The safest surgical approach to the insertion of the tibial posterior cruciate ligament uses the interval between which of the following muscles?

Semimembranosus and medial gastrocnemius

An otherwise healthy 57-year-old man has persistent, severe hip pain after undergoing total hip arthroplasty 3 months ago. What is the next most appropriate step in management?

Assessment of C-reactive protein, erythroctye sedimentation rate, and CBC, followed by aspiration

A young gymnast fell awkwardly onto an outstretched hand during a competition. At the time of impact, his forearm was positioned in supination. Axial and posterolateral forces were loaded along the forearm into the elbow and the elbow underwent a sig

Coronoid fracture, olecranon fracture and elbow dislocation

An 11-year-old girl is struck in the leg by a loaded sled while sledding and is seen in the emergency department; she is reporting severe knee pain. Radiographs are read as normal. Examination reveals that she is exquisitely tender over the proximal

Splinting, admission, and frequent neurovascular checks

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

open reduction and internal fixation.

The patient subsequently requires split-thickness skin grafting over his lateral fasciotomy wound during soft-tissue reconstruction. In this setting, NPWT

- will likely improve incorporation of the graft.

Orthopedic Sports Medicine MCQ Review by Dr Hutaif

Question 1

A 10-year-old male sustains an anterior cruciate ligament (ACL) tear. His skeletal age indicates substantial remaining growth. Which of the following surgical techniques for ACL reconstruction poses the highest risk of physeal arrest and subsequent angular deformity?

Explanation

Using a bone plug across an open physis significantly increases the risk of premature physeal closure, growth arrest, and angular deformity. Soft tissue grafts placed vertically and centrally through the physis (typically <8mm) have a lower risk. Physeal-sparing and all-epiphyseal techniques are specifically designed to avoid the physis entirely in skeletally immature patients.

Question 2

During a Latarjet procedure for recurrent anterior shoulder instability, the coracoid process is transferred to the anterior glenoid neck. The 'sling effect' is considered the most significant contributor to stability in this procedure. Which of the following describes the mechanism of this dynamic sling?

Explanation

The primary stabilizing mechanism of the Latarjet procedure is the 'sling effect', which contributes up to 70% of the stability at the end ranges of motion. It is produced by the conjoined tendon (short head of the biceps and coracobrachialis) passing through the split in the subscapularis, which acts as a dynamic sling to tension the lower subscapularis and anterior capsule when the arm is placed in abduction and external rotation.

Question 3

A 48-year-old female presents with acute medial knee pain after a minor pivoting episode. MRI demonstrates a medial meniscus posterior root tear with 4 mm of meniscal extrusion. Which of the following best describes the biomechanical consequence of this specific injury if left untreated?

Explanation

A posterior root tear of the medial meniscus completely disrupts the meniscal hoop stresses. Biomechanical studies have shown that this loss of hoop tension results in peak tibiofemoral contact pressures that are statistically equivalent to those seen after a total medial meniscectomy, drastically accelerating medial compartment arthrosis.

Question 4

A 21-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction. Biomechanically, which bundle of the native UCL is the primary restraint to valgus stress at 30 degrees of elbow flexion, and therefore the primary target of this reconstruction?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress of the elbow. It is subdivided into the anterior and posterior bands. The anterior band is the primary restraint to valgus stress from 0 to 90 degrees of flexion, while the posterior band becomes more taut and clinically significant in deeper flexion (typically >90-120 degrees).

Question 5

A 23-year-old hockey player is diagnosed with Cam-type femoroacetabular impingement (FAI). Anteroposterior and Dunn view radiographs show an elevated alpha angle (>55 degrees). Where is the most common anatomic location of the Cam lesion on the proximal femur?

Explanation

Cam lesions are characterized by an aspherical extension of the articular surface or loss of head-neck offset. They are most commonly located at the anterosuperior portion of the femoral head-neck junction. Impingement typically occurs against the anterosuperior acetabular rim during hip flexion and internal rotation.

Question 6

A 25-year-old male is 3 months post-operative from an ACL reconstruction using a bone-patellar tendon-bone (BPTB) autograft. He complains of a new, audible 'clunk' and anterior knee pain as he reaches terminal extension. Which of the following conditions is most likely responsible for his symptoms?

Explanation

A Cyclops lesion is a localized nodule of fibrovascular tissue (arthrofibrosis) that typically forms anterior to the ACL graft in the intercondylar notch. It manifests with an audible or palpable 'clunk' near terminal extension and a loss of full extension. It is a classic complication post-ACL reconstruction causing mechanical block.

Question 7

A 28-year-old male sustains a severe knee injury during a rugby tackle. The dial test demonstrates 15 degrees of increased external rotation compared to the contralateral knee at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees of knee flexion. Which injury pattern does this specifically indicate?

