was 21.1 mm (range, 18.1 mm to 31.7 mm). Other approaches, such as the transtibial tunnel technique which involves drilling an anterior-posterior tunnel, have also been studied in cadavers. Matava and associates noted that increasing flexion reduces but does not completely eliminate the risk of arterial injury during arthroscopic posterior cruciate ligament reconstruction. However, this study did not use the small, medial utility incision recommended by Fanelli and associates, which creates an interval for the surgeon's finger between the medial gastrocnemius and the posteromedial capsule so that any migration of the guidepin can be palpated and changed prior to any injury to the posterior neurovascular bundle. Matava MJ, Sethi NS, Totty WG: Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796-804. Miller MD, Kline AJ, Gonzales J, et al: Vascular risk associated with posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. J Knee Surg 2002;15:137-140.

Question 4

Which of the following knee ligament injury patterns is most associated with an increase in external tibial rotation with the knee at 90 degrees of flexion?

Explanation

Cadaveric studies have shown that external rotation of the tibia is most pronounced following transection of the posterior cruciate and lateral collateral ligaments with the knee at 90 degrees of flexion. Isolated release of the lateral collateral ligament results in increased external tibial rotation at 30 degrees. Gollehon DL, Torzilli PA, Warren RF: The role of the posterolateral and cruciate ligaments in the stability of the human knee: A biomechanical study. J Bone Joint Surg Am 1987;69:233-242. Cooper DE: Tests for posterolateral instability of the knee in normal subjects: Results of examination under anesthesia. J Bone Joint Surg Am 1991;73:30-36.

Question 5

A 28-year-old professional dancer reports a 3-month history of progressive pain in the posterior aspect of the left ankle. Her symptoms are worse when she assumes the en pointe position. Examination reveals tenderness to palpation at the posterolateral aspect of the ankle posterior to the peroneal tendons which is made worse with passive plantar flexion. There is no nodularity, fluctuance, or tenderness of the Achilles tendon. The neurovascular examination is unremarkable. A lateral radiograph and MRI scan are shown in Figures 16a and 16b, respectively. Management should consist of

Explanation

The imaging studies reveal findings typical of the os trigonum syndrome. This condition results from inflammation between the os trigonum and the adjacent talus. The symptoms of posterior ankle pain are exacerbated by plantar flexion, which stresses the fibrous union between these two bones. Definitive management of the high-level athlete involves excision of the os trigonum from a medial approach, although arthroscopic excision has also been described. The os trigonum is not an intra-articular structure; therefore, ankle arthroscopy is neither diagnostic nor therapeutic. Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051-1057. Mouhsine E, Crevoisier X, Leyvraz P, et al: Post-traumatic overload or acute syndrome of the os trigonum: A possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 2004;12:250-253.

Question 6

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient's desire to return to sport?

Explanation

Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing. Miller MD, Cooper DE, Warner JJP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 230. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, p 227.

Question 7

A 20-year-old collegiate football player who sustained blunt head trauma during the first half of a game is emotional and confused. During the halftime intermission, his affect, memory, and disorientation are totally resolved and have returned to preinjury baseline. The only residual finding is a very mild headache. He wants to play the second half. What is the most appropriate course of action?

Explanation

There is almost universal acceptance that an athlete may return to play after blunt head trauma only if he or she is totally asymptomatic. Mild residual symptoms are considered an absolute contraindication for return to play. Returning to play after a cardiovascular challenge or sport-specific activities is permitted on the pretext that the athlete is totally asymptomatic prior to these maneuvers. Neuropsychiatric testing is being used more frequently to monitor residual cognitive effects after head trauma. It has not been used as a return to play criterion. Garrick J (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 29-48.

Question 8

Which of the following actions best enhances performance when an athlete is participating in a 10K race?

Explanation

Proper hydration prior to an athletic event is the most important determinant of performance. It is virtually impossible to keep pace with fluid loss during an athletic competition. When a net loss of fluid occurs and the athlete is properly prehydrated, this fluid loss will not adversely affect performance. It is not necessary to load up on carbohydrates prior to a 10K race, or to replace calories burned during the race. Hyponatremia can develop in ultra-endurance athletes, especially marathoners, if they hydrate without replacing electrolytes lost through sweating; however, this is highly unlikely for a 10K race. Newmark SR, Toppo FR, Adams G: Fluid and electrolyte replacement in the ultramarathon runner. Am J Sports Med 1991;19:389-391.

Question 9

A 25-year-old competitive skier sustains a twisting injury to the right ankle while skiing. She is unable to continue the activity secondary to severe lateral ankle pain. Examination reveals ecchymosis and fullness over the lateral malleolus with pain and weakness on active ankle dorsiflexion and external rotation. There is no medial-sided pain. Neurovascular examination is normal. An AP radiograph and MRI scan are shown in Figures 17a and 17b, respectively. Management should consist of

Explanation

The MRI scan shows a dislocated peroneus brevis tendon with disruption of the peroneal retinaculum. This injury is commonly seen in skiers and is the result of peroneal contraction with the ankle everted and dorsiflexed. Nonsurgical management is rarely successful; therefore, repair of the peroneal retinaculum is the treatment of choice. Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670-672. Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.

Question 10

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Explanation

Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation. Schepsis AA, Grafe MW, Jones HP, et al: Rupture of the pectoralis major muscle: Outcome or repair of acute and chronic injuries: Am J Sports Med 2000;28:9-15.

Question 11

A 20-year-old man reports painless snapping about the lateral aspect of the right hip. He denies any history of trauma. Examination reveals no limp or tenderness. Hip range of motion is full, and there is good strength. Radiographs are normal. What anatomic structure is most likely causing these symptoms?

Explanation

Coxa saltans (snapping hip syndrome) can occur in two forms: external/lateral or interior/medial/anterior. This patient has the external/lateral form. The external/lateral form involves the iliotibial band, tensor fascia, or gluteus medius, which snaps over the greater trochanter. The external form usually can be treated with physical therapy alone; however, several recent studies report satisfactory results with surgical treatment. Faraj and associates reported good results from surgical Z-plasty in a series of 10 patients. White and associates reported good results in a series of 16 patients with 17 hips who underwent surgical release of an external snapping hip. The interior/medial/anterior form can involve the iliopsoas tendon, acetabular labrum, subluxation of the hip, and loose bodies. White RA, Hughes MS, Burd T, et al: A new operative approach in the correction of external coxa saltans: The snapping hip. Am J Sports Med 2004;32:1504-1508. Faraj AA, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature. Acta Orthop Belg 2001;67:19-23.

