Question 1

To avoid injury associated with repetitive internal impingement, the pitchers long humeral axis must be in which position during the late cocking phase of throwing:

Explanation

Hyperangulation during the late cocking phase of throwing can result in impingement of the greater tuberosity on the posterosuperior glenoid rim leading to labral or rotator cuff lesions. Positioning of the humeral axis parallel to the plane of the scapula is recommended to avoid injury associated with internal impingement.

Question 2

Which of the following factors is related to recurrence after primary anterior shoulder dislocation:

Explanation

The only known factor that statistically correlates with recurrence of anterior shoulder instability is patient age at the time of initial dislocation. A recent study demonstrated that patients having an initial dislocation during the third decade have more than a 60% chance of redislocating. The type of sport practiced, type of nonoperative treatment, and patient gender do not influence recurrence rate.

Question 3

Use of functional knee bracing after anterior cruciate ligament (AC L) reconstruction will most likely result in which of the following scenarios:

Explanation

Two-year follow-up has failed to show any differences in range of motion, stability, function, strength, pain, or atrophy in patients who were braced after AC L reconstruction vs. patients who were treated without a brace. The only difference between the two groups is that the braced group has better knee function in the early postoperative period, despite having more quadriceps atrophy.

Question 4

The stabilizing ligamentous pulley of the long head of the biceps at the shoulder is composed of fibers from all of the following structures except:

Explanation

The stabilizing ligamentous pulley system of the long head of the biceps at the shoulder is a coalescence of the coracohumeral ligament and superior glenohumeral ligament. It also receives fiber contributions from the supraspinatus and subscapularis tendons.

Question 5

Which of the following is the principal function of the biceps during throwing:

Explanation

The function of the biceps at the shoulder is controversial, especially in the throwing athlete. The biceps may act as a secondary shoulder stabilizer, weak shoulder flexor, arm decelerator, or weak depressor of the humeral head. However, it is widely agreed upon that the biceps principal function during throwing is elbow flexion.

Question 6

Which of the following arteries provides the main vascular supply to the humeral head:

Explanation

The ascending branch of the anterior humeral circumflex artery provides the main vascular supply to the humeral head. Disruption of this blood supply can result in osteonecrosis of the humeral head.

Question 7

When assessing patient outcomes after rotator cuff repair, which of the following is not related to poor functional outcome:

Explanation

A large outcome study of more than 600 rotator cuff repairs demonstrated that workmanâ s compensation, revision surgery, male gender, and age younger than 55 years at the time of repair are factors contributing to poor functional outcome and decreased workability following rotator cuff repair.

Question 8

When using open measurement as the standard, which of the following is the most reliable instrument to measure rotator cuff tear size:

Explanation

Of the modalities listed, arthroscopy most closely estimates the actual size of a rotator cuff tear. Magnetic resonance imaging and ultrasound are similar in their ability to determine rotator cuff tear size. Computed tomography (without arthrography) is poor in evaluation of the rotator cuff. A detailed clinical examination is helpful in determining which tendons are torn, however elucidation of the specific size of the tear on physical examination is unlikely.

Question 9

When biomechanically comparing reconstruction of the anterior band of the medial collateral ligament of the elbow to the intact ligament, the reconstructed ligament behaves nearly identical to the intact ligament when subjected to valgus stress at all of the following degrees of elbow flexion except:

Explanation

Mullen and associates biomechanically compared reconstruction of the medial collateral ligament of the elbow to the intact ligament at 30°, 60°, 90°, and 120° of elbow flexion. They identified a significant difference in displacement with an applied valgus load at 120° of elbow flexion, leading them to conclude that medial collateral ligament reconstruction is a biomechanically sound procedure.

Question 10

Which of the following is the most commonly reported cause of nontraumatic humeral head osteonecrosis:

Explanation

Corticosteroid therapy is the most commonly reported cause of osteonecrosis of the humeral head. Other risk factors include alcohol abuse, hemoglobinopathies, Gaucherâ s disease, dysbarism, connective tissue disorders, arteritis, vasculitis, hypercoagulability, prior radiation, pregnancy, and pancreatitis.

Question 11

The microfracture technique for articular cartilage lesions is most successful for which chondral lesions:

Explanation

The inventors of the microfracture technique described a 70% to 80% success rate after microfracture of lesions smaller than 2 cm in diameter. The technique involves maintenance of some subchondral bone integrity and is indicated for full thickness chondral lesions. Lesions involving both the tibia and femur have resulted in less satisfactory outcomes.