Explanation

The dial test evaluates for posterolateral instability. Increased external rotation (>10 degrees compared to the normal side) at 30 degrees of flexion, but returning to symmetry at 90 degrees, indicates an isolated posterolateral corner (PLC) injury. If the asymmetry is present at BOTH 30 and 90 degrees, it indicates a combined PLC and PCL injury.

Question 8

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, identifying the anatomic femoral insertion is critical. According to Schöttle's radiographic landmarks on a strict lateral radiograph, where is the femoral origin of the MPFL located?

Explanation

Schöttle's point defines the radiographic femoral origin of the MPFL on a true lateral view. It 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 posterior extension of Blumensaat's line.

Question 9

A 45-year-old bodybuilder feels a pop in his shoulder during a heavy bench press. Examination reveals increased passive external rotation and a positive belly-press test. An MRI confirms an isolated, full-thickness tear of the upper subscapularis tendon. What additional pathology is most strongly associated with this specific injury?

Explanation

The upper fibers of the subscapularis tendon form the medial wall of the bicipital groove and contribute to the biceps reflection pulley. A tear of the superior subscapularis, especially when combined with a coracohumeral ligament tear, disrupts this pulley, frequently leading to medial subluxation or dislocation of the long head of the biceps tendon.

Question 10

Surgical reconstruction of a chronic Type V acromioclavicular (AC) joint separation requires addressing the coracoclavicular (CC) ligaments to restore biomechanical stability. Which of the following statements regarding the native CC ligaments is correct?

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is located posteromedial to the trapezoid and acts as the primary restraint to superior translation of the clavicle. The trapezoid is located anterolateral and is the primary restraint to axial compression of the shoulder.

Question 11

A 22-year-old soccer player undergoes microfracture for a 1.5 cm^2 full-thickness chondral defect on the medial femoral condyle. Which of the following best describes the predominant histological composition of the reparative tissue generated by this procedure?

Explanation

Microfracture stimulates the release of marrow elements to form a super clot over a chondral defect. The resulting reparative tissue is predominantly fibrocartilage, which is composed primarily of Type I collagen. This is mechanically inferior to the native articular hyaline cartilage, which is composed primarily of Type II collagen.

Question 12

In an overhead throwing athlete, a Type II Superior Labrum Anterior and Posterior (SLAP) tear is often symptomatic during specific phases of throwing due to the 'peel-back' mechanism. During which phase of the throwing motion does maximum peel-back force occur?

Explanation

The 'peel-back' mechanism is a primary cause of Type II SLAP tears in overhead athletes. During the late cocking phase, the shoulder is placed in maximum abduction and external rotation. This position causes a posterior and inferior shift in the vector of the biceps tendon, creating a torsional force that peels the superior labrum off the glenoid rim.

Question 13

A 9-year-old male gymnast presents with lateral elbow pain and stiffness. Radiographs show sclerosis and fragmentation of the capitellum with an open proximal radial physis. An MRI confirms diffuse high T2 signal in the capitellum without a discrete osteochondral fragment. What is the most appropriate management?

Explanation

The clinical presentation (age <10 years, typical radiographic findings without a discrete loose body) is classic for Panner's disease (osteochondrosis of the capitellum). Unlike osteochondritis dissecans (OCD) of the capitellum, which typically occurs in older adolescents and often requires surgery, Panner's disease is self-limiting. The standard treatment is conservative, consisting of rest and avoidance of inciting activities until symptoms resolve.

Question 14

A 26-year-old male sustains a complete anterior knee dislocation (KD-IV) during a motorcycle accident and presents with absent distal pulses. The popliteal artery is at high risk of injury in this scenario due to anatomic tethering. At which two anatomical points is the popliteal artery firmly fixed, making it susceptible to traction injury?

Explanation

The popliteal artery is firmly tethered proximally at the adductor hiatus (where the superficial femoral artery exits Hunter's canal to become the popliteal artery) and distally at the fibrous arch of the soleus muscle. These unyielding fixation points prevent the artery from moving freely during severe joint displacement, leading to traction and intimal tearing or complete rupture during knee dislocations.

Question 15

During surgical stabilization of an acute syndesmotic injury of the ankle, a thorough understanding of the native anatomy is required. Which of the following ligaments provides the greatest biomechanical strength and resistance to diastasis of the distal tibiofibular joint?

Explanation

The syndesmotic complex consists of the AITFL, PITFL, transverse ligament, and interosseous ligament/membrane. Biomechanical studies demonstrate that the Posterior Inferior Tibiofibular Ligament (PITFL) provides the strongest restraint, accounting for approximately 42% of the total strength against syndesmotic widening, followed by the AITFL (35%) and the interosseous ligament (22%).