Question 12

Which of the following statements correctly describes the results of gamma irradiation of musculoskeletal allograft?

Explanation

Low dose gamma irradiation (less than 3.0 megarads) with antibiotic soaks is one of the most common techniques for secondary sterilization. Elimination of HIV with gamma irradiation requires doses estimated to be greater than 3.5 megarads. Gamma irradiation levels of 4 megarads have been shown to alter the mechanical properties of human infrapatellar tendons. Ethylene oxide, also used for allograft sterilization, has been associated with a chronic inflammatory process that resolved after graft removal. Jackson DW, Windler GE, Simon TM: Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstruction of the anterior cruciate ligament. Am J Sports Med 1990;18:1-10. Conway B, Tomford W, Mankin HJ, et al: Radiosensitivity of HIV-1: Potential application to sterilization of bone allografts. AIDS 1991;5:608-609.

Question 13

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

Explanation

Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker's cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T1- and T2-weighted images. A lipoma would be bright on the T1-weighted image only. Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.

Question 14

A 12-year-old boy who pitches on two "select" baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of

Explanation

The imaging study demonstrates characteristics of Little Leaguer's shoulder, including physeal widening. This condition is secondary to overuse (typically throwing) and responds well to rest from the inciting activity. There is no evidence from the patient's history or examination that he has an impingement syndrome, nor is there any indication of labral pathology on the MRI scan. The changes in the proximal humerus are classic for this condition and are not suggestive of a neoplastic process requiring biopsy for definitive diagnosis. Lipscomb AB: Baseball pitching injuries in growing athletes. J Sports Med 1975;3:25-34. Cahill BR, Tullos HS, Fain RH: Little league shoulder: Lesions of the proximal humeral epiphyseal plate. J Sports Med 1974;2:150-152.

Question 15

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman's test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?

Explanation

The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman's test. Physical therapy and bracing will have little effect. Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.

Question 16

As a baseball player dives to catch a line drive in the outfield, the ball strikes the tip of the player's finger when extended, causing forcible flexion to avulse the extensor tendon from the distal phalanx. Following evaluation and normal radiographic findings, initial management should include

Explanation

Avulsion of the terminal extensor tendon from the distal phalanx (mallet or baseball finger) may or may not be associated with a bony avulsion. The injury is caused by forcible flexion of the DIP joint while catching a ball or hitting an object with the finger extended. Most authorities recommend continuous extension splinting to the DIP joint for 6 weeks, followed by nighttime splinting for an additional 6 weeks. It must be emphasized to the patient that at no time during the initial 6 weeks of treatment should the DIP joint be allowed to fall into flexion or an additional 6 weeks of continuous splinting is required. Miller MD, Cooper DE, Warner JP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 255. Rettig AC: Closed tendon injuries of the hand and wrist in the athlete. Clin Sports Med 1992;11:77-99.

Question 17

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

Explanation

Rehabilitation of the quadriceps muscle following a partial tear of the PCL has been associated with a favorable outcome. The quadriceps acts an antagonist to the PCL because its contraction results in anterior tibial translation, which reduces the tensile stress on the injured ligament. Strengthening of the hamstring musculature increases posterior tibial translation and is contraindicated during the early rehabilitative phase following a PCL injury. Brace use has not been found to significantly alter the outcome following nonsurgical management of PCL tears. Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14:35-38.

Question 18

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

Explanation

When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media. Tucker AM: Ethics and the professional team physician. Clin Sports Med 2004;23:227-241.

Question 19

A 20-year-old basketball player reports a 6-month history of right groin pain that radiates into his testicles with activities of daily living. He denies any history of trauma. Examination reveals tenderness about the groin, and he has full hip range of motion. The abdomen is soft. Radiographs are normal. Nonsurgical management has consisted of rest and physical therapy, but he continues to have pain. What is the next step in management?

Explanation

Sports hernias may be one of the most common causes of groin pain in athletes. Resisted hip adduction is painful in the case of groin disruption. Radiation of pain into the testicles and/or adductor region is often present. Sports hernias are associated with weakening of the posterior inguinal wall. In contrast with sports hernias, traditional or classic hernias can be readily detected on physical examination. Diagnostic imaging studies are not helpful and only serve to help exclude other diagnoses. Systemic high-dose steroids or sacroiliac joint injections have no role in treatment. High success rates have been reported for laparoscopic hernia repair in athletes. Kluin J, den Hoed PT, van Linschoten R, et al: Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 2004;32:944-949. Genitsaris M, Goulimaris I, Sikas N: Laparoscopic repair of groin pain in athletes. Am J Sports Med 2004;32:1238-1242.

Question 20

A 45-year-old tennis player undergoes surgery for chronic lateral epicondylitis. After returning to play, he notes increasing lateral elbow pain with mechanical catching and locking. Examination shows positive supine posterolateral rotatory instability. What ligament has been injured?

Explanation

The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability. O'Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 21

A female cross-country runner has an insidious onset of right groin pain. Radiographs of the right hip reveal a tension-side stress fracture. History reveals that she was treated for a "foot" fracture 1 year ago. In addition to performing internal fixation of the femoral neck, which of the following should be obtained?

Explanation

Stress fractures in female long distance runners are frequently associated with the Female Athletic Triad. The triad consists of osteoporosis, amenorrhea, and altered eating habits. A thorough menstrual history, including age of menarche, history of amenorrhea, and use of oral contraceptives, is imperative. Amenorrhea leads to osteoporosis and predisposes the athlete to fractures. An MRI of the hip is not necessary because a fracture is evident on the radiograph. Serum calcium levels are normal in osteoporosis, a family history would be noncontributory, and it is highly unlikely that a contralateral hip radiograph will yield useful information. Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.