Question 12

The results of anteromedial tibial tubercle transfer for patellar malalignment are best when patellar lesions are located:

Explanation

A study revealed that results after tibial tubercle anteromedialization are best if patellar lesions are located distally or laterally. The results were poor when the lesions were located proximally or on the medial facet.

Question 13

The following structures are found in the superficial layer of the posterolateral corner:

Explanation

An anatomic study described three distinct layers that compose the posterolateral corner of the knee. Layer one includes the biceps tendon, the iliotibial tract, the prepatellar bursa, and peroneal nerve. Layer two includes the quadriceps retinaculum and patellofemoral ligaments. Layer three, the deepest layer, includes the lateral part of the joint capsule, the popliteus tendon passing through the hiatus, the fibular collateral ligament, the fabellofibular ligament, arcuate complex, and popliteofibular ligament.

Question 14

The following structures are found in the second, or middle layer, of the posterolateral corner:

Explanation

An anatomic study described three distinct layers that compose the posterolateral corner of the knee. Layer one includes the biceps tendon, the iliotibial tract, the prepatellar bursa, and peroneal nerve. Layer two includes the quadriceps retinaculum and patellofemoral ligaments. Layer three, the deepest layer, includes the lateral part of the joint capsule, the popliteus tendon passing through the hiatus, the fibular collateral ligament, the fabellofibular ligament, arcuate complex, and popliteofibular ligament.

Question 15

The following structures are found in the deep layer of the posterolateral corner:

Explanation

An anatomic study described three distinct layers that compose the posterolateral corner of the knee. Layer one includes the biceps tendon, the iliotibial tract, the prepatellar bursa, and peroneal nerve. Layer two includes the quadriceps retinaculum and patellofemoral ligaments. Layer three, the deepest layer, includes the lateral part of the joint capsule, the popliteus tendon passing through the hiatus, the fibular collateral ligament, the fabellofibular ligament, arcuate complex, and popliteofibular ligament.

Question 16

Sectioning the posterolateral structures alone affects lateral tibial plateau translation with:

Explanation

Biomechanical studies show that sectioning the posterolateral structures alone results in increases in posterior translation of the lateral tibial plateau primarily at 30° of knee flexion.

Question 17

Sectioning the posterolateral structures and posterior cruciate ligament results in:

Explanation

Biomechanical studies show that sectioning the posterolateral structures and posterior cruciate ligament results in increases in posterior translation of the medial and lateral tibial plateaus at 30° and 90° of knee flexion.

Question 18

The maximal restraint to varus stress provided by the posterolateral structures of the knee is at what degree of knee flexion:

Explanation

Biomechanical studies show that sectioning the posterolateral structures results in increases in varus rotation of the knee from 0º to 30° of knee flexion, with maximal increase observed at 30°.

Question 19

The reverse pivot shift is most useful for diagnosing which of the following knee injuries:

Explanation

The reverse pivot shift is positive if there is a palpable shift or jerk as the lateral tibial plateau reduces while bringing the knee from 90° of flexion to full extension with the foot in external rotation. This is indicative of posterolateral corner knee injury but has been reported to be positive in 11% to 35% of normal asymptomatic patients.

Question 20

When using the tibial external rotation test on a patient, increased external rotation at 30° but not at 90° of knee flexion is indicative of:

Explanation

The tibial external rotation test is performed at 30° and 90° of knee flexion. The degree of foot external rotation with regard to the femur is evaluated. Increased external rotation at 30 ° is consistent with an isolated posterolateral corner injury. Increased external rotation at 30° and 90° is consistent with a combined posterolateral and posterior cruciate ligament injury.

Question 21

A 32-year-old weightlifter presents with acute anterior shoulder pain and bruising after a heavy bench press. Examination reveals loss of the anterior axillary fold. If surgical repair is planned, where is the anatomic footprint of the ruptured tendon?

Explanation

The pectoralis major inserts onto the lateral lip of the bicipital groove. Ruptures commonly occur at the musculotendinous junction or insertion and are treated surgically in young, active individuals.

Question 22

In a 16-year-old elite female soccer player undergoing primary ACL reconstruction, which of the following graft choices is associated with the highest risk of re-rupture?

Explanation

Allografts, especially irradiated ones, have a significantly higher failure rate in young, highly active patients compared to autografts. Bone-patellar tendon-bone and hamstring autografts remain the gold standard in this demographic.

