Question 1

Studies have shown that anterior cruciate ligament (AC L) deficiency may result in abnormal meniscal strain found particularly in what region:

Explanation

While acute anterior cruciate ligament (AC L) injury alters the strain patterns in the lateral meniscus, chronic AC L insufficiency increases the strain in the medial meniscus and often results in tears of the posterior horn. In a study of 176 consecutive patients undergoing AC L reconstruction, there was an increasing incidence of meniscal tears as the AC L injury became more chronic with a significant increase in all medial meniscal tears and a relatively constant incidence of lateral meniscal tears.

Question 2

When comparing women to men, the NC AA Injury Surveillance System has demonstrated a higher rate of injury to what structure:

Explanation

Anterior cruciate ligament injury has been observed to be 2 to 3 times more common in female basketball players than in their male counterparts. The higher risk of AC L injury in women may be related to laxity, larger Q angles, excessive pronation, increased hamstring flexibility, decreased notch width index, posture (less knee and hip flexion), and possible hormone influences.

Question 3

After landing awkwardly on his flexed knee, a 22-year-old basketball player has immediate onset of pain and difficulty bearing weight. With the knee flexed 30°, examination reveals increased varus, external rotation, and posterior translation which decreases when the knee is flexed to 90°. The patient most likely has injured what structure(s):

Explanation

With an isolated injury to the posterior cruciate ligament (PC L), posterior translation increases at greater degrees of flexion demonstrating the greatest posterior translation at 90°. Injury to the lateral collateral ligament leads to varus laxity in 30° flexion without posterior translation. With an injury to the PC L and posterolateral complex, varus, external rotation, and posterior translation are detectable at 30° and increase as the knee is flexed to 90°. Isolated tears of the posterolateral complex lead to increased varus, external rotation, and posterior translation at 30° that decreases as the knee is flexed to 90° and the PC L tightens.

Question 4

When interference screws are used for femoral fixation during an endoscopic anterior cruciate ligament (AC L) reconstruction using autograft patellar tendon, how much divergence between the screw and bone plug is acceptable before pull-out strength is compromised to a clinically significant level:

Explanation

Recent studies have indicated that nearly 40% of endoscopic anterior cruciate ligament reconstructions demonstrate screw-bone plug divergence. Divergence angles of less than 30° do not significantly alter pull-out strength clinically.

Question 5

All of the following structures have attachment to the medial femoral condyle except the:

Explanation

The popliteus attaches to the posterior aspect of the lateral femoral condyle. All of the other mentioned structures attach to the medial femoral condyle: the adductor magnus superiorly, the superficial medial collateral ligament and the gastrocnemius inferiorly, and the medial patellofemoral ligament anteriorly deep to the vastus medialis.

Question 6

In anterior cruciate ligament (AC L) rehabilitation, closed-chain kinetic exercises are associated with all of the following except:

Explanation

Closed-chain exercises for the lower extremity have been shown to be effective following anterior cruciate ligament reconstruction for several reasons. They allow co-contraction of the muscles crossing the knee, stabilize the foot against resistance, apply compressive loads to the knee, and allow for hip motion for stability. Such exercises have not been shown to have any effect on the aerobic capacity of the leg.

Question 7

A 24-year-old cross-country runner complains of anterior knee pain after running. Palpation reveals point tenderness at the inferior pole of the patella. Range of motion is full and exam demonstrates no patellofemoral crepitus. Management should include:

Explanation

This scenario is consistent with infrapatellar tendinitis (jumpers knee), which is common in runners and jumpers. The mechanism often involves chronic overloads of the tendon. Anti-inflammatory medication may alleviate symptoms while quadriceps stretching decreases the load on the tendon by increasing the resting length of the muscle-tendon unit. Open patellar tendon debridement should be reserved for cases of chronic tendonitis that are refractory to conservative management.

Question 8

To be considered for repair, a meniscal tear must fulfill all of the following criteria except:

Explanation

Meniscal repair is now recognized as an effective treatment method for certain types of meniscal tears. To be considered for repair, a meniscal tear must be long enough to cause instability of the torn portion (usually longer than 10 mm). The tear should also be within the vascular zone of the mensicus where healing is most likely to occur. There must also be minimal damage to the torn segment. In general, meniscal tears in older patients tend to be degenerative in nature, precluding a successful repair. Although the peripheral tissue must be minimally damaged for a successful repair, the presence of meniscal tissue peripherally is not necessary prior to considering repair.

Question 9

In which of the following anatomic locations have authors described a characteristic MRI edema pattern lesion that occurs with an acute anterior cruciate ligament (AC L) injury:

Explanation

During anterior cruciate ligament (AC L) injury, anterior translation of the tibia and the associated valgus force create a compressive load on the articular cartilage in the posterolateral aspect of the tibia and the anterolateral aspect of the lateral femoral condyle. It has been estimated that approximately 80% of acute AC L injuries demonstrate this pattern on magnetic resonance imaging.