Question 16

A 21-year-old collegiate pitcher is diagnosed with SICK scapula syndrome (Scapular malposition, Inferior medial border prominence, Coracoid pain, and dysKinesis). Examination shows significant anterior tilt of the scapula. Tightness of which of the following muscular structures is the primary driver of this anterior tilt?

Explanation

SICK scapula syndrome typically features an anteriorly tilted and protracted scapula. This is classically driven by tightness or contracture of the pectoralis minor (which inserts on the coracoid process, pulling the scapula anteriorly and inferiorly) combined with weakness of the primary scapular stabilizers, notably the lower trapezius and serratus anterior.

Question 17

Following arthroscopic rotator cuff repair, tendon-to-bone healing progresses through inflammatory, proliferative, and remodeling phases. During the early proliferative phase (weeks 2 to 4), what type of collagen is predominately synthesized by fibroblasts at the repair site?

Explanation

Tendon-to-bone healing initially involves the deposition of fibrovascular granulation tissue. During the proliferative phase (starting around week 1 and peaking at 3-4 weeks), fibroblasts primarily synthesize Type III collagen, which forms mechanically inferior, disorganized scar tissue. During the subsequent remodeling phase, this is gradually replaced by the stronger, more organized Type I collagen.

Question 18

A 20-year-old male with an acute ACL tear is suspected of having an associated 'ramp lesion'. Which of the following best defines a true ramp lesion of the knee?

Explanation

A 'ramp lesion' refers specifically to a longitudinal tear at the peripheral meniscocapsular junction or the meniscotibial ligament of the posterior horn of the medial meniscus. It is highly associated with ACL tears and is often missed on standard anterior portal arthroscopy, frequently requiring evaluation via a posteromedial viewing or working portal.

Question 19

A 19-year-old collegiate football player sustains a midshaft clavicle fracture with 2.5 cm of shortening and no comminution. He desires to return to play as safely and predictably as possible. According to current literature, what is the primary advantage of open reduction internal fixation (ORIF) over non-operative management in this specific patient?

Explanation

For significantly displaced or shortened (>2 cm) midshaft clavicle fractures in young, active patients, ORIF has been shown to significantly reduce the rates of nonunion and symptomatic malunion compared to non-operative management, leading to more predictable functional outcomes. Return to contact sports still requires clinical and radiographic evidence of healing (usually 8-12 weeks).

Question 20

A 40-year-old recreational weightlifter undergoes surgical repair of an acute distal biceps tendon rupture via a single-incision anterior approach. Post-operatively, he complains of numbness and tingling along the lateral aspect of his forearm. Which nerve is most likely injured?

Explanation

The lateral antebrachial cutaneous nerve (LABCN), which is the terminal sensory branch of the musculocutaneous nerve, exits deep to the biceps and lies in the subcutaneous tissue of the lateral forearm. Due to necessary lateral retraction during a single-incision anterior approach for distal biceps repair, the LABCN is the most commonly injured nerve, leading to lateral forearm paresthesias.

Question 21

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the femoral tunnel is inadvertently placed 1 cm proximal to Schöttle's point. Which of the following describes the most likely biomechanical consequence of this non-anatomic graft placement?

Explanation

Non-anatomic placement of the femoral tunnel during MPFL reconstruction profoundly alters graft kinematics. Schöttle's point defines the anatomic radiographic landmark for the femoral origin of the MPFL. If the femoral tunnel is placed too proximal, the distance between the patellar and femoral attachments increases as the knee flexes, causing the graft to become overly tight in flexion and loose in extension. This typically presents clinically as postoperative stiffness and a loss of terminal knee flexion.

Question 22

A 22-year-old elite baseball pitcher presents with posterior shoulder pain and a significant loss of internal rotation (GIRD). Physical examination reveals a glenohumeral internal rotation deficit of 25 degrees compared to the contralateral side. Pathologic contracture of the posterior band of the inferior glenohumeral ligament (IGHL) alters glenohumeral kinematics during the late cocking phase of throwing. In which direction does the glenohumeral contact point abnormally shift as a result of this contracture?

Explanation

In the throwing athlete, repeated microtrauma can lead to contracture of the posterior capsule, specifically the posterior band of the IGHL. This contracture tethering forces the humeral head to shift posterosuperiorly during the late cocking phase of throwing (abduction and maximal external rotation). This posterosuperior shift increases contact between the greater tuberosity and the posterosuperior glenoid, leading to internal impingement and 'peel-back' superior labrum anterior-posterior (SLAP) tears.

Question 23

A surgeon is performing a posterior cruciate ligament (PCL) reconstruction using a transtibial tunnel technique. This technique is classically associated with the 'killer turn' at the posterior tibial aperture. Which of the following is the most frequent complication directly resulting from this specific anatomical geometry?