Question 23

During reconstruction of the medial patellofemoral ligament (MPFL) for recurrent patellar instability, the femoral tunnel must be placed at the anatomic origin. Where is this located radiographically (Schottle's point)?

Explanation

Schottle's point is located approximately 1 mm anterior to the posterior cortical line and proximal to the posterior extension of Blumensaat's line. Precise placement is critical to avoid non-isometric graft tensioning.

Question 24

A patient presents with knee pain and instability after a hyperextension injury. The Dial test demonstrates increased external rotation at 30 degrees of knee flexion but normal rotation at 90 degrees compared to the contralateral side. This finding indicates injury to which of the following structures?

Explanation

Increased external rotation at 30 degrees of flexion with normal rotation at 90 degrees indicates an isolated posterolateral corner injury. If external rotation is increased at both 30 and 90 degrees, it suggests a combined PLC and PCL injury.

Question 25

A 22-year-old collegiate baseball pitcher presents with medial elbow pain and decreased pitching velocity. An MRI arthrogram confirms a high-grade tear of the anterior bundle of the ulnar collateral ligament (UCL). Which phase of throwing places the highest valgus stress on the elbow?

Explanation

The highest valgus stress on the elbow occurs during the acceleration phase of throwing. The anterior bundle of the UCL is the primary restraint to this extreme valgus force.

Question 26

A 50-year-old woman complains of posterior medial knee pain after a deep squat. MRI reveals a medial meniscus posterior root tear. Biomechanically, this injury is most equivalent to which of the following?

Explanation

A posterior meniscal root tear disrupts the circumferential hoop stresses of the meniscus, causing it to extrude. Biomechanically, it leads to increased contact pressures comparable to a total meniscectomy.

Question 27

In posterior cruciate ligament (PCL) reconstruction, the tibial inlay technique was developed primarily to avoid which of the following complications associated with the transtibial technique?

Explanation

The tibial inlay technique avoids the sharp angle, known as the 'killer turn', at the posterior tibial aperture seen in transtibial PCL reconstruction. This sharp turn can lead to graft abrasion, attenuation, and eventual failure.

Question 28

A 24-year-old overhead athlete is diagnosed with a Type II SLAP lesion. During diagnostic arthroscopy, the 'peel-back' mechanism is observed. In which shoulder position is this sign most optimally elicited?

Explanation

The peel-back mechanism is evaluated by placing the arm in abduction and external rotation (ABER). This causes the biceps vector to shift posteriorly and peel the superior labrum off the glenoid rim.

Question 29

A 19-year-old gymnast presents with bilateral shoulder pain and a sensation of instability. Examination shows a positive sulcus sign and positive apprehension in both anterior and posterior directions. What is the most appropriate initial management?

Explanation

The patient has multidirectional instability (MDI). The first-line treatment for MDI is a prolonged course of physical therapy focusing on periscapular and rotator cuff strengthening to provide dynamic stabilization.

Question 30

A 30-year-old motorcyclist sustains a traumatic knee dislocation. Following closed reduction, distal pulses are palpable but slightly asymmetric. The Ankle-Brachial Index (ABI) is measured at 0.85. What is the next most appropriate 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 gold standard next step to rapidly identify the location and extent of popliteal artery injury.

Question 31

A 12-year-old boy presents with vaguely localized knee pain and intermittent catching. Radiographs reveal an osteochondritis dissecans (OCD) lesion. What is the most common anatomic location for an OCD lesion in the knee?

Explanation

The most common location for osteochondritis dissecans in the knee is the lateral aspect of the medial femoral condyle. It accounts for approximately 70-80% of all knee OCD lesions.

Question 32

During an open reduction and internal fixation of a distal clavicle fracture, the surgeon visualizes the coracoclavicular ligaments. Which of the following accurately describes their anatomy?

Explanation

The conoid ligament is located medial and posterior to the trapezoid ligament. It inserts on the conoid tubercle of the clavicle, while the trapezoid inserts laterally on the trapezoid line.

Question 33

A 13-year-old elite baseball pitcher complains of gradually worsening shoulder pain while throwing. Radiographs demonstrate widening and irregularity of the proximal humeral physis. What is the mainstay of treatment for this condition?

Explanation

Little League Shoulder (proximal humeral epiphysiolysis) is a pediatric overuse injury. The definitive treatment is absolute rest from throwing until radiographic and clinical resolution, usually followed by a structured return-to-throw program.