Question 10

Six days following anterior cruciate ligament (AC L) reconstruction, a patient returns for follow-up with a fever of 102° F, local incisional drainage, painful decreased knee motion, effusion, erythema, and warmth in the knee. Aspiration of the knee reveals cloudy, blood-tinged synovial fluid. A white blood cell count of the aspirate was 60,000 with 85% polymorphonuclear cells. Appropriate management at this time should include:

Explanation

Although reported infection rates following anterior cruciate ligament (AC L) reconstruction are as low as 0.3%, the treatment of septic arthritis in the early postoperative period can be challenging. In a patient with a suspected infection, immediate arthroscopic lavage with debridement of necrotic tissue and partial synovectomy is paramount. In a recent review of 831 arthroscopically guided AC L reconstructions, McAllister and associates reported complete resolution of all four infected cases with early lavage, debridement, and graft retention followed by IV, then oral antibiotics. However, the clinical outcome of these patients was inferior to that of patients who had undergone uncomplicated AC L reconstruction due to the damage of the articular cartilage as a result of the infection.

Question 11

In a congruent patellofemoral joint, the patella centers within the trochlear groove by what degree of flexion:

Explanation

Laurin and colleagues recognized that the normally tracking patella centered within the trochlea by 20° of knee flexion. Fulkerson and Hungerford demonstrated patellar engagement between 15° to 20° using computerized tomography scans.

Question 12

Which of the following statements correctly describes the relationship of screw length to pull-out strength in anterior cruciate ligament (AC L) fixation using hamstring tendon graft fixation with soft tissue interference screws:

Explanation

A recent study compared the cyclic and time-zero pull-out forces of 7 25 mm and 7 40 mm blunt-threaded metal interference screws for hamstring graft tibial fixation in 8 paired human cadaveric specimens. There were no measurable differences in the mean cyclic failure strength, pull-out strength, or stiffness between the 2 sizes of screws. One potential advantage of using a longer screw is the relative ease with which it can be removed compared with a shorter screw should revision surgery become necessary.

Question 13

Which of the following statements concerning allograft use in anterior cruciate ligament (AC L) reconstruction is incorrect:

Explanation

Secondary sterilization is achieved with the use of ethylene oxide or gamma irradiation, both of which have detrimental effects on the allograft. Ethylene oxide residues remain on the tissue and stimulate an intra-articular reaction. Gamma radiation has been shown to decrease structural and mechanical properties of the tissue. Irradiation also alters the collagen morphology of sterilized tissues. C urrently, the most accepted method of allograft sterilization involves sterile harvesting and deep freezing.

Question 14

Which of the following choices represents the correct order of layers in the direct insertion of a human ligament:

Explanation

Histologic sectioning of a direct ligament insertion of rotator cuffs in cadavers demonstrates 4 discrete layers: ligament, uncalcified fibrocartilage layer, calcified fibrocartilage layer, and bone. Some authors have suggested that the uncalcified fibrocartilage ensures that the tendon fibers do not compress at a hard tissue interface.

Question 15

When describing patellar instability, which of the following is the correct relationship between maltracking and malalignment:

Explanation

Terminology describing the setting for patellar instablility can be confusing when the terms â malalignment,â â maltracking,and instabilityâ are used interchangeably. Malalignment is an abnormal static relationship between the patella, its associated soft tissues, and the femoral and tibial axes. Maltracking is an expression of the dynamic relationships of these components and is noted during both active and passive motion.

Question 16

Which of the following findings has not been reported following abrasion arthroplasty as treatment for the painful, arthritic knee:

Explanation

Although popular in the 1980s, abrasion arthroplasty for the treatment of osteoarthritis of the knee has not been shown to reliably improve patientsâ symptoms. Although some authors have found radiographic evidence of an increased joint space inapproximately 50% of patients, these findings have not corresponded to an improvement in symptomatology. Abrasion arthroplasty results in the formation of a fibrocartilaginous articular surface that varies in composition with immature type I collagen predominant.C orrect Answer: Intermediate or long-term symptomatic improvement in the majority of patients

Question 17

Which of the following anatomic landmarks of the knee represents the contact area between the lateral femoral condyle and the anterior horn of the lateral meniscus when the knee is in full extension:

Explanation

The indentation on the lateral femoral condyle often seen on the lateral radiograph of the knee represents the contact area between the femoral condyle and the anterior portion of the lateral meniscus and is often referred to as the sulcus terminalis. After an acute anterior cruciate ligament (AC L) injury or recurrent giving way episode in a chronically AC L deficient knee, the sulcus terminalis is the region in which a bone contusion is typically seen on an magnetic resonance image.

Question 18

Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:

Explanation

The overall results following adequate reduction of the tibial spine are good to excellent. Loss of terminal knee extension is thought to occur due to hyperemia, subsequent hypertrophy or displacement of the tibial spine and resultant bony blockage.

Question 19

Which of the following initial treatment regimens is most appropriate for a 12-year-old boy with osteochondritis dissecans and no effusion or mechanical symptoms:

Explanation

Arthroscopic treatment of osteochondritis dissecans is limited to those patients with mechanical symptoms, effusion, and/or radiographic evidence of loose bodies in the joint. Osteochondritis of the femoral condyle may well heal with moderation of activities.