Explanation

The 'killer turn' refers to the acute angle the PCL graft must take as it exits the posterior tibial tunnel to travel superiorly to the medial femoral condyle in a transtibial PCL reconstruction. This sharp turn creates high friction and repetitive abrasion on the graft, making it highly susceptible to gradual attenuation, elongation, and ultimate clinical failure. This biomechanical disadvantage is the primary rationale for many surgeons preferring the tibial inlay technique, which avoids this acute angle.

Question 24

A 25-year-old male presents with recurrent anterior shoulder instability. CT imaging demonstrates a Hill-Sachs lesion and a glenoid bone loss of 12%. Applying the 'glenoid track' concept, the Hill-Sachs lesion is calculated to be 'off-track.' Which of the following is the most appropriate surgical management to prevent recurrent instability?

Explanation

The glenoid track concept is used to evaluate bipolar bone loss in shoulder instability. An 'off-track' Hill-Sachs lesion means the lesion engages the anterior glenoid rim during abduction and external rotation. For subcritical glenoid bone loss (<20-25%) coupled with an off-track Hill-Sachs lesion, the standard of care is an arthroscopic Bankart repair combined with a Remplissage procedure (filling the humeral defect with the infraspinatus tendon and posterior capsule). A Latarjet procedure is generally reserved for glenoid bone loss exceeding 20-25% or revision settings.

Question 25

A 28-year-old female undergoes hip arthroscopy for femoroacetabular impingement (FAI). Postoperatively, she complains of numbness in the perineal region and labia. Which of the following nerves is most likely injured due to compression against the perineal post during prolonged surgical traction?

Explanation

The pudendal nerve is vulnerable to compression neurapraxia against the perineal post during hip arthroscopy due to prolonged traction. This presents as numbness or paresthesia in the perineum, scrotum, or labia. To minimize this risk, traction time should be limited (ideally under 2 hours), and a well-padded, adequately oversized post should be utilized, with the traction vector properly aligned to relieve direct perineal pressure. The lateral femoral cutaneous nerve is also at risk during portal placement, but causes anterolateral thigh numbness.

Question 26

During a surgical reconstruction of the posterolateral corner (PLC) of the knee, anatomic femoral tunnel placement is critical for restoring normal kinematics. In relation to the popliteus tendon attachment on the lateral femoral epicondyle, where is the anatomical origin of the fibular collateral ligament (FCL)?

Explanation

Knowledge of the complex anatomy of the posterolateral corner (PLC) is essential for successful reconstruction. On the lateral femoral condyle, the attachment of the fibular collateral ligament (FCL) is situated approximately 1.4 mm proximal and 3.1 mm posterior to the origin of the popliteus tendon. Misplacement of these tunnels alters knee kinematics, leading to either graft failure or loss of range of motion.

Question 27

A highly active 22-year-old male presents with persistent anterior knee pain. MRI and subsequent diagnostic arthroscopy reveal an isolated, 3.5 cm2 Outerbridge grade IV full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle. The subchondral bone is intact. Which of the following is the most appropriate surgical treatment?

Explanation

The treatment algorithm for focal articular cartilage defects in the knee depends largely on the patient's age, activity level, and the size of the defect. Microfracture and OATS are generally indicated for smaller defects (<2.0 to 2.5 cm2). For larger, symptomatic full-thickness defects (>2.5 cm2) in a young, active patient with intact subchondral bone, cell-based therapies such as Matrix-induced autologous chondrocyte implantation (MACI) or autologous chondrocyte implantation (ACI) are the gold standard procedures to restore hyaline-like cartilage.

Question 28

A 35-year-old male professional volleyball player presents with progressive weakness in his dominant shoulder. Physical examination reveals isolated atrophy of the infraspinatus fossa and severe weakness in external rotation. Supraspinatus strength and muscle bulk are normal. An MRI is most likely to demonstrate a paralabral cyst compressing the suprascapular nerve at which of the following anatomical locations?

Explanation

The suprascapular nerve innervates both the supraspinatus and infraspinatus muscles. It passes through the suprascapular notch (giving motor branches to the supraspinatus) and then courses through the spinoglenoid notch to innervate the infraspinatus. A paralabral cyst (often secondary to a posterior labral tear) located at the spinoglenoid notch compresses the nerve distal to the supraspinatus branches, resulting in isolated infraspinatus denervation, atrophy, and external rotation weakness. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 29

A surgeon is performing an inside-out meniscal repair for a longitudinal tear involving the posterior horn of the lateral meniscus. To protect neurovascular structures, a retractor must be properly placed. Which of the following structures is at the highest risk of iatrogenic injury during suture passage in this specific area?