Question 34

A 22-year-old female runner complains of a painful clicking sensation deep in her anterior groin when extending her hip from a flexed position. Ultrasound confirms the diagnosis of internal snapping hip syndrome. Which anatomical structure is responsible for this snapping?

Explanation

Internal snapping hip syndrome is caused by the iliopsoas tendon snapping over the iliopectineal eminence or the anterior femoral head. External snapping hip involves the IT band snapping over the greater trochanter.

Question 35

A 40-year-old male sustains an acute Achilles tendon rupture playing basketball. When comparing operative to non-operative management with early functional rehabilitation, which statement is true?

Explanation

Recent literature shows that with early functional rehabilitation, re-rupture rates between operative and non-operative groups are similar. However, operative management consistently carries a higher risk of soft-tissue complications such as infection and wound breakdown.

Question 36

A 55-year-old man stumbles on the stairs and feels a pop in his knee. He is unable to perform a straight leg raise. Lateral radiographs show patella baja (inferior displacement of the patella). What is the most likely diagnosis?

Explanation

Quadriceps tendon ruptures typically occur in older patients (>40 years) and result in an inferiorly displaced patella (patella baja) due to intact distal attachments. Patellar tendon ruptures cause an upwardly displaced patella (patella alta).

Question 37

A 50-year-old woman with type 1 diabetes presents with severe left shoulder pain and stiffness. Which of the following represents the typical sequence of motion loss in idiopathic adhesive capsulitis?

Explanation

In adhesive capsulitis, the classic progression of passive motion loss begins with external rotation. This is characteristically followed by a loss of abduction, and finally internal rotation.

Question 38

Glenohumeral internal rotation deficit (GIRD) in an overhead throwing athlete is most commonly attributed to the pathologic contracture of which of the following capsular structures?

Explanation

GIRD is caused by contracture of the posteroinferior capsule, leading to a shift in the glenohumeral center of rotation. This results in increased external rotation and a corresponding loss of internal rotation.

Question 39

In overhead throwing athletes, a Type II SLAP tear is most commonly generated by which of the following biomechanical mechanisms during the late cocking phase of throwing?

Explanation

The 'peel-back' mechanism occurs during the late cocking phase when the shoulder is in maximum abduction and external rotation. This position creates a torsional force at the biceps anchor, peeling the superior labrum off the glenoid.

Question 40

A 22-year-old football player suffers a twisting knee injury. Radiographs reveal a small avulsion fracture of the lateral tibial plateau (Segond fracture). This pathognomonic finding is most strongly associated with an injury to which of the following structures?

Explanation

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

Question 41

When performing a posterior cruciate ligament (PCL) reconstruction, the tibial inlay technique is theoretically chosen over the transtibial endoscopic technique to minimize which of the following graft-related complications?

Explanation

The tibial inlay technique places the bone block directly into the posterior tibia, avoiding the sharp angulation ('killer turn') seen in transtibial techniques. This theoretically reduces graft abrasion and subsequent attenuation.

Question 42

A 16-year-old gymnast presents with bilateral shoulder pain, a sensation of subluxation, a positive sulcus sign, and generalized ligamentous laxity. What should be the initial management for this condition?

Explanation

This patient has multidirectional instability (MDI). The primary and initial treatment for MDI is a prolonged course of physical therapy focusing on rotator cuff and periscapular stabilizer strengthening.

Question 43

A 30-year-old male sustains a traumatic knee dislocation. Clinical examination reveals an asymmetric foot drop and an inability to extend the great toe. Which of the following injury patterns is most likely present?

Explanation

Foot drop indicates common peroneal nerve palsy. This nerve travels around the fibular neck and is highly susceptible to traction injuries during a posterolateral corner (PLC) injury or knee dislocation.

Question 44

When reconstructing the medial patellofemoral ligament (MPFL) for recurrent patellar instability, the anatomical femoral attachment site (Schöttle's point) is best described as being located:

Explanation

The anatomic femoral origin of the MPFL lies in a saddle-shaped depression between the adductor tubercle proximally and the medial epicondyle distally. Precise placement is critical to avoid non-isometric graft tensioning.

Question 45

A patient presents with knee instability after a hyperextension injury. The dial test shows 15 degrees of increased external rotation compared to the contralateral side at 30 degrees of knee flexion, but symmetric rotation at 90 degrees. This finding indicates an isolated injury to the:

Explanation

Increased external rotation at 30 degrees of flexion that normalizes at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If rotation is increased at both 30 and 90 degrees, a combined PLC and PCL injury is present.