Question 22

An 18-year-old gymnast has had a 1-year history of foot pain. Examination reveals medial midfoot tenderness without swelling. Non-weight-bearing in a cast for 6 weeks has failed to provide relief. An axial CT scan of the midfoot is shown in Figure 20. What is the optimal treatment for this condition?

Explanation

Stress fractures of the navicular are often seen in running and jumping sports. Whereas most individuals heal with nonsurgical management consisting of 6 weeks of casting, this gymnast has had pain for 1 year and nonsurgical management has failed. Open reduction with bone grafting is the preferred treatment. Quirk RM: Stress fractures of the navicular. Foot Ankle Int 1998;19:494-496.

Question 23

A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80 degrees F (26.6 degrees C) with a relative humidity of 80%. Management should consist of

Explanation

There is a spectrum of heat-related conditions. Heat cramps are the mildest form of heat illness. In heat exhaustion, cramps are associated with headache and weakness, and the skin is pale and moist. Treatment of heat cramps or heat exhaustion consists of removing and loosening excess clothing, applying ice to the axilla and groin, ingestion of cool water, and cool water sprays. This patient demonstrates symptoms of heat stroke which is a medical emergency. The core body temperature may be as high as 106 to 110 degrees F (41.1 to 43.3 degrees C). In heat stroke, the patient may no longer be sweating, and the skin may be hot and red. The athlete is usually confused, weak, nauseated, and may have seizure activity. Central nervous system depression has been called the most important marker of heat stroke, and progresses from confusion and bizarre behavior to collapse, delirium, and coma. Bizarre behavior is often the first sign of heat stroke. The patient needs to be treated and moved to a medical facility rapidly. During transfer, IV fluids and cooling of the athlete should be initiated. The best treatment of heat-related illness appears to be prevention with adequate hydration and monitoring of conditions (temperature and humidity), with cancellation of competition when conditions do not comply with guidelines. Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902. Barker TA, Motz HA, Gersoff WK: Environmental factors in athletic performance, in Fu FH, Stone DA (eds): Sports Injuries, ed 2. Philadelphia, PA, Lippincott, 2001, pp 67-68.

Question 24

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Explanation

Ford and associates studied 81 high school basketball players and found that females landed with greater total valgus knee loading and a greater maximum valgus knee angle than male athletes. Hewett and associates reported in a study of 205 female athletes that those with increased dynamic valgus and high abduction loads were at increased risk of anterior cruciate ligament injury. Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.

Question 25

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Explanation

Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female. Constantini NW: Clinical consequences of amenorrhea. Sports Med 1994;17:213-223.

Question 26

During an anterior cruciate ligament (ACL) reconstruction, the surgeon inadvertently places the femoral tunnel too anteriorly (shallow) in the intercondylar notch. What is the most likely biomechanical consequence of this tunnel malposition?

Explanation

Placing the ACL femoral tunnel too anteriorly (shallow) in the notch results in a graft that becomes tight in flexion and loose in extension. This error restricts knee flexion and often leads to gradual stretching and failure of the graft over time.

Question 27

A 24-year-old rugby player presents with recurrent anterior shoulder instability. Advanced imaging reveals an 'inverted-pear' shaped glenoid. At what threshold of glenoid bone loss is an arthroscopic Bankart repair generally contraindicated in favor of a bony augmentation procedure like the Latarjet?

Explanation

Glenoid bone loss exceeding 20-25% drastically alters the concavity-compression mechanism of the shoulder. Arthroscopic soft-tissue stabilization alone has an unacceptably high failure rate in this setting, making bone-block augmentation (e.g., Latarjet) the standard of care.

Question 28

Which of the following correctly describes the tensioning pattern of the native posterior cruciate ligament (PCL) bundles during knee range of motion?

Explanation

The PCL consists of two primary bundles. The larger anterolateral (AL) bundle is tight in flexion, providing primary restraint to posterior tibial translation at 90 degrees. The smaller posteromedial (PM) bundle is tight in extension.

Question 29

A 28-year-old male sustains a traumatic knee injury. On physical examination, the dial test is performed. The examiner notes 15 degrees of increased external rotation of the tibia compared to the contralateral leg at 30 degrees of flexion, and 20 degrees of increased external rotation at 90 degrees of flexion. This finding is most indicative of:

Explanation

The dial test evaluates external rotation laxity. Increased external rotation at 30 degrees only suggests an isolated PLC injury. Asymmetry at both 30 and 90 degrees of flexion indicates a combined injury to both the PLC and the PCL.

Question 30

A 20-year-old collegiate quarterback is undergoing evaluation for recurrent anterior shoulder instability. Imaging demonstrates 15% anterior glenoid bone loss and a large Hill-Sachs lesion. Applying the 'glenoid track' concept, the Hill-Sachs lesion is determined to be 'off-track'. What is the most appropriate surgical management?

Explanation

For subcritical glenoid bone loss (<20%) paired with an 'off-track' (engaging) Hill-Sachs lesion, an arthroscopic Bankart repair combined with an infraspinatus tenodesis (Remplissage) is highly effective. This prevents the humeral defect from engaging the anterior glenoid rim.

Question 31

A 12-year-old boy is tackled from the lateral side of his knee during a football game. He presents with medial knee pain and significant valgus laxity at 30 degrees of flexion. Radiographs appear normal. What is the most critical next step in the diagnostic workup to rule out a severe pathology that mimics a medial collateral ligament (MCL) tear?

Explanation

In skeletally immature patients, the collateral ligaments are often stronger than the open physes. Apparent severe valgus laxity may actually represent a Salter-Harris fracture of the distal femur, which must be ruled out with stress views or MRI before treating as a simple MCL sprain.

Question 32

A 35-year-old male presents to the emergency department with a locked, painful shoulder following a severe generalized seizure. He holds his arm in internal rotation and adduction, and external rotation is physically blocked. Radiographs reveal a dislocation. What associated bony defect is most likely present?

Explanation

The clinical presentation is classic for a posterior shoulder dislocation, commonly caused by the severe muscle contractions of a seizure or electrocution. The posterior glenoid rim impacts the anteromedial aspect of the humeral head, creating a reverse Hill-Sachs lesion.