Question 20

Which of the following radiographic views allows the best visualization of the acromioclavicular (AC ) joint:

Explanation

In addition to standard views, a 10° cephalic tilt (Zanca) view is helpful to evaluate anteroposterior arthritis or distal clavicle osteolysis. This view is taken with approximately half the voltage of a standard anteroposterior shoulder radiograph and allows an unobstructed look at the acromioclavicular joint without soft tissue or bony overlay. The Stryker notch radiograph allows visualization of a Hill-Sachs impression fracture of the posterior humeral head. The glenoid fossa, or Garth view, is a true anteroposterior of the glenohumeral joint with the radiograph beam directed 45° from the plane of the thorax. The Serendipity view is used to evaluate the sternoclavicular joint and is a 40° cephalic tilt view with the patient supine.

Question 21

A 25-year-old male sustains a twisting knee injury. Examination reveals a positive dial test at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees compared to the contralateral knee. Which structure is most likely isolated in this injury?

Explanation

An increase in external rotation of >10 degrees at 30 degrees of flexion, but not at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. Combined PLC and PCL injuries show increased external rotation at both 30 and 90 degrees.

Question 22

A 50-year-old woman hears a "pop" in her knee while squatting. MRI demonstrates a medial meniscus posterior root tear with 4 mm of meniscal extrusion. Biomechanically, this injury is most equivalent to which of the following?

Explanation

A posterior root tear of the medial meniscus severely disrupts hoop stresses, rendering the meniscus functionally incompetent. Biomechanically, contact pressures and areas are equivalent to those seen after a total meniscectomy.

Question 23

A 28-year-old male is brought to the trauma bay after a severe knee hyperextension injury. The knee is grossly unstable in multiple planes. Ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury. CT angiography is the standard of care to accurately localize and define the arterial injury before surgical intervention.

Question 24

During medial patellofemoral ligament (MPFL) reconstruction, the femoral attachment is identified fluoroscopically using Schöttle's point. Where is this point located anatomically?

Explanation

Schöttle's point is located 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the Blumensaat line. Proper placement is critical to maintain graft isometry.

Question 25

The anterior cruciate ligament (ACL) is composed of two primary bundles. Which of the following best describes the tensioning pattern of the anteromedial (AM) and posterolateral (PL) bundles during normal knee range of motion?

Explanation

The AM bundle is primarily tight in knee flexion and controls anterior translation, whereas the PL bundle is tight in extension and provides rotational stability.

Question 26

A 45-year-old male presents with acute knee pain and an inability to actively extend his knee after a fall. Radiographs show a low-riding patella (patella baja) with an Insall-Salvati ratio of 0.6. Which structure is most likely injured?

Explanation

A quadriceps tendon rupture typically results in a low-riding patella (patella baja) due to the unopposed distal pull of the intact patellar tendon. An Insall-Salvati ratio < 0.8 is consistent with this diagnosis.

Question 27

A 6-year-old boy presents with a painless "snapping" sensation in his lateral knee during extension. MRI reveals a thickened lateral meniscus covering the entire tibial plateau. The Wrisberg variant of this condition is unique due to the absence of which structure?

Explanation

The Wrisberg variant of a discoid lateral meniscus lacks the normal posterior capsular attachments (coronary ligaments). It is tethered only by the ligament of Wrisberg, leading to hypermobility and the classic snapping knee syndrome.

Question 28

A 30-year-old athlete undergoes an isolated posterior cruciate ligament (PCL) reconstruction. If a single-bundle technique is utilized, which native bundle is typically reconstructed to restore primary posterior stability?

Explanation

Single-bundle PCL reconstruction aims to recreate the anterolateral (AL) bundle. The AL bundle is larger, stiffer, and is the primary restraint to posterior tibial translation in the flexed knee.

Question 29

A 24-year-old professional soccer player has a symptomatic 1.5 cm^2 focal osteochondral defect on the medial femoral condyle. Which of the following surgical options is most appropriate as a primary, single-stage procedure yielding hyaline-like cartilage?

Explanation

For small to medium symptomatic lesions (< 2.5 cm^2) in high-demand athletes, OATS is a preferred single-stage procedure that provides mature hyaline cartilage. Microfracture yields fibrocartilage, while ACI/MACI typically require two stages.

Question 30

A 22-year-old football player sustains a valgus knee injury. MRI demonstrates a complete rupture of the medial collateral ligament (MCL) with the distal end flipped superficial to the pes anserinus tendons. What is the most appropriate management?

Explanation

While most MCL tears are managed non-operatively, a distal avulsion where the MCL retracts superficial to the pes anserinus (a "Stener-like" lesion of the knee) prevents anatomic healing. This specific injury pattern typically requires surgical repair.

Question 31

The primary static stabilizers of the posterolateral corner (PLC) of the knee include the fibular collateral ligament (FCL), the popliteus tendon (PT), and which other major structure?

Explanation

The three major static stabilizers of the posterolateral corner are the FCL, popliteus tendon, and popliteofibular ligament (PFL). Surgical reconstruction of the PLC specifically aims to recreate these three core structures.

Question 32

A 10-year-old Tanner stage 1 female sustains a complete ACL tear. Due to recurrent instability, surgical reconstruction is planned. To minimize the risk of growth arrest, which technique is most appropriate?

Explanation

In prepubescent children with significant remaining growth, physeal-sparing techniques such as an all-epiphyseal reconstruction are recommended. Bone blocks or implants traversing an open physis carry a high risk of growth arrest and angular deformity.

Question 33

A 32-year-old male complains of a palpable, tender mass over the lateral joint line of his knee. MRI reveals a large parameniscal cyst. This finding is most strongly associated with which underlying meniscal pathology?