Explanation

During an inside-out meniscal repair of the lateral meniscus, the common peroneal nerve is the most vulnerable neurovascular structure. It courses posterior to the biceps femoris tendon and wraps around the fibular neck. To protect it, a lateral incision is made between the iliotibial band and the biceps femoris, and a retractor is placed anterior to the lateral head of the gastrocnemius. In contrast, the saphenous nerve is at highest risk during medial inside-out meniscal repairs.

Question 30

The coracoclavicular (CC) ligaments provide the primary vertical stability to the acromioclavicular (AC) joint. Which of the following best describes the anatomical location and primary biomechanical role of the conoid ligament?

Explanation

The coracoclavicular (CC) complex consists of the conoid and trapezoid ligaments. Anatomically, the conoid ligament is positioned posteromedial to the trapezoid ligament. Biomechanically, the conoid ligament is the primary restraint to superior translation of the clavicle relative to the acromion. The trapezoid ligament, located anterolaterally, acts primarily to resist axial compression (posterior translation of the clavicle toward the acromion).

Question 31

A 24-year-old professional soccer player undergoes an anterior cruciate ligament (ACL) reconstruction. During diagnostic arthroscopy, the surgeon suspects a 'ramp lesion'. Which of the following approaches is most critical for the accurate identification and repair of this specific pathology?

Explanation

Ramp lesions are tears of the peripheral meniscocapsular attachment of the posterior horn of the medial meniscus. They are frequently missed using standard anterior portals and require a trans-notch view or an accessory posteromedial portal for visualization and repair.

Question 32

A 19-year-old female presents with recurrent lateral patellar instability. Imaging demonstrates an Insall-Salvati ratio of 1.4, a Caton-Deschamps index of 1.3, and a Tibial Tubercle-Trochlear Groove (TT-TG) distance of 22 mm. Which of the following surgical strategies is most appropriate?

Explanation

This patient has severe patella alta (Insall-Salvati >1.2) and an abnormal TT-TG distance (>20 mm). A combined distalizing and anteromedializing tibial tubercle osteotomy (Fulkerson-type modified) alongside an MPFL reconstruction is necessary to address both anatomic risk factors.

Question 33

A 30-year-old male sustains a posterior knee injury. Physical examination reveals a positive posterior drawer test. The Dial test demonstrates 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side, but symmetric external rotation at 90 degrees. Which structure is most likely injured?

Explanation

The Dial test evaluates external rotation of the tibia. Increased rotation at 30 degrees of flexion with symmetric rotation at 90 degrees indicates an isolated posterolateral corner (PLC) injury. Combined PCL and PLC injuries show increased rotation at both 30 and 90 degrees.

Question 34

A 25-year-old rugby player sustains an acute knee dislocation (Schenck KD-III). After immediate successful closed reduction in the emergency department, the patient is noted to have palpable and symmetric pedal pulses. What is the most appropriate next step in management?

Explanation

Even in the presence of normal pedal pulses, patients with knee dislocations are at high risk for popliteal artery intimal tears. An Ankle-Brachial Index (ABI) must be calculated; an ABI less than 0.9 mandates further vascular imaging, such as CT angiography.

Question 35

A 20-year-old competitive rugby player presents with his fourth anterior shoulder dislocation. A 3D CT scan reveals 23% anterior glenoid bone loss. According to the Instability Severity Index Score (ISIS) and current literature, what is the most appropriate definitive surgical management?

Explanation

The open Latarjet procedure is the gold standard for recurrent anterior shoulder instability in collision athletes with critical anterior glenoid bone loss (>20%). An ISIS score greater than 6 correlates with an unacceptably high failure rate for isolated arthroscopic soft-tissue repair.

Question 36

A 22-year-old collegiate baseball pitcher complains of vague posterior shoulder pain and a decrease in pitching velocity. Examination reveals 15 degrees of internal rotation and 125 degrees of external rotation in 90 degrees of abduction. Which of the following is the most appropriate initial management?

Explanation

This athlete exhibits Glenohumeral Internal Rotation Deficit (GIRD), characterized by posterior capsular contracture and loss of internal rotation. The first-line treatment is a dedicated physical therapy regimen focusing on posterior capsular stretching.

Question 37

During an ulnar collateral ligament (UCL) reconstruction in a professional throwing athlete, the surgeon elects to use the docking technique rather than the traditional figure-of-eight (Jobe) technique. What is the primary anatomic and biomechanical advantage of the docking technique?

Explanation

The docking technique utilizes a single larger socket in the medial epicondyle with smaller exit holes for sutures, rather than large intersecting tunnels. This minimizes bone loss in the medial epicondyle, thereby reducing the risk of iatrogenic epicondylar fracture.