Question 33

When counseling a 22-year-old elite soccer player on graft choices for primary ACL reconstruction, which of the following is a well-documented disadvantage of bone-patellar tendon-bone (BPTB) autograft compared to hamstring autograft?

Explanation

BPTB autografts provide excellent stability and robust bone-to-bone healing, but they carry a significantly higher risk of donor site morbidity. Anterior knee pain, patellar tendonitis, and pain with kneeling are well-known complications of the BPTB harvest.

Question 34

A 26-year-old male sustains a high-energy multiligamentous knee injury resulting in a knee dislocation (KD-III). After successful closed reduction in the trauma bay, his Ankle-Brachial Index (ABI) is measured at 0.8. The foot is warm and pink. 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 an occult vascular injury, such as a popliteal artery intimal tear. CT angiography is the gold standard next step to accurately localize and characterize the vascular lesion.

Question 35

A 21-year-old collegiate baseball pitcher presents with vague, deep shoulder pain and a subjective decrease in pitching velocity. MRI arthrogram reveals a Type II SLAP tear. What biomechanical mechanism is primarily responsible for this specific injury in throwing athletes?

Explanation

In overhead throwers, Type II SLAP tears are predominantly caused by the 'peel-back' mechanism. During the late cocking phase, maximal external rotation and abduction create a torsional force at the biceps anchor, peeling the superior labrum off the posterior glenoid.

Question 36

During a physical examination of a patient with a suspected posterolateral corner (PLC) injury, the clinician applies a varus stress to the knee at 30 degrees of flexion. Which specific anatomic structure is the primary restraint to this applied force?

Explanation

While the PLC functions as a complex, the lateral collateral ligament (LCL) is the primary restraint to varus stress, tested most accurately at 30 degrees of knee flexion. The popliteus and popliteofibular ligaments are primary restraints to external rotation.

Question 37

A surgeon is performing an open Latarjet procedure for a patient with recurrent anterior shoulder instability and significant glenoid bone loss. During the mobilization and transfer of the coracoid process, which nerve is at the highest risk of iatrogenic injury due to traction on the conjoint tendon?

Explanation

The musculocutaneous nerve enters the conjoint tendon (coracobrachialis and short head of the biceps) typically 3 to 8 cm distal to the coracoid tip. Vigorous medial retraction of the conjoint tendon during a Latarjet procedure places this nerve at significant risk for neuropraxia.

Question 38

The anterior cruciate ligament (ACL) is composed of two distinct bundles. Which of the following best describes the biomechanical function of the posterolateral (PL) bundle?

Explanation

The PL bundle of the ACL is tightest in extension and provides the primary restraint to rotatory loads. The anteromedial (AM) bundle is tightest in flexion and primarily resists anterior tibial translation.

Question 39

A 25-year-old soccer player sustains a twisting injury to his knee. Physical examination reveals a positive Dial test with 15 degrees of increased external rotation compared to the contralateral knee at 30 degrees of flexion, but no side-to-side difference at 90 degrees of flexion. Which of the following structures is most likely injured?

Explanation

Increased external rotation of >10 degrees at 30 degrees of flexion with symmetry at 90 degrees indicates an isolated posterolateral corner (PLC) injury. Asymmetry at both 30 and 90 degrees indicates a combined PCL and PLC injury.

Question 40

A 20-year-old collegiate rugby player with recurrent anterior shoulder instability presents for evaluation. CT scan demonstrates 25% anterior glenoid bone loss. Which of the following is the most appropriate surgical management?

Explanation

In the setting of recurrent anterior shoulder instability with critical glenoid bone loss (typically defined as >20-25%), a bone-block augmentation such as the Latarjet procedure is indicated to restore glenohumeral stability.

Question 41

A 28-year-old skier sustains an isolated grade III medial collateral ligament (MCL) tear. An MRI is obtained to evaluate the injury. Which of the following MRI findings is associated with the highest rate of failure with nonoperative management?

Explanation

A Stener-like lesion of the MCL occurs when the tibial avulsion is displaced superficial to the pes anserinus, preventing healing. These lesions have a high failure rate with nonoperative management and generally require surgical repair.

Question 42

A 38-year-old recreational weightlifter complains of deep anterior shoulder pain. MRI confirms an isolated Type II SLAP tear. After failing 6 months of physical therapy, surgical management is planned. Which of the following is the most appropriate surgical treatment?

Explanation

In patients older than 35 years or those who are not overhead throwers, biceps tenodesis provides more reliable pain relief and higher satisfaction rates compared to SLAP repair for Type II SLAP lesions.

Question 43

When performing a posterior cruciate ligament (PCL) reconstruction using an open tibial inlay technique, the surgeon must be mindful of the popliteal artery. During the posterior approach, between which two muscle intervals is the popliteal neurovascular bundle typically protected?

Explanation

The classic open posterior approach to the knee for a tibial inlay PCL reconstruction develops the interval between the medial head of the gastrocnemius and the semimembranosus, protecting the neurovascular bundle laterally.

Question 44

A 24-year-old male is evaluated in the emergency department following a high-speed motorcycle accident. He has a grossly unstable knee with suspected multi-ligamentous injury. His ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 in the setting of a suspected knee dislocation requires further vascular evaluation, typically with a CT angiogram, to rule out a popliteal artery injury.

Question 45

A patient with recurrent anterior shoulder instability is found to have an "off-track" Hill-Sachs lesion and 10% anterior glenoid bone loss on advanced imaging. Which of the following procedures is most appropriate to prevent recurrent instability?

Explanation

An "off-track" Hill-Sachs lesion with subcritical (<20%) glenoid bone loss is best treated with an arthroscopic Bankart repair combined with a Remplissage procedure (infraspinatus tenodesis into the defect) to prevent the lesion from engaging the anterior glenoid.

Question 46

A 19-year-old female basketball player feels a "pop" in her knee while pivoting. Plain radiographs demonstrate an elliptic bone fragment adjacent to the lateral tibial plateau. This finding is highly associated with an injury to which of the following structures?