Explanation

Meniscal cysts are almost exclusively associated with horizontal cleavage tears, which allow synovial fluid to be pumped out of the joint space into the parameniscal tissue. They are more commonly found on the lateral meniscus.

Question 34

What is the most common anatomical location for osteochondritis dissecans (OCD) lesions in the adolescent knee?

Explanation

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

Question 35

A patient undergoes anterior cruciate ligament reconstruction using a central third bone-patellar tendon-bone (BPTB) autograft. Postoperatively, what is the most frequently reported complication specific to this graft choice compared to hamstring autograft?

Explanation

BPTB autografts are highly associated with donor site morbidity, most notably anterior knee pain and discomfort during kneeling. Hamstring grafts tend to avoid this issue but may cause mild deficits in deep knee flexion strength.

Question 36

A 26-year-old male sustains a dashboard injury during a motor vehicle collision. Examination reveals a positive posterior tibial sag. The dial test shows 20 degrees of external rotation asymmetry at both 30 and 90 degrees of knee flexion. This indicates injury to which of the following?

Explanation

Increased external rotation asymmetry at both 30 degrees and 90 degrees of knee flexion on the dial test indicates a combined injury to both the posterior cruciate ligament (PCL) and the posterolateral corner (PLC).

Question 37

Which nerve injury is most commonly associated with a severe varus and hyperextension multiligamentous knee injury (KD-III)?

Explanation

The common peroneal nerve is highly vulnerable to traction injuries during severe varus and hyperextension trauma, especially in posterolateral corner injuries or frank knee dislocations.

Question 38

During a surgical approach for a lateral tibial plateau fracture, the surgeon must mobilize the lateral meniscus. The posterior horn of the lateral meniscus attaches to the medial femoral condyle via which structures?

Explanation

The posterior horn of the lateral meniscus is tethered to the medial femoral condyle by the anterior (Humphrey) and posterior (Wrisberg) meniscofemoral ligaments, which run anterior and posterior to the PCL, respectively.

Question 39

A 29-year-old distance runner presents with lateral knee pain. Pain is reproduced when pressure is applied over the lateral femoral epicondyle while extending the knee from 90 degrees to full extension. At what angle of flexion is the pain typically most severe (Noble compression test)?

Explanation

In Iliotibial (IT) band friction syndrome, the IT band rubs over the lateral femoral epicondyle. This friction is maximal at approximately 30 degrees of knee flexion, the basis for a positive Noble compression test.

Question 40

A 24-year-old male presents with chronic knee instability after a hyperextension injury. Physical examination reveals a positive posterior drawer test. A dial test is performed, which demonstrates 15 degrees of increased external rotation compared to the contralateral knee at both 30 degrees and 90 degrees of knee flexion. Which of the following injury patterns is most consistent with these findings?

Explanation

A positive dial test (asymmetric external rotation >10 degrees) at both 30 and 90 degrees of knee flexion indicates a combined posterior cruciate ligament (PCL) and posterolateral corner (PLC) injury. An isolated PLC injury shows increased external rotation at 30 degrees but not at 90 degrees.

Question 41

When comparing bone-patellar tendon-bone (BTB) autograft to hamstring autograft for primary anterior cruciate ligament (ACL) reconstruction, high-level evidence demonstrates that the BTB autograft is associated with a significantly higher rate of which of the following postoperative complications?

Explanation

BTB autografts are associated with a higher incidence of donor site morbidity, specifically anterior knee pain and discomfort while kneeling. Hamstring autografts are associated with decreased deep flexion strength, but they generally have equivalent rates of graft rupture and clinical stability.

Question 42

A 45-year-old male sustains a traumatic posterior root tear of the medial meniscus. From a biomechanical perspective, an untreated posterior root tear of the medial meniscus leads to which of the following joint contact property alterations?

Explanation

A posterior root tear of the medial meniscus disrupts circumferential hoop stresses, leading to meniscal extrusion. Biomechanically, this completely eliminates the load-sharing function of the meniscus, rendering the joint equivalent to a state of total medial meniscectomy.

Question 43

A 19-year-old collegiate football player sustains an acute grade III medial collateral ligament (MCL) injury. MRI demonstrates a distal avulsion of the superficial MCL from the tibia. The distal end of the ligament is retracted and rests superficial to the pes anserinus. What is the most appropriate management for this specific injury pattern?

Explanation

This describes a Stener-like lesion of the medial knee, where the distal superficial MCL avulses and flips over the pes anserinus tendons. Because the interposed pes anserinus prevents spontaneous healing, acute surgical repair is indicated.

Question 44

A 9-year-old boy presents with a painful snapping sensation in his lateral knee. MRI demonstrates a discoid lateral meniscus. The Wrisberg variant of a discoid meniscus is characterized by the absence of which of the following anatomic structures?

Explanation

The Wrisberg variant of a discoid lateral meniscus lacks the normal posterior meniscotibial (coronary) attachments. Its only posterior attachment is the ligament of Wrisberg, allowing hypermobility and causing the classic snapping knee syndrome.

Question 45

In an anterior cruciate ligament (ACL) reconstruction, if the surgeon places the femoral tunnel too vertically (in the 12 o'clock position in the notch), which of the following clinical outcomes is most likely?