Question 38

A 28-year-old male undergoes hip arthroscopy for Femoroacetabular Impingement (FAI) with a symptomatic Cam lesion and labral tear. To minimize the risk of a postoperative iatrogenic femoral neck fracture, the femoral osteochondroplasty should not exceed what percentage of the femoral neck diameter?

Explanation

Biomechanical studies have demonstrated that resecting more than 30% of the anterolateral femoral neck diameter during Cam osteochondroplasty significantly increases the risk of postoperative femoral neck fracture. Resection is ideally limited to less than 20% to 30%.

Question 39

A 21-year-old elite gymnast presents with persistent knee pain. MRI reveals a 3.5 cm squared full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle. She has failed conservative management. Which of the following surgical options is most appropriate?

Explanation

For large (>2-3 cm squared), symptomatic, full-thickness chondral defects in high-demand patients, cell-based therapies like MACI or structural restoration via Osteochondral Allograft are indicated. Microfracture and OATS are typically reserved for smaller lesions (<2 cm squared).

Question 40

Recent high-level evidence regarding the management of acute Achilles tendon ruptures suggests that the re-rupture rates between non-operative and operative management become statistically similar when which of the following postoperative protocols is utilized?

Explanation

Level I evidence demonstrates that early functional rehabilitation with dynamic bracing and early weight-bearing equalizes the re-rupture rate between operative and non-operative management of Achilles tendon ruptures, while reducing other complications.

Question 41

A 58-year-old laborer presents with an MRI-confirmed massive, irreparable posterosuperior rotator cuff tear. He has preserved active forward elevation but severe pain. The teres minor and subscapularis are intact, and there is no glenohumeral arthritis (Hamada Grade 1). Which is the most appropriate surgical option?

Explanation

Superior Capsular Reconstruction (SCR) is indicated for younger, active patients with massive, irreparable supraspinatus/infraspinatus tears without severe arthritis, provided they have an intact or repairable subscapularis and functional deltoid/teres minor.

Question 42

A 25-year-old athlete presents with lateral knee pain and instability after a hyperextension injury. Physical examination reveals increased external rotation on the dial test of 15 degrees compared to the contralateral knee at 30 degrees of flexion, but symmetric rotation at 90 degrees of flexion. Which of the following structures is most likely injured?

Explanation

An isolated posterolateral corner (PLC) injury results in increased external rotation at 30 degrees of flexion but symmetric rotation at 90 degrees. If both the PLC and PCL are injured, the dial test will be positive at both 30 and 90 degrees.

Question 43

A 22-year-old rugby player has recurrent anterior shoulder instability. CT scan shows a 15% anterior glenoid bone loss and a Hill-Sachs lesion. Applying the glenoid track concept, an off-track lesion is determined. Which of the following best defines an off-track Hill-Sachs lesion?

Explanation

An off-track Hill-Sachs lesion occurs when its medial margin extends medial to the glenoid track, meaning it can engage the anterior glenoid rim. This scenario typically necessitates a procedure to address the bone loss or an adjunct like a Remplissage to prevent recurrent instability.

Question 44

A 19-year-old female undergoes medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. Postoperatively, she complains of severe medial knee pain and restricted flexion. What is the most likely technical error made during femoral tunnel placement?

Explanation

A femoral tunnel placed too proximal and anterior during MPFL reconstruction causes the graft to tighten excessively in knee flexion. This non-isometric placement leads to restricted flexion and severely elevated medial compartment pressures.

Question 45

A 28-year-old football player undergoes posterior cruciate ligament (PCL) reconstruction. The surgeon decides to use a single-bundle technique to reconstruct the anterolateral (AL) bundle. At what knee flexion angle does the AL bundle normally experience maximum tension?

Explanation

The anterolateral (AL) bundle of the PCL is the larger of the two bundles and is tightest in deeper knee flexion, reaching maximum tension near 90 degrees. Conversely, the posteromedial (PM) bundle is tightest in knee extension.

Question 46

A 24-year-old skier sustains an acute ACL tear. MRI suggests a posterior horn tear of the medial meniscus at the meniscocapsular junction. Arthroscopic evaluation via a posteromedial portal confirms a ramp lesion. Which of the following biomechanical effects is most exacerbated if this lesion is left untreated?

Explanation

A meniscal ramp lesion involves the meniscocapsular attachments of the posterior horn of the medial meniscus. If left untreated in an ACL-deficient knee, it significantly increases anterior tibial translation and places higher stress on an ACL graft.

Question 47

A 26-year-old baseball pitcher presents with vague posterior shoulder pain and a subjective dead arm. He has a positive O'Brien test and a positive peel-back test during arthroscopy. Which of the following is the most appropriate management for a Type II SLAP tear in this overhead throwing athlete?

Explanation

In overhead throwing athletes, SLAP repairs for Type II lesions have shown low return-to-play rates and a high incidence of postoperative stiffness. Biceps tenodesis is increasingly favored as it provides predictable pain relief without restricting the throwing motion.