Explanation

A Segond fracture is an avulsion of the anterolateral complex (specifically the anterolateral ligament/capsule) from the lateral tibia. It is pathognomonic for an anterior cruciate ligament (ACL) tear.

Question 47

A 45-year-old male presents with severe shoulder pain and inability to externally rotate his arm after experiencing a generalized tonic-clonic seizure. An axillary radiograph reveals a posterior glenohumeral dislocation with an impaction fracture on the anteromedial aspect of the humeral head involving 30% of the articular surface. Which of the following is the most appropriate surgical treatment?

Explanation

Posterior shoulder dislocations are frequently associated with a reverse Hill-Sachs lesion (anteromedial impaction fracture). For defects between 20% and 40%, a McLaughlin procedure (transfer of the subscapularis or lesser tuberosity into the defect) is indicated.

Question 48

Which of the following structures is considered the primary static stabilizer to varus stress of the knee at 30 degrees of flexion?

Explanation

The fibular (lateral) collateral ligament is the primary static stabilizer to varus stress in the knee, best isolated and tested clinically at 30 degrees of knee flexion.

Question 49

During arthroscopy for recurrent anterior shoulder instability, the surgeon identifies an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion. How does this lesion anatomically differ from a classic Bankart lesion?

Explanation

An ALPSA lesion involves an avulsion of the anterior labrum where the intact scapular periosteum allows the labroligamentous complex to strip and displace medially and inferiorly along the glenoid neck. Unlike a Bankart lesion, the periosteal sleeve remains intact.

Question 50

During an anterior cruciate ligament (ACL) reconstruction, the femoral tunnel is inadvertently placed anterior to the anatomic footprint. What is the expected postoperative complication resulting from this technical error?

Explanation

Placing the ACL femoral tunnel too anteriorly results in a graft that is excessively tight in flexion. This typically leads to a loss of knee flexion and increased mechanical stress on the graft, predisposing it to failure.

Question 51

A 24-year-old football player sustains a blow to the anteromedial knee. He demonstrates a positive dial test at 30 degrees of flexion, which normalizes at 90 degrees of flexion. Which of the following structures is most likely injured?

Explanation

A positive dial test (increased external rotation of the tibia) at 30 degrees that normalizes at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If the dial test is positive at both 30 and 90 degrees, it suggests a combined PCL and PLC injury.

Question 52

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

Explanation

The musculocutaneous nerve is at highest risk during the Latarjet procedure as it enters the coracobrachialis muscle 3 to 8 cm distal to the coracoid tip. Retraction of the conjoint tendon must be carefully managed to avoid neuropraxia to this nerve.

Question 53

A 19-year-old collegiate soccer player sustains an isolated Grade III medial collateral ligament (MCL) tear. What is the most appropriate initial management?

Explanation

Isolated Grade III MCL tears typically heal well with nonoperative management, including the use of a hinged knee brace to protect against valgus stress while allowing early range of motion. Surgical treatment is generally reserved for chronic instability or multiligamentous knee injuries.

Question 54

The posterior cruciate ligament (PCL) consists of two main bundles. Which of the following statements correctly describes the biomechanics of the anterolateral (AL) bundle?

Explanation

The PCL is composed of the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle is tight in flexion and lax in extension, whereas the PM bundle is tight in extension and lax in flexion.

Question 55

Which of the following is the most significant risk factor for recurrent shoulder dislocation following a primary traumatic anterior shoulder dislocation?

Explanation

The patient's age at the time of the initial dislocation is the most significant risk factor for recurrence. Patients under the age of 20 have recurrence rates approaching 80 to 90% when treated with conservative management.

Question 56

What is the primary blood supply to the anterior cruciate ligament (ACL)?

Explanation

The middle genicular artery, a branch of the popliteal artery, provides the primary blood supply to the ACL. It pierces the posterior capsule to supply both cruciate ligaments and the surrounding synovial tissue.

Question 57

A 35-year-old man presents to the emergency department with severe shoulder pain following a generalized tonic-clonic seizure. His arm is locked in adduction and internal rotation. An AP radiograph shows a symmetric appearance of the proximal humerus without the normal overlap of the humeral head and glenoid. What is the most likely diagnosis?

Explanation

Seizures commonly cause posterior shoulder dislocations due to the dominant strength of the internal rotators (latissimus dorsi, pectoralis major, subscapularis). The AP radiograph classically shows the 'lightbulb sign' due to internal rotation of the humeral head and a lack of normal glenohumeral overlap.

Question 58

A 42-year-old manual laborer presents with anterior shoulder pain and a positive O'Brien's test. MRI arthrogram reveals a Type II SLAP tear. During arthroscopy, there is significant fraying of the biceps tendon with detachment of the superior labrum. What is the most appropriate surgical treatment?

Explanation

In patients over age 40 or those with significant biceps tendinopathy, biceps tenodesis provides more reliable pain relief and functional improvement than a SLAP repair. SLAP repairs in older patients have a higher rate of postoperative stiffness and clinical failure.

Question 59

A 25-year-old male sustains a contact injury to his knee resulting in a combined ACL and medial collateral ligament (MCL) grade III tear. What is the most appropriate initial management for the MCL injury in the setting of ACL reconstruction?

Explanation

Grade III MCL tears combined with ACL injuries are typically managed nonoperatively for the MCL to allow healing, followed by delayed ACL reconstruction once range of motion is restored. This prevents postoperative arthrofibrosis.

Question 60

A 22-year-old rugby player has recurrent anterior shoulder instability. CT reveals 25 percent anterior glenoid bone loss. Which of the following procedures is most appropriate to restore stability?

Explanation

In cases of significant anterior glenoid bone loss (greater than 20 percent), isolated soft-tissue procedures like a Bankart repair have an unacceptably high failure rate. The Latarjet procedure restores the bony arc and provides a dynamic sling effect with the conjoint tendon.

Question 61

During an anatomic double-bundle PCL reconstruction, the anterolateral and posteromedial bundles are reconstructed. Which of the following statements regarding the biomechanics of these bundles is true?

Explanation

The anterolateral bundle of the PCL is the larger of the two and becomes tight in knee flexion. The smaller posteromedial bundle is tight in knee extension.