Explanation

A vertical femoral tunnel placement in ACL reconstruction may control straight anterior tibial translation but fails to restore the native biomechanics needed to control rotatory forces. Consequently, the patient is likely to demonstrate a persistent positive pivot shift test.

Question 46

During medial patellofemoral ligament (MPFL) reconstruction, anatomic placement of the femoral tunnel is critical to ensure proper graft tension throughout the range of motion. According to Schöttle's anatomical studies, where is the optimal femoral origin of the MPFL located?

Explanation

Schöttle's point, identifying the anatomic femoral origin of the MPFL, is located radiographically and anatomically in the saddle between the medial epicondyle distally and the adductor tubercle proximally.

Question 47

A 10-year-old male sustains a Type III tibial eminence fracture during a bicycle accident. Closed reduction is attempted but is unsuccessful. What is the most common anatomical block to closed reduction in this injury?

Explanation

In pediatric Meyers-McKeever Type II and III tibial eminence fractures, the anterior horn of the medial meniscus (or the transverse intermeniscal ligament) is the most common structure that becomes entrapped, preventing anatomic closed reduction.

Question 48

A surgeon is performing an opening wedge high tibial osteotomy (HTO) on a patient with medial compartment osteoarthritis and varus alignment. If the osteotomy gap is opened significantly more anteriorly than posteriorly, what biomechanical alteration will occur to the knee joint?

Explanation

Opening an HTO anteriorly more than posteriorly increases the posterior tibial slope. Increased posterior slope can place excessive strain on the anterior cruciate ligament by increasing anterior tibial translation forces.

Question 49

In the setting of chronic anterior cruciate ligament (ACL) deficiency, which of the following structures serves as the primary secondary restraint to anterior tibial translation?

Explanation

The posterior horn of the medial meniscus acts as the primary secondary restraint to anterior translation of the tibia relative to the femur. This wedge effect is why patients with chronic ACL deficiency often go on to develop medial meniscus tears.

Question 50

A 22-year-old athlete presents with recurrent instability 18 months after a primary anterior cruciate ligament (ACL) reconstruction. Imaging and clinical evaluation confirm a graft failure. What is the most common underlying cause for technical failure of an ACL reconstruction?

Explanation

While traumatic reinjury occurs, the most common technical error leading to ACL graft failure is non-anatomic tunnel placement. Specifically, a femoral tunnel placed too anteriorly or too vertically alters graft kinematics and tension, leading to failure.

Question 51

During a posterolateral corner (PLC) reconstruction, the surgeon is preparing to drill the femoral tunnel for the fibular collateral ligament (FCL). What is the correct anatomic location of the FCL femoral footprint relative to the lateral epicondyle?

Explanation

The anatomic footprint of the fibular collateral ligament (FCL) on the lateral femur is situated slightly proximal (1.4 mm) and posterior (3.1 mm) to the prominence of the lateral epicondyle.

Question 52

A 25-year-old professional basketball player has an isolated, symptomatic full-thickness articular cartilage defect on the weight-bearing surface of the medial femoral condyle. The defect measures 3.5 cm2. Which of the following is the most appropriate surgical intervention?

Explanation

For large chondral defects (>2.5 to 3.0 cm2) in high-demand patients, cell-based therapies like Autologous Chondrocyte Implantation (ACI/MACI) or Osteochondral Allografts are indicated. Microfracture and OATS are typically reserved for smaller lesions (<2.0 cm2).

Question 53

A 35-year-old female presents with recurrent, spontaneous knee effusions and a diffuse, boggy synovitis. MRI reveals a thickened synovium with a prominent 'blooming artifact' on gradient-echo sequences. What is the most likely diagnosis?

Explanation

Pigmented villonodular synovitis (PVNS), also known as tenosynovial giant cell tumor (TGCT), is characterized by repetitive intra-articular bleeding. The hemosiderin deposition within the hypertrophic synovium causes a classic blooming artifact on gradient-echo MRI.

Question 54

During the evaluation of a patient with a suspected multiligamentous knee injury, the examiner performs a 'quadriceps active test.' The knee is positioned at 90 degrees of flexion with the foot flat on the table, and the patient is asked to slide the foot forward against resistance. An anterior shift of the tibia is observed. This finding indicates a deficiency of which structure?

Explanation

The quadriceps active test assesses for posterior cruciate ligament (PCL) deficiency. In a PCL-deficient knee flexed to 90 degrees, the tibia subluxates posteriorly; active quadriceps contraction pulls the tibia anteriorly, reducing the subluxation.

Question 55

A patient is evaluated in the emergency department after a high-velocity knee dislocation. After reduction, distal pulses are palpable but the ankle-brachial index (ABI) is measured at 0.85. According to current guidelines, what is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, an Ankle-Brachial Index (ABI) of less than 0.9 is highly predictive of a clinically significant vascular injury and is a strict indication to proceed with CT angiography or standard angiography.

Question 56

An 18-year-old soccer player sustains a twisting injury to the knee. Anteroposterior radiographs demonstrate a small avulsion fracture from the proximal lateral tibia, just distal to the joint line. This fracture pattern is pathognomonic for an anterior cruciate ligament (ACL) tear and represents avulsion of which structure?