Question 46

A 45-year-old non-laborer sustains a Grade III acromioclavicular (AC) joint separation. According to current literature, what is the most widely accepted initial management for this patient?

Explanation

Non-operative management consisting of a brief period of sling immobilization and early physical therapy is the standard of care for acute Type III AC joint separations in most patients, yielding excellent functional outcomes.

Question 47

Which of the following surgical or patient factors provides the best prognosis for healing following a meniscal repair?

Explanation

Concomitant ACL reconstruction enhances meniscal healing. The intra-articular bleeding and release of bone marrow elements from drilling the ACL tunnels create a biologically favorable environment for the meniscus to heal.

Question 48

A 45-year-old male feels a pop in his knee while descending stairs. Lateral radiographs reveal patella alta (high-riding patella). He is unable to perform an active straight leg raise. The most likely diagnosis is:

Explanation

Patella alta is indicative of a patellar tendon rupture because the unopposed pull of the quadriceps pulls the patella proximally. A quadriceps tendon rupture would typically result in patella baja (low-riding patella).

Question 49

A professional baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. MRI demonstrates articular-sided fraying of the posterior supraspinatus and posterosuperior labrum. This is classically described as:

Explanation

Internal impingement occurs in overhead athletes during maximum abduction and external rotation. The articular surface of the rotator cuff gets pinched between the greater tuberosity and the posterosuperior glenoid.

Question 50

In an overhead baseball pitcher, the ulnar collateral ligament (UCL) of the elbow experiences the greatest amount of valgus stress during which phase of the throwing motion?

Explanation

The UCL experiences maximal valgus stress during the late cocking and early acceleration phases of throwing. This repetitive microtrauma can lead to attenuation and eventual rupture of the anterior bundle.

Question 51

A 24-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals a 28% defect of the anterior glenoid rim. The most appropriate surgical intervention to prevent recurrence is:

Explanation

In the setting of critical anterior glenoid bone loss (typically > 20-25%), a soft tissue repair (Bankart) has an unacceptably high failure rate. A bony augmentation procedure, such as the Latarjet (coracoid transfer), is required.

Question 52

During hip arthroscopy, the establishment of the anterior portal places which of the following neurovascular structures at the greatest risk of iatrogenic injury?

Explanation

The anterior portal in hip arthroscopy carries the highest risk of injury to the lateral femoral cutaneous nerve branches. Safe portal placement requires careful superficial dissection and proper trajectory.

Question 53

A 13-year-old Little League pitcher presents with shoulder pain. Radiographs reveal widening of the proximal humeral physis compared to the contralateral side. What is the most appropriate initial treatment?

Explanation

This presentation is consistent with 'Little League Shoulder' (proximal humeral epiphysiolysis). The primary treatment is absolute rest from throwing until symptoms resolve and radiographic healing is evident, followed by mechanical rehabilitation.

Question 54

A 32-year-old bodybuilder feels a tearing sensation in his anterior chest while performing a heavy bench press. Examination reveals an asymmetric loss of the anterior axillary fold. A pectoralis major rupture is suspected. Where does this rupture most commonly occur?

Explanation

Pectoralis major ruptures typically occur during eccentric loading, such as the eccentric phase of a bench press. The most common location for the tear is at or near the tendinous insertion onto the proximal humerus.

Question 55

Recent high-level evidence comparing operative versus non-operative management of acute Achilles tendon ruptures, when utilizing modern early functional rehabilitation protocols, concludes that:

Explanation

When early weight-bearing and functional rehabilitation protocols are used, re-rupture rates between operative and non-operative groups are essentially equal. However, operative management carries a higher risk of complications such as infection and nerve injury.

Question 56

A 20-year-old runner complains of severe bilateral lower leg pain, numbness on the dorsum of the foot, and foot drop occurring 15 minutes into a run and resolving with rest. The gold standard diagnostic test for this condition is:

Explanation

The clinical scenario strongly suggests chronic exertional compartment syndrome (CECS), most commonly affecting the anterior compartment. The gold standard for diagnosis is dynamic intra-compartmental pressure testing before and after exercise.

Question 57

A 19-year-old male presents to the trauma bay with dyspnea, dysphagia, and a choking sensation following a high-energy tackle. Clinical exam shows the medial clavicle is displaced posteriorly. What is the most appropriate management?