Question 48

A 22-year-old hockey player presents with anterior hip pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate a pistol-grip deformity and an alpha angle of 65 degrees. What is the primary mechanism of labral injury in this condition?

Explanation

The patient has Cam-type femoroacetabular impingement (FAI) characterized by an elevated alpha angle. The aspherical femoral head creates outside-in shear forces at the chondrolabral junction during flexion, leading to labral tears and cartilage delamination.

Question 49

A 35-year-old recreational basketball player suffers an acute Achilles tendon rupture. He considers non-operative management with a functional rehabilitation protocol versus surgical repair. According to recent high-level evidence, which of the following statements comparing these two approaches is most accurate?

Explanation

Modern functional rehabilitation protocols utilizing early weight-bearing have demonstrated re-rupture rates comparable to surgical repair. Surgical repair, however, carries inherently higher risks of complications such as infection and sural nerve injury.

Question 50

A 30-year-old weightlifter feels a pop in his anterior chest while performing a heavy bench press. Examination reveals an asymmetric chest wall and weakness in internal rotation. Which portion of the pectoralis major tendon is most commonly ruptured and during which phase of the bench press?

Explanation

Pectoralis major tendon ruptures most commonly involve the sternocostal head. They typically occur during maximal eccentric contraction, such as lowering the heavy bar during a bench press.

Question 51

A 27-year-old cyclist falls directly onto his shoulder and is diagnosed with a Type III acromioclavicular (AC) joint separation. If surgical reconstruction is chosen, biomechanical restoration of the coracoclavicular ligaments is crucial. Which of the following describes the correct anatomic relationship and primary function of these ligaments?

Explanation

The coracoclavicular (CC) ligaments consist of the medial conoid and the lateral trapezoid. The conoid primarily resists superior displacement of the clavicle, while the trapezoid mainly resists anterior-posterior horizontal displacement.

Question 52

A 14-year-old male presents with persistent right knee pain and catching. Radiographs and MRI reveal a 2 cm osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. The physes are open, and the cartilage is intact with no subchondral fluid. What is the most appropriate initial management?

Explanation

In juvenile patients with open physes and a stable OCD lesion (intact cartilage without subchondral fluid), initial management is non-operative. Activity modification and protected weight-bearing have a high success rate in allowing spontaneous healing.

Question 53

A 55-year-old male with end-stage renal disease on dialysis sustains a hyperflexion injury to his knee, resulting in an inability to actively extend the knee. A palpable defect is noted superior to the patella. Which of the following is the most likely location of the tissue failure in this patient?

Explanation

Quadriceps tendon ruptures most commonly occur as an avulsion at the osteotendinous junction located at the superior pole of the patella. This specific injury pattern is heavily associated with systemic conditions like chronic renal failure and diabetes.

Question 54

A 19-year-old female collegiate cross-country runner presents with a femoral neck stress fracture. She reports oligomenorrhea and restrictive eating habits. This triad of conditions is primarily driven by which of the following underlying physiological deficits?

Explanation

The Female Athlete Triad is fundamentally driven by low energy availability, with or without a diagnosed eating disorder. This energy deficit disrupts the hypothalamic-pituitary-ovarian axis, leading to hypoestrogenism and subsequent osteopenia or stress fractures.

Question 55

During an open subpectoral biceps tenodesis, the surgeon inadvertently places a medial retractor too aggressively on the humerus. The patient postoperatively demonstrates weakness in elbow flexion and numbness over the lateral forearm. Which nerve was most likely injured?

Explanation

Medial retraction during a subpectoral biceps tenodesis places the musculocutaneous nerve at risk. Injury presents as weakness in the biceps and brachialis muscles alongside sensory loss in the lateral antebrachial cutaneous nerve distribution.

Question 56

A 21-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction utilizing the docking technique. Prior to surgery, he reported medial elbow pain during the late cocking and early acceleration phases of throwing. Which specific bundle of the UCL was most likely incompetent and reconstructed?

Explanation

The anterior bundle of the ulnar collateral ligament is the primary static restraint to valgus stress at the elbow, particularly during the late cocking and early acceleration phases of throwing. Modern UCL reconstructions aim to restore this specific functional bundle.

Question 57

A 24-year-old professional football player sustains a posterolateral corner (PLC) injury of the knee. Which of the following structures is the primary restraint to varus instability at both 0 and 30 degrees of knee flexion?

Explanation

The fibular collateral ligament (FCL) is the primary restraint to varus stress at both 0 and 30 degrees of knee flexion. The popliteus tendon and popliteofibular ligament are primary restraints to external rotation.