Explanation

The Segond fracture is an avulsion of the anterolateral complex (anterolateral ligament and lateral capsule) from the proximal lateral tibia. It is considered pathognomonic for an ACL tear.

Question 57

Microfracture is a marrow-stimulating technique used to treat focal chondral defects. The repair tissue that fills the defect following a successful microfracture procedure is predominantly composed of which type of collagen?

Explanation

Microfracture allows bone marrow elements to form a super-clot in the chondral defect. The resulting repair tissue is fibrocartilage, which is biomechanically inferior to native hyaline cartilage and is composed predominantly of Type I collagen.

Question 58

During medial patellofemoral ligament (MPFL) reconstruction, securing the graft with the knee in full extension and under excessive tension is most likely to result in which of the following complications?

Explanation

The MPFL is tightest in full extension and becomes lax as the knee flexes. Tensioning the graft too tightly in extension restricts normal patellar tracking during flexion, leading to severe stiffness, loss of flexion, and iatrogenic medial compartment overload.

Question 59

A 28-year-old marathon runner presents with lateral knee pain. Examination reveals a positive Noble compression test, with pain maximal at 30 degrees of knee flexion. The pathogenesis of this condition is most commonly related to friction of the iliotibial band against which underlying anatomic structure?

Explanation

Iliotibial band friction syndrome (ITBFS) is caused by the IT band snapping or rubbing repetitively over the prominent lateral femoral epicondyle. This friction is maximal at approximately 30 degrees of knee flexion.

Question 60

A 25-year-old football player sustains a direct blow to the anteromedial aspect of his knee. Physical examination reveals increased external rotation of the tibia at 30 degrees of knee flexion, but symmetric rotation at 90 degrees when compared to the contralateral side. Which structure is most likely injured?

Explanation

An isolated injury to the posterolateral corner (PLC) causes increased external rotation at 30 degrees of flexion but not at 90 degrees. Combined PLC and PCL injuries typically show increased external rotation at both 30 and 90 degrees.

Question 61

A 19-year-old female collegiate soccer player is undergoing anterior cruciate ligament (ACL) reconstruction. Which of the following biomechanical or anatomical factors has been most consistently shown to increase the risk of ACL injury in female athletes compared to males?

Explanation

Females have a higher rate of ACL tears primarily due to neuromuscular factors, particularly increased dynamic knee valgus during landing and pivoting. They also often exhibit a lower hamstring-to-quadriceps strength ratio and narrower intercondylar notches.

Question 62

A 45-year-old male undergoes arthroscopy for a medial meniscal tear. Biomechanically, an unrepaired posterior root tear of the medial meniscus most closely approximates the tibiofemoral contact pressures seen in which of the following conditions?

Explanation

A posterior root tear disrupts the hoop stresses of the meniscus, causing it to extrude. This results in altered biomechanics and peak contact pressures that are essentially equivalent to a total meniscectomy.

Question 63

A 28-year-old male presents to the emergency department following a high-energy multiligament knee injury. The knee is reduced, but the Ankle-Brachial Index (ABI) is measured at 0.85. There are no hard signs of vascular injury. What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 or asymmetric pulses (without hard signs of ischemia) warrants advanced imaging, most commonly CT angiography, to rule out a popliteal artery injury.

Question 64

A 30-year-old male presents with persistent anterior knee pain and a block to terminal extension 6 months following an ACL reconstruction. MRI reveals a nodular fibrous mass anterior to the ACL graft. Which of the following surgical technical errors is most closely associated with this complication?

Explanation

Anterior tibial tunnel placement causes the ACL graft to impinge against the intercondylar notch roof in extension. This repetitive trauma leads to the formation of a localized anterior arthrofibrosis known as a Cyclops lesion.

Question 65

During the surgical approach for a medial patellofemoral ligament (MPFL) reconstruction, the femoral insertion site is identified using fluoroscopy to locate Schöttle's point. Where is this radiographic point located anatomically?

Explanation

Schöttle's point is a radiographic landmark for the femoral MPFL footprint. It is defined as 1 mm anterior to the posterior cortex line, 2.5 mm distal to the posterior articular margin, and proximal to Blumensaat's line.

Question 66

The superficial medial collateral ligament (sMCL) is the primary restraint to valgus stress at the knee. At what degree of knee flexion does the sMCL provide the highest percentage of this restraining force?

Explanation

The sMCL is the primary restraint to valgus stress, providing nearly 80% of the restraining force at 25-30 degrees of knee flexion, as the posteromedial capsule is relaxed in this position.

Question 67

A 16-year-old male gymnast presents with anterior knee pain, swelling, and episodic catching. Radiographs and MRI confirm osteochondritis dissecans (OCD) of the knee. What is the most common anatomical location for this lesion?

Explanation

The classic and most frequent location for osteochondritis dissecans in the knee is the lateral aspect of the medial femoral condyle, accounting for over 70% of cases.

Question 68

When performing a high tibial osteotomy (HTO) for isolated medial compartment osteoarthritis in a varus knee, the mechanical axis is typically corrected to pass through which specific point on the tibial plateau?

Explanation

The goal of an HTO in medial compartment osteoarthritis is slight overcorrection to unload the medial compartment. The target mechanical axis is the Fujisawa point, located at 62-62.5% of the tibial plateau width from medial to lateral.