Question 62

A 28-year-old male presents with a locked knee and lack of full extension 4 months after an ACL reconstruction. MRI shows a nodular soft tissue mass anterior to the ACL graft in the intercondylar notch. What is the primary etiology of this complication?

Explanation

A cyclops lesion is a fibrocartilaginous nodule that forms anterior to the graft, leading to a loss of full terminal extension. It is most commonly associated with anterior placement of the tibial tunnel, causing impingement of the graft in extension.

Question 63

A 19-year-old college football player presents with posterior shoulder pain. Examination reveals a positive OBrien test and pain with resisted supination. MRI confirms a Type II SLAP tear. What is the most appropriate initial management?

Explanation

The initial management for a Type II SLAP tear in a young overhead or contact athlete is nonoperative, focusing on physical therapy to correct glenohumeral internal rotation deficit and scapular dyskinesia. Surgery is reserved for patients who fail an extensive course of targeted rehabilitation.

Question 64

A positive Dial test at 30 degrees of flexion but symmetric at 90 degrees indicates an isolated injury to which of the following?

Explanation

Increased external rotation (a positive Dial test) at 30 degrees of flexion that reduces at 90 degrees indicates an isolated posterolateral corner injury. If the asymmetry persists or increases at 90 degrees, it suggests a combined posterolateral corner and posterior cruciate ligament injury.

Question 65

In the setting of a multiple ligament knee injury, an avulsion of the fibular collateral ligament and biceps femoris tendon from the fibular head is encountered. During surgical repair, which nerve is at greatest risk of iatrogenic injury?

Explanation

The common peroneal nerve courses posterior to the biceps femoris tendon and wraps around the fibular neck. It is at high risk of injury during trauma to the posterolateral corner and during surgical approaches in this region.

Question 66

A 32-year-old recreational skier presents with anterior shoulder instability. Imaging shows an engaging Hill-Sachs lesion and 10 percent anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention?

Explanation

For patients with subcritical glenoid bone loss (less than 20 percent) but an engaging or off-track Hill-Sachs lesion, an arthroscopic Bankart repair combined with a remplissage effectively prevents engagement and restores stability. A remplissage involves tenodesing the infraspinatus into the humeral defect.

Question 67

A 14-year-old male with wide-open physes sustains a midsubstance ACL tear. Which of the following graft choices and techniques minimizes the risk of growth arrest?

Explanation

In a young patient with significant remaining growth (wide-open physes), physeal-sparing techniques, such as an iliotibial band over-the-top extra-articular reconstruction, are recommended to avoid crossing the physes and causing growth arrest.

Question 68

A 40-year-old male sustains a seizure and complains of bilateral shoulder pain and inability to externally rotate his arms. Radiographs show a lightbulb sign. What is the most likely diagnosis?

Explanation

Seizures or electrical shocks are classic mechanisms for bilateral posterior shoulder dislocations. The lightbulb sign on AP radiographs is due to the humerus being locked in internal rotation, obscuring the greater tuberosity.

Question 69

When performing an arthroscopic Bankart repair, the anteroinferior labrum is mobilized and repaired. The suture anchors should ideally be placed at which location to maximize biomechanical stability?

Explanation

Suture anchors for a Bankart repair must be placed directly on the glenoid rim or slightly onto the articular face to recreate the labral bumper. Placing them medially on the anterior neck (ALPSA position) fails to restore the native capsulolabral tension.

Question 70

A patient undergoes PCL reconstruction utilizing an inlay technique for tibial fixation. This approach specifically minimizes the risk of which of the following complications compared to a transtibial tunnel technique?

Explanation

The tibial inlay technique secures the bone block directly to the posterior tibia, avoiding the acute angle (the killer turn) that the graft must negotiate when passed through a transtibial tunnel. This reduces the risk of graft abrasion and attenuation.

Question 71

A 24-year-old male sustains a knee injury resulting in a dimple sign on the medial joint line with valgus stress. MRI reveals an MCL tear with the distal end of the superficial MCL displaced superficial to the pes anserinus. What is this lesion called, and what is its clinical significance?

Explanation

A Stener-like lesion of the knee occurs when the distal end of the superficial MCL flips superficial to the pes anserinus. This displacement prevents anatomic reduction and healing, necessitating operative repair or reconstruction.

Question 72

A 20-year-old gymnast presents with multidirectional shoulder instability. She has failed 6 months of supervised physical therapy. An examination under anesthesia demonstrates 3+ inferior translation and a positive sulcus sign. What is the preferred surgical treatment?

Explanation

When nonoperative management fails in multidirectional instability, an arthroscopic or open inferior capsular shift/plication is the treatment of choice to reduce capsular volume. Thermal capsulorrhaphy is obsolete due to high failure rates and the risk of chondrolysis.

Question 73

During an ACL reconstruction using a bone-patellar tendon-bone autograft, a non-displaced fracture of the distal patellar pole occurs intraoperatively while harvesting the bone plug. What is the most appropriate management?

Explanation

An intraoperative patellar fracture during graft harvest should be stabilized internally. The surgeon should then abandon the patellar tendon harvest from that knee and select an alternative graft, such as a hamstring or allograft, to complete the ACL reconstruction.

Question 74

A 25-year-old professional rugby player presents with recurrent anterior shoulder dislocations. CT imaging reveals 28% glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

Explanation

Glenoid bone loss greater than 20-25% in the setting of recurrent anterior instability is considered critical bone loss. Soft tissue stabilization alone has unacceptably high failure rates, making a bony augmentation procedure like the Latarjet the treatment of choice.

Question 75

A 22-year-old female presents 6 months after an uncomplicated anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone autograft. She complains of an inability to fully straighten her knee and an audible clunk at terminal extension. What is the most likely etiology?

Explanation

A Cyclops lesion is a localized fibroproliferative nodule located anterior to the ACL graft. It classically causes a mechanical block to terminal extension and a palpable or audible clunk, requiring arthroscopic excision.

Question 76

During a posterior cruciate ligament (PCL) reconstruction, the surgeon evaluates the native anatomy to properly place the graft bundles. Which of the following statements regarding the normal biomechanics of the PCL is correct?