Explanation

A posterior sternoclavicular dislocation is a true orthopedic emergency due to the proximity of the mediastinal structures (trachea, esophagus, great vessels). Closed reduction should be performed in the OR with cardiothoracic surgery available in case a great vessel injury is unmasked.

Question 58

Valgus extension overload in baseball pitchers leads to osteophyte formation primarily in which area of the elbow?

Explanation

Valgus extension overload syndrome is characterized by posteromedial olecranon impingement during the deceleration phase of throwing. This repetitive stress causes osteophyte formation on the posteromedial tip of the olecranon.

Question 59

In a throwing athlete, the peel-back mechanism of the superior labrum occurs predominantly during which phase of the throwing motion?

Explanation

The peel-back mechanism happens during the late cocking phase when the shoulder is maximally abducted and externally rotated. This position places increased torsional stress on the biceps anchor, peeling back the posterosuperior labrum.

Question 60

A 24-year-old football player sustains a knee injury. The dial test shows 15 degrees of increased external rotation compared to the contralateral knee at 30 degrees of flexion, but equal external rotation at 90 degrees. What is the most likely diagnosis?

Explanation

Asymmetrical external rotation at 30 degrees but symmetrical at 90 degrees indicates an isolated posterolateral corner (PLC) injury. A combined PCL and PLC injury would show increased external rotation at both 30 and 90 degrees.

Question 61

When evaluating a patient with recurrent anterior shoulder instability, a glenoid bone loss of greater than 20% on a 3D CT scan is best treated with which of the following procedures?

Explanation

Critical glenoid bone loss (>20-25%) is an indication for a bony augmentation procedure like the Latarjet. Soft tissue repairs (Bankart) have an unacceptably high recurrence rate in the setting of critical bone loss.

Question 62

Which of the following radiographic findings is most specific for diagnosing Cam-type femoroacetabular impingement (FAI)?

Explanation

An alpha angle > 55 degrees on a lateral or frog-leg lateral radiograph indicates a loss of normal femoral head-neck offset, which is characteristic of Cam-type FAI. The crossover sign is indicative of Pincer-type FAI (acetabular retroversion).

Question 63

A 68-year-old male presents with pseudo-paralysis of the shoulder and a massive, irreparable rotator cuff tear involving the supraspinatus and infraspinatus. The subscapularis is intact. What is the most appropriate definitive surgical management?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for older patients with massive, irreparable rotator cuff tears and pseudo-paralysis. It utilizes the deltoid to restore active elevation and joint stability.

Question 64

During an arthroscopic Brostrom-Gould procedure for chronic ankle instability, which structure is utilized to augment the repair of the anterior talofibular ligament?

Explanation

The modified Brostrom-Gould procedure involves an anatomic repair of the ATFL and CFL, augmented by pulling the inferior extensor retinaculum over the repair. This provides a secondary restraint and limits excessive inversion.

Question 65

A patient sustains a KD III knee dislocation. The ankle-brachial index (ABI) in the emergency department is 0.85. What is the next most appropriate step in management?

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury and requires definitive vascular imaging, typically CT angiography. Immediate exploration is reserved for hard signs of ischemia, such as absent pulses or an expanding hematoma.

Question 66

When repairing an acute rupture of the pectoralis major tendon, to which anatomic location should the tendon be reattached to optimize biomechanical restoration?

Explanation

The pectoralis major inserts onto the lateral lip of the bicipital groove on the humerus. Anatomic repair lateral to the bicipital groove restores the normal length-tension relationship and biomechanics of the shoulder.

Question 67

A 14-year-old male baseball pitcher complains of lateral elbow pain. Radiographs reveal a radiolucency of the capitellum with a sclerotic margin. What is the most likely diagnosis?

Explanation

Osteochondritis dissecans (OCD) of the capitellum typically occurs in adolescent throwers or gymnasts (ages 12-15) presenting with lateral elbow pain and radiolucent defects. Panner disease affects younger children (ages 7-10) and typically involves the entire capitellum without focal loose body formation.

Question 68

Which of the following is the most consistent anatomic landmark for femoral tunnel placement during a Medial Patellofemoral Ligament (MPFL) reconstruction (Schottle's point)?

Explanation

Schottle's point is the radiographic landmark for the femoral origin of the MPFL. It is located 1 mm anterior to the posterior femoral cortical line and proximal to Blumensaat's line.