Question 69

An 11-year-old boy presents with a clicking and snapping knee. MRI reveals a symptomatic Wrisberg-variant discoid meniscus. What anatomical feature distinguishes this specific variant from other types of discoid menisci?

Explanation

The Wrisberg variant lacks normal posterior meniscotibial (coronary) ligament attachments. The meniscus relies solely on the ligament of Wrisberg, leading to hypermobility and the classic "snapping knee" presentation.

Question 70

In evaluating a failed ACL reconstruction, it is noted that the femoral tunnel was placed vertically (at the 12 o'clock position) in the intercondylar notch. Which of the following physical examination findings is most likely directly attributable to this specific technical error?

Explanation

A vertical graft adequately resists anterior tibial translation (rendering a negative Lachman test) but fails to properly resist rotational forces, resulting in persistent rotational instability and a positive pivot shift test.

Question 71

The blood supply to the meniscus is critical in determining its healing potential following surgical repair. Which vascular structures primarily supply the peripheral 10-25% ("red-red" zone) of the menisci?

Explanation

The medial and lateral inferior geniculate arteries form the peripheral capillary plexus that supplies the peripheral 10-25% of the meniscus, making this "red-red" zone amenable to biological healing.

Question 72

Which layer of healthy articular cartilage contains the highest concentration of water and features collagen fibrils strictly oriented parallel to the joint surface to resist shear forces?

Explanation

The superficial (tangential) zone of articular cartilage has the highest water content and lowest proteoglycan content. Its collagen fibers run parallel to the surface to provide immense resistance to shear stress.

Question 73

A 28-year-old male sustained a multiligament knee injury. Examination reveals a foot drop and decreased sensation over the dorsal aspect of his foot. Which specific ligamentous injury pattern is most highly associated with this neurological deficit?

Explanation

Common peroneal nerve palsies are highly associated with injuries to the posterolateral corner (PLC) and lateral collateral ligament (LCL) of the knee due to their anatomic proximity at the fibular head.

Question 74

A 55-year-old male with end-stage renal disease presents with acute knee pain and an inability to actively extend his knee after a fall. Lateral radiographs demonstrate significant patella baja. Which of the following is the most likely diagnosis?

Explanation

A quadriceps tendon rupture leaves the patellar tendon intact, allowing the patella to migrate inferiorly (patella baja). Conversely, a patellar tendon rupture results in patella alta.

Question 75

During an inside-out meniscal repair of the posterior horn of the medial meniscus, which neurovascular structure is at greatest risk of iatrogenic injury if proper retractor placement is not maintained?

Explanation

The saphenous nerve and vein are at greatest risk during an inside-out repair of the medial meniscus. A posteromedial incision and retractor are required to protect them.

Question 76

The anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) have distinct biomechanical roles. Which of the following statements is true regarding the PL bundle?

Explanation

The posterolateral (PL) bundle of the ACL is tightest in extension and serves as the primary restraint to rotatory loads. The anteromedial (AM) bundle is tightest in flexion.

Question 77

The posterior oblique ligament (POL) of the knee acts as a primary secondary restraint to which of the following kinematic forces?

Explanation

The POL is a thickening of the posteromedial capsule. It becomes tight in extension and serves as a primary restraint to internal rotation and a secondary restraint to valgus stress near full extension.

Question 78

A 28-year-old male sustains a KD-III multi-ligament knee injury. Following closed reduction, the limb is well-perfused, but the Ankle-Brachial Index (ABI) is measured at 0.8. What is the most appropriate next step in management?

Explanation

An ABI less than 0.9 in a knee dislocation with a well-perfused limb warrants a CT angiogram to rule out a clinically significant intimal tear or vascular injury. Immediate surgical exploration is reserved for hard signs of vascular compromise.

Question 79

Biomechanical studies have shown that a medial meniscus posterior root tear alters knee joint contact pressures most similarly to which of the following conditions?

Explanation

A posterior root tear disrupts the hoop stresses of the meniscus, causing it to extrude. This results in an increase in peak contact pressures and a decrease in contact area equivalent to a total medial meniscectomy.

Question 80

Which of the following structures is considered the primary static restraint to lateral patellar translation at 20 degrees of knee flexion?

Explanation

The MPFL is the primary soft-tissue restraint to lateral patellar translation in early flexion (0 to 30 degrees). Beyond 30 degrees, the bony geometry of the trochlea becomes the primary stabilizer.

Question 81

A 24-year-old athlete undergoes an anterior cruciate ligament (ACL) reconstruction. When comparing bone-patellar tendon-bone (BPTB) autograft to hamstring autograft, BPTB is historically associated with a higher incidence of:

Explanation

BPTB autografts are associated with a higher rate of donor site morbidity, specifically anterior knee pain and pain with kneeling. Both graft types have comparable long-term rates of stability and graft rupture.

Question 82

A patient with a suspected posterolateral corner (PLC) injury undergoes the Dial test. The test reveals greater than 10 degrees of increased external rotation compared to the contralateral knee at 30 degrees of flexion, but normal and symmetric external rotation at 90 degrees. This finding suggests:

Explanation

Increased external rotation at 30 degrees of flexion that reduces at 90 degrees indicates an isolated PLC injury. If the external rotation remains asymmetrical at 90 degrees, it suggests a combined PLC and PCL injury.