Explanation

The PCL consists of two main bundles: the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle tightens in flexion, while the PM bundle tightens in extension.

Question 77

A 30-year-old male sustains a traumatic knee injury. On examination, a Dial test is performed. There is 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side, but symmetric external rotation at 90 degrees of flexion. This finding is most indicative of:

Explanation

The Dial test is utilized to differentiate isolated PLC injuries from combined PCL/PLC injuries. Asymmetry of >10 degrees of external rotation at 30 degrees of flexion, but not at 90 degrees, indicates an isolated PLC injury.

Question 78

A 45-year-old male presents with a locked posterior shoulder dislocation following a seizure. CT scan reveals a reverse Hill-Sachs lesion involving 35% of the humeral head articular surface. What is the most appropriate surgical intervention?

Explanation

A reverse Hill-Sachs defect involving 20-40% of the articular surface is generally treated with a modified McLaughlin procedure (transfer of the lesser tuberosity and subscapularis into the defect). Defects >40% typically require arthroplasty.

Question 79

A 9-year-old female soccer player (Tanner stage 1) sustains a midsubstance ACL tear. The family wishes to proceed with surgical intervention. Which of the following techniques minimizes the risk of premature physeal closure?

Explanation

In prepubescent patients with wide open physes (Tanner stages 1 and 2), physeal-sparing techniques like the modified MacIntosh (extraphyseal iliotibial band over-the-top technique) are recommended. Transphyseal drilling carries a significant risk of growth arrest.

Question 80

A 21-year-old collegiate baseball pitcher presents with vague posterior shoulder pain and decreased throwing velocity. MRI arthrogram reveals a Type II SLAP lesion. After a failed 4-month course of focused physical therapy, the most appropriate surgical treatment is:

Explanation

For young, high-demand overhead athletes like collegiate pitchers with a Type II SLAP lesion, arthroscopic repair of the superior labrum remains the preferred treatment. Biceps tenodesis is typically reserved for older patients or revision settings.

Question 81

A 19-year-old collegiate football player sustains an isolated Grade II PCL tear based on physical examination and MRI. What is the best initial management strategy?

Explanation

Isolated Grade I and II PCL tears are generally treated non-operatively with excellent functional results. Initial management includes bracing in extension to prevent posterior tibial sag, followed by therapy emphasizing quadriceps strengthening to dynamically stabilize the tibia.

Question 82

A 35-year-old male is evaluated in the trauma bay following a high-velocity knee dislocation (KD-III). He has absent active foot eversion and dorsiflexion, as well as decreased sensation over the dorsum of the foot. Injury to which of the following ligamentous structures is most highly associated with this neurologic deficit?

Explanation

Common peroneal nerve injuries occur in up to 15-30% of knee dislocations and are most closely associated with posterolateral corner (PLC) disruptions. The nerve's anatomic course around the fibular neck makes it vulnerable to traction during severe varus or hyperextension injuries.

Question 83

Following an open Latarjet procedure for recurrent anterior shoulder instability, a patient complains of new-onset numbness along the lateral aspect of the forearm and weakness in elbow flexion. Which nerve was most likely injured during the coracoid transfer?

Explanation

The musculocutaneous nerve typically penetrates the coracobrachialis 3 to 8 cm distal to the coracoid process. It is at significant risk of traction or iatrogenic injury during coracoid osteotomy and retraction in the Latarjet procedure.

Question 84

A 28-year-old alpine skier sustains a severe valgus injury to the knee. MRI demonstrates a complete avulsion of the distal medial collateral ligament (MCL) that is flipped superficial to the pes anserinus tendons. Which of the following is the most appropriate management?

Explanation

A distal MCL avulsion that retracts and flips superficial to the pes anserinus tendons creates a Stener-like lesion. This soft tissue interposition prevents anatomic healing and is an established indication for acute surgical repair.

Question 85

A 20-year-old male undergoes an MR arthrogram for recurrent anterior shoulder instability. The radiologist notes an intact anterior periosteal sleeve with the anterior labrum medially displaced and healed to the glenoid neck. This pathoanatomy is best described as a:

Explanation

An Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion occurs when the anterior labrum strips off the glenoid and heals medially along the neck with an intact periosteum. It requires adequate lateral mobilization during arthroscopic repair.

Question 86

A patient is evaluated 1 year after an ACL reconstruction. The Lachman test is negative, but a pivot shift test is prominently positive. Radiographs demonstrate that the femoral tunnel is positioned at the 12 o'clock position in the coronal plane. This tunnel placement primarily fails to control which biomechanical force?

Explanation

A vertical femoral tunnel (e.g., 12 o'clock position) in ACL reconstruction successfully limits sagittal plane translation, resulting in a negative Lachman test. However, it fails to restore rotational stability, yielding a persistent pivot shift.

Question 87

An 18-year-old athlete with recurrent anterior shoulder instability has a normal-appearing anterior labrum on MRI. However, a "J-sign" is noted on the MR arthrogram, showing fluid extravasation into the axillary pouch. Which of the following lesions is most likely present?

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) causes anterior instability in the absence of a Bankart lesion. It is classically identified on MR arthrography by a "J-sign" where contrast leaks into the axillary pouch through the lateral capsular defect.

Question 88

During an anatomic reconstruction of the posterolateral corner (PLC) of the knee, accurate placement of the fibular collateral ligament (FCL) femoral tunnel is crucial. Relative to the lateral epicondyle, where is the native femoral footprint of the FCL located?

Explanation

The anatomic femoral footprint of the fibular collateral ligament (FCL) is situated approximately 1.4 mm proximal and 3.1 mm posterior to the lateral epicondyle. Accurate placement ensures proper isometric tensioning of the graft during PLC reconstruction.

Question 89

A 17-year-old female gymnast complains of bilateral shoulder pain and a sensation of the shoulders 'sliding out' of joint. Exam reveals a positive sulcus sign, anterior apprehension, and generalized ligamentous laxity (Beighton score 7/9). What is the most appropriate initial treatment?