Question 69

A medial meniscus posterior root tear is most strongly associated with which of the following secondary knee pathologies on MRI?

Explanation

Medial meniscus posterior root tears result in the loss of hoop stresses, which is functionally equivalent to a total meniscectomy. This biomechanical failure commonly leads to meniscal extrusion of >3 mm and rapid progression of unicompartmental osteoarthritis.

Question 70

The internal snapping hip syndrome, characterized by an audible and palpable snap over the anterior hip with hip extension, is most commonly caused by which of the following?

Explanation

Internal snapping hip syndrome is caused by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. External snapping hip involves the IT band or gluteus maximus snapping over the greater trochanter.

Question 71

Compared to hamstring autograft, the use of a bone-patellar tendon-bone (BPTB) autograft for ACL reconstruction is associated with a higher incidence of which of the following complications?

Explanation

BPTB autografts have historically been associated with a higher incidence of anterior knee pain and kneeling pain compared to hamstring autografts. However, graft failure rates are generally comparable or slightly lower for BPTB in young, high-demand athletes.

Question 72

In evaluating a shoulder with an acromioclavicular (AC) joint injury, a Type V injury according to the Rockwood classification is best defined by which of the following findings?

Explanation

A Rockwood Type V AC joint injury involves complete rupture of the AC and CC ligaments with >100% superior displacement of the clavicle relative to the acromion. This degree of displacement typically necessitates surgical reconstruction.

Question 73

What is the primary function of the anterolateral ligament (ALL) of the knee?

Explanation

The anterolateral ligament (ALL) functions as a secondary restraint to internal tibial rotation and heavily influences the pivot-shift phenomenon. It is often reconstructed or augmented in high-risk ACL injuries to restore rotational stability.

Question 74

During an arthroscopic SLAP repair, careful anchor placement in the superior glenoid is required to avoid injury to which nerve?

Explanation

The suprascapular nerve courses through the spinoglenoid notch, typically 1 to 2 cm medial to the posterosuperior glenoid rim. Deep drilling or aberrant anchor placement at the 11 to 1 o'clock position puts this nerve at significant risk.

Question 75

A 24-year-old overhead athlete presents with shoulder pain and weakness. On examination, he has a positive Hornblower's sign. Which muscle is most likely pathologically involved?

Explanation

Hornblower's sign evaluates teres minor pathology. It is positive if the patient is unable to hold the forearm in external rotation when the arm is abducted to 90 degrees.

Question 76

During an anterior cruciate ligament (ACL) reconstruction, the risk of injuring the infrapatellar branch of the saphenous nerve is highest when utilizing which graft?

Explanation

The infrapatellar branch of the saphenous nerve is at the highest risk of injury during the harvest of hamstring tendons via an oblique or longitudinal anteromedial tibial incision.

Question 77

A 14-year-old baseball pitcher presents with generalized shoulder pain. Radiographs reveal widening of the proximal humeral physis. What is the most appropriate initial management?

Explanation

Little League Shoulder (proximal humeral epiphysiolysis) is an overuse injury. Absolute rest from throwing for 2 to 3 months is the standard of care until symptoms resolve and radiographs normalize.

Question 78

An isolated popliteus tendon avulsion from the femoral footprint in an adult athlete is generally best managed by:

Explanation

Isolated popliteus tendon injuries are rare and typically do well with nonoperative management, allowing athletes to return to play after targeted physical therapy.

Question 79

Which of the following physical examination findings is most indicative of a combined posterior cruciate ligament (PCL) and posterolateral corner (PLC) injury?

Explanation

A positive Dial test (increased external rotation >10 degrees compared to the contralateral side) at 30 degrees indicates an isolated PLC injury. Positivity at both 30 and 90 degrees indicates combined PLC and PCL injuries.

Question 80

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, non-anatomic femoral tunnel placement that is too proximal will most likely result in which of the following?

Explanation

Placing the femoral tunnel too proximal during MPFL reconstruction causes the graft to tighten excessively as the knee moves into deep flexion, leading to restricted motion and elevated medial patellofemoral cartilage pressures.

Question 81

In treating overhead throwing athletes with symptomatic Glenohumeral Internal Rotation Deficit (GIRD), the primary anatomical target of the "sleeper stretch" is the:

Explanation

GIRD is characterized by a thickened and contracted posteroinferior capsule. Sleeper stretches specifically target this region, specifically the posterior band of the inferior glenohumeral ligament.