Question 83

When performing an inside-out meniscal repair for a lateral meniscus middle-third tear, caution must be exercised to avoid injury to which of the following neurovascular structures?

Explanation

During a lateral inside-out meniscal repair, the common peroneal nerve is at greatest risk as it courses around the fibular neck. Medial inside-out repairs place the saphenous nerve at risk.

Question 84

A 16-year-old female basketball player sustains a non-contact twisting knee injury resulting in an ACL rupture. Which of the following anatomic risk factors is most strongly associated with her injury?

Explanation

A decreased intercondylar notch width index (a narrow notch) is a well-established anatomical risk factor for ACL tears. Increased posterior tibial slope is also a known risk factor.

Question 85

The anterolateral ligament (ALL) of the knee, which originates near the lateral epicondyle and inserts on the proximal tibia, is recognized for its primary biomechanical role as a restraint to:

Explanation

The anterolateral ligament (ALL) is an important secondary stabilizer of the knee. It primarily acts as a restraint to internal tibial rotation, particularly at higher angles of knee flexion.

Question 86

A 30-year-old male sustains a high-energy knee dislocation. Following reduction, his limb is neurovascularly intact with an Ankle-Brachial Index (ABI) of 1.1. What is the most appropriate vascular management?

Explanation

In the setting of a reduced knee dislocation with normal pulses and an ABI > 0.9, the risk of a flow-limiting vascular injury is extremely low. Standard of care is admission for serial neurovascular observation for 24 to 48 hours.

Question 87

Which of the following medial collateral ligament (MCL) injury patterns has the poorest healing potential and is most likely to require surgical repair rather than non-operative management?

Explanation

A distal avulsion of the superficial MCL where the ligament flips superficial to the pes anserinus tendons creates a 'Stener-like' lesion of the knee. This prevents apposition of the torn ends, necessitating surgical repair.

Question 88

A 14-year-old male presents with chronic anterior knee pain. Radiographs reveal a bipartite patella. According to the Saupe classification, which type of bipartite patella is most common?

Explanation

The Type III bipartite patella, located at the superolateral pole, is the most common variant, accounting for approximately 75% of cases. It is also the type most frequently associated with symptoms.

Question 89

In the evaluation of a traumatic multi-ligament knee injury, the presence of a 'dimple sign' on the medial joint line typically indicates which of the following?

Explanation

The 'dimple sign' represents buttonholing of the medial femoral condyle through the anteromedial capsule in a posterolateral knee dislocation. This finding indicates that the dislocation is irreducible by closed means and requires open reduction.

Question 90

A 25-year-old runner complains of lateral knee pain that is worst at 30 degrees of knee flexion, leading to a diagnosis of Iliotibial Band (ITB) Syndrome. The ITB passes relative to the lateral femoral epicondyle in what manner during range of motion?

Explanation

The ITB glides anterior to the lateral femoral epicondyle during full extension and moves posterior to it during knee flexion. Friction occurs primarily at around 30 degrees of flexion as it crosses the epicondyle.

Question 91

During an arthroscopic anterior cruciate ligament (ACL) reconstruction, the surgeon evaluates the native ACL footprint. The anteromedial (AM) bundle of the ACL is primarily responsible for providing:

Explanation

The ACL is composed of two main bundles. The anteromedial (AM) bundle tightens in flexion to control anterior translation, while the posterolateral (PL) bundle tightens in extension to control rotational stability.

Question 92

A 45-year-old high-demand patient presents with an isolated full-thickness distal femoral osteochondral defect measuring 3.5 cm^2. He has failed non-operative management. Which of the following is the most appropriate surgical treatment?

Explanation

Autologous chondrocyte implantation (ACI) or osteochondral allograft are indicated for larger symptomatic defects (> 2 to 4 cm^2). Microfracture and OATS are typically reserved for smaller defects (< 2 cm^2).

Question 93

Regarding the vascular supply of the adult meniscus, which of the following statements is most accurate?

Explanation

In the adult knee, the meniscus is largely avascular. Blood supply is limited to the peripheral 10% to 25% (the red-red zone), which receives branches from the medial and lateral genicular arteries.

Question 94

A 19-year-old female presents with recurrent patellar dislocation. Lateral knee radiographs reveal a Caton-Deschamps index of 1.4. This radiographic finding indicates the presence of:

Explanation

The Caton-Deschamps index measures the ratio of the distance from the inferior pole of the patella to the anterior superior angle of the tibia over the articular length of the patella. A ratio > 1.2 indicates patella alta.

Question 95

Following a direct blow to the proximal tibia with the knee flexed, a patient demonstrates a positive posterior drawer test. The posterior cruciate ligament (PCL) consists of two bundles. Which bundle is typically the tightest in knee flexion?

Explanation

The PCL has a larger anterolateral (AL) bundle and a smaller posteromedial (PM) bundle. The AL bundle is tight in knee flexion, whereas the PM bundle is tight in knee extension.

Question 96

Which of the following clinical tests is considered the most specific for diagnosing an anterior cruciate ligament (ACL) tear?

Explanation

The pivot shift test evaluates rotational instability and is the most specific test (approx. 98%) for an ACL tear. The Lachman test is considered the most sensitive test.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 38

Orthopedic Prometric MCQs - Chapter 3 Part 38

Chapter Index