Explanation

Multidirectional instability (MDI) is typically atraumatic and bilateral, common in patients with generalized hyperlaxity. The cornerstone of treatment is a prolonged (minimum 6 months) physical therapy program focusing on dynamic stabilization via the rotator cuff and periscapular muscles.

Question 90

A 29-year-old male sustains an acute knee dislocation that is reduced in the emergency department. Pulses are palpable but somewhat asymmetric. The ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

An Ankle-Brachial Index (ABI) less than 0.90 following a knee dislocation is highly sensitive for an underlying arterial injury. This finding mandates immediate advanced vascular imaging, such as CT angiography, to rule out a surgical vascular lesion.

Question 91

The arthroscopic Remplissage procedure is utilized as an adjunct to a Bankart repair in cases of significant, engaging Hill-Sachs lesions without critical glenoid bone loss. Which anatomical structure is tenodesed into the humeral defect during this procedure?

Explanation

The Remplissage procedure involves capsulotenodesis of the infraspinatus tendon and posterior capsule into a large Hill-Sachs defect. This essentially makes the defect extra-articular and prevents it from engaging on the anterior glenoid rim during abduction and external rotation.

Question 92

During the first 6 weeks following an ACL reconstruction utilizing a quadrupled hamstring autograft, what represents the weakest biomechanical link in the reconstructed knee?

Explanation

In the early postoperative phase (first 6 to 12 weeks) following soft-tissue ACL reconstruction, the initial fixation device (the graft-fixation interface) represents the weakest biomechanical link. Over time, biological incorporation occurs, shifting the weakest point to the graft mid-substance.

Question 93

During the harvest of a hamstring autograft for ACL reconstruction, the surgeon utilizes an oblique incision over the pes anserinus. The patient later reports an area of numbness over the anterolateral aspect of the proximal leg. Which nerve was most likely injured during the harvest?

Explanation

The infrapatellar branch of the saphenous nerve courses anteriorly and laterally across the proximal tibia. It is highly susceptible to iatrogenic transection or traction injury during the surgical approach for hamstring graft harvesting, leading to anterolateral leg numbness.

Question 94

A 24-year-old athlete presents with progressive loss of knee flexion and anterior knee pain 6 months after an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. Radiographs demonstrate that the femoral tunnel was placed anterior to the anatomic footprint (high and anterior in the notch). What is the primary biomechanical consequence of this tunnel malposition?

Explanation

An anteriorly placed femoral tunnel creates a cam effect, causing the ACL graft to become tight in flexion and loose in extension. This commonly presents as a loss of terminal knee flexion and subsequent graft stretch or failure.

Question 95

A 35-year-old man presents to the emergency department after a first-time seizure. His arm is locked in internal rotation and adduction. Radiographs reveal a posterior shoulder dislocation. A subsequent CT scan shows an anteromedial humeral head defect involving 30% of the articular surface. Following closed reduction, the shoulder remains unstable in internal rotation. What is the most appropriate surgical management?

Explanation

For a reverse Hill-Sachs defect involving 20% to 40% of the articular surface, transferring the lesser tuberosity with the attached subscapularis into the defect (modified McLaughlin procedure) prevents the defect from engaging the posterior glenoid rim.

Question 96

A 22-year-old collegiate soccer player sustains a twisting injury to his knee. On examination, he has a normal Lachman test and normal posterior drawer test. The dial test shows 15 degrees of increased external rotation of the tibia at 30 degrees of knee flexion compared to the contralateral side, but symmetric external rotation at 90 degrees of flexion. Which structure is most likely injured?

Explanation

An isolated posterolateral corner (PLC) injury presents with increased external rotation at 30 degrees of flexion but symmetric rotation at 90 degrees. If the posterior cruciate ligament (PCL) were also injured, the dial test would be positive at both 30 and 90 degrees.

Question 97

A 20-year-old rugby player evaluates for recurrent anterior shoulder instability. A 3D CT scan reveals 25% anterior glenoid bone loss. MRI shows an engaging Hill-Sachs lesion. Based on the glenoid track concept, which of the following procedures is most appropriate to minimize the risk of recurrent instability?

Explanation

Critical glenoid bone loss (>20%) requires bony augmentation, such as the Latarjet procedure, to restore the glenoid arc and stability. Arthroscopic Bankart with Remplissage is reserved for subcritical bone loss with an off-track Hill-Sachs lesion.

Question 98

A 28-year-old woman is brought to the trauma bay after a high-speed motor vehicle collision. She has an obvious knee deformity, which is reduced by the ER physician. Post-reduction, she has an absent dorsalis pedis pulse and an Ankle-Brachial Index (ABI) of 0.6. The foot is cool, and the pulse remains absent after optimizing alignment. What is the next most appropriate step in management?

Explanation

Hard signs of vascular injury (absent pulse post-reduction, expanding hematoma, active pulsatile bleeding) demand immediate surgical exploration. Delaying for CT angiography in the presence of hard signs risks irreversible limb ischemia.

Question 99

A 23-year-old professional baseball pitcher complains of vague posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals a 25-degree glenohumeral internal rotation deficit (GIRD) compared to the contralateral side, and a positive peel-back sign on arthroscopic simulation. What is the recommended initial management?

Explanation

Symptomatic GIRD with internal impingement and posterior labral peel-back in throwing athletes initially responds well to a stretching program targeting the posterior capsule (sleeper stretches). Operative intervention is reserved only for refractory cases after a prolonged course of therapy.

Question 100

During the open reconstruction of a chronic medial-sided knee injury, the surgeon isolates the specific capsuloligamentous structure that serves as the primary restraint to internal tibial rotation near full extension. Which of the following structures is being addressed?

Explanation

The posterior oblique ligament (POL) is dynamically tensioned by the semimembranosus and acts as the primary restraint to internal rotation near full extension. It is a critical component to address in chronic medial instability to prevent residual rotational laxity.

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

AAOS Sports Medicine MCQs (Set 3): Knee Ligament Injuries & Shoulder Instability | ABOS Review

Key Takeaway

AAOS Sports Medicine MCQs (Set 3): Knee Ligament Injuries & Shoulder Instability | ABOS Review

Chapter Index