Question 82

Which structure provides the primary restraint to valgus stress at the elbow during the late cocking and early acceleration phases of throwing?

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion, which covers the late cocking and acceleration phases.

Question 83

What is the most classic and frequent anatomical location for osteochondritis dissecans (OCD) lesions in the knee?

Explanation

Approximately 70-80% of knee osteochondritis dissecans (OCD) lesions occur on the lateral aspect of the medial femoral condyle.

Question 84

Which of the following nerves is most commonly injured in an acute anterior-inferior shoulder dislocation?

Explanation

The axillary nerve is the most commonly injured nerve in anterior-inferior shoulder dislocations due to its anatomical course directly inferior to the glenohumeral joint and around the surgical neck of the humerus.

Question 85

A 55-year-old patient presents with anterior knee pain, a palpable gap above the patella, and an inability to perform a straight leg raise after a fall. Lateral radiographs demonstrate patella baja. What is the most likely diagnosis?

Explanation

A quadriceps tendon rupture causes loss of active knee extension and results in patella baja (low-riding patella) due to the unopposed pull of the intact patellar tendon.

Question 86

A 25-year-old athlete undergoes an inside-out repair of a medial meniscus tear. Postoperatively, he complains of medial-sided knee pain and paresthesias along the medial aspect of the lower leg. Which nerve was most likely injured?

Explanation

The saphenous nerve runs posteromedially and is at high risk during inside-out repair of the medial meniscus, particularly when sutures are passed blindly through the posteromedial capsule.

Question 87

When evaluating a patient with an acutely dislocated knee, the initial ankle-brachial index (ABI) is calculated to be 0.85. What is the next most appropriate step in management?

Explanation

An ABI less than 0.90 after a knee dislocation is highly suspicious for a popliteal artery injury. Advanced imaging, such as CT angiography or standard angiography, is immediately indicated.

Question 88

The "peel-back" mechanism during the late cocking phase of overhead throwing is primarily responsible for the development of which shoulder pathology?

Explanation

The peel-back mechanism occurs when maximal external rotation shifts the biceps vector posteriorly, placing torsional stress on the superior labrum and leading to Type II SLAP tears.

Question 89

In treating massive, irreparable rotator cuff tears in patients without severe glenohumeral arthritis, a superior capsular reconstruction (SCR) primarily aims to achieve which biomechanical effect?

Explanation

Superior capsular reconstruction utilizes a graft to bridge the glenoid and greater tuberosity. This depresses the humeral head, prevents superior migration, and restores a stable fulcrum for the deltoid.

Question 90

An 18-year-old football player sustains a high-energy valgus and twisting knee injury. MRI confirms rupture of the ACL, MCL, and a medial meniscus tear. What is the classic eponym for this injury pattern?

Explanation

O'Donoghue's unhappy triad traditionally consists of injury to the ACL, MCL, and the medial meniscus. Note that modern literature shows lateral meniscus tears are actually more common in acute ACL injuries.

Question 91

Regarding the vascular supply and healing potential of the menisci, which anatomical zone has the highest intrinsic capacity for healing following a surgical repair?

Explanation

The peripheral 10% to 30% of the meniscus (the red-red zone) has a rich vascular supply derived from the perimeniscal capillary plexus, giving it the highest potential for healing after repair.

Question 92

Which specific radiographic view is considered the most sensitive for profiling the posterolateral humeral head to identify a Hill-Sachs lesion?

Explanation

The Stryker notch view is obtained with the patient supine and the arm elevated, directing the beam cephalad. It is specifically designed to profile the posterolateral humeral head and optimally identify Hill-Sachs defects.

Question 93

A 45-year-old diabetic female presents with severe, progressive shoulder stiffness. Passive range of motion is globally restricted, with external rotation being the most limited. Radiographs are normal. What is the primary underlying pathological mechanism?

Explanation

Adhesive capsulitis (frozen shoulder) involves synovial inflammation leading to reactive capsular fibroplasia and contracture. This produces a global restriction of active and passive motion, particularly external rotation.

Question 94

A medial meniscus posterior root tear is strongly associated with which of the following biomechanical consequences in the knee joint?

Explanation

A posterior root tear functionally unanchors the meniscus, destroying its ability to convert axial loads into hoop stresses. This leads to meniscal extrusion and medial compartment cartilage loads equivalent to a total meniscectomy.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 45

Orthopedic Prometric MCQs - Chapter 3 Part 45

Chapter Index