Question 58

During a Latarjet procedure for recurrent anterior shoulder instability, the subscapularis muscle is typically split to expose the anterior glenoid. Which nerve is at greatest risk of injury during the mobilization and transfer of the coracoid process through this split?

Explanation

The musculocutaneous nerve penetrates the coracobrachialis muscle distal to the coracoid process. It is highly susceptible to stretch or direct injury during retraction and coracoid transfer in the Latarjet procedure.

Question 59

A 19-year-old female undergoes medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocations. Postoperatively, she reports severe medial knee pain and stiffness when trying to bend her knee past 60 degrees. What is the most likely technical error made during the surgery?

Explanation

Placing the femoral tunnel too proximal to Schöttle's point makes the MPFL graft non-isometric, causing it to become inappropriately tight in flexion. This leads to increased medial patellofemoral cartilage pressure and stiffness.

Question 60

A 22-year-old collegiate hockey player presents with groin pain exacerbated by deep flexion and internal rotation. Radiographs demonstrate an alpha angle of 65 degrees. During the pathomechanical process of this specific deformity, where does the maximal shear stress occur?

Explanation

An alpha angle greater than 55 degrees indicates a Cam deformity, which creates an aspherical femoral head. During flexion and internal rotation, this prominent bone causes shear stress at the anterosuperior chondrolabral junction, leading to labral tears and cartilage delamination.

Question 61

A 25-year-old skier sustains an acute ACL rupture. Preoperative MRI shows a hyperintense signal in the posterior medial compartment. During arthroscopy, a 'ramp lesion' is identified. Which of the following best describes the anatomic location of this tear?

Explanation

A ramp lesion is a longitudinal tear at the meniscocapsular junction of the posterior horn of the medial meniscus. It is highly associated with acute ACL tears and can lead to increased anterior and rotatory instability if left untreated.

Question 62

A 21-year-old baseball pitcher presents with medial elbow pain during the late cocking phase of throwing. He is diagnosed with a severe ulnar collateral ligament (UCL) tear. Which bundle of the UCL acts as the primary restraint to valgus stress at 90 degrees of elbow flexion?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress of the elbow between 30 and 120 degrees of flexion. It is the bundle most frequently injured in overhead throwing athletes.

Question 63

A 32-year-old competitive weightlifter feels a tearing sensation in his anterior chest while performing a heavy bench press. MRI confirms a complete pectoralis major rupture. Which of the following describes the typical pathoanatomy of the torn tendinous insertion?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting onto the humerus. This causes the sternocostal head to insert posterior (deep) and superior to the clavicular head, making it the most vulnerable to rupture during eccentric loading.

Question 64

A 26-year-old male is evaluated following a knee hyperextension injury. Physical examination reveals 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral knee. However, at 90 degrees of flexion, the external rotation is symmetric. What injury pattern does this indicate?

Explanation

A positive dial test (increased external rotation >10 degrees) only at 30 degrees of knee flexion indicates an isolated posterolateral corner (PLC) injury. If the asymmetry is present at both 30 and 90 degrees, it indicates a combined PCL and PLC injury.

Question 65

A 28-year-old elite volleyball attacker complains of insidious onset posterior shoulder pain and isolated external rotation weakness. EMG reveals denervation isolated to the infraspinatus. What pathology is most likely responsible for this presentation?

Explanation

A ganglion cyst at the spinoglenoid notch compresses the suprascapular nerve after it has already innervated the supraspinatus, leading to isolated infraspinatus weakness. These cysts are highly associated with posterior labral tears.

Question 66

A 30-year-old male sustains a severe multiligament knee injury (KD III-M) after a motorcycle accident. After closed reduction in the emergency department, his 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 after a knee dislocation is highly suspicious for a vascular injury, particularly to the popliteal artery. The definitive next step in evaluation is a CT angiography (CTA) to confirm the presence and level of arterial injury.

Question 67

A 45-year-old water polo player undergoes arthroscopic repair of a Type II SLAP tear. Which of the following describes the primary mechanism responsible for this injury in overhead athletes?

Explanation

In overhead athletes, Type II SLAP tears are primarily caused by the 'peel-back' mechanism. During the late cocking phase (maximum abduction and external rotation), the biceps vector shifts posteriorly, transmitting torsional force that peels the superior labrum off the glenoid.

Question 68

A 20-year-old female runner has recurrent lateral patellar instability. CT imaging demonstrates a tibial tubercle-trochlear groove (TT-TG) distance of 24 mm with normal patellar height. Alongside MPFL reconstruction, which additional procedure is most indicated?

Explanation

A TT-TG distance greater than 20 mm is generally considered pathologic and a risk factor for patellar instability. A medializing tibial tubercle osteotomy (e.g., Fulkerson or Elmslie-Trillat) is indicated to correct this abnormal extensor mechanism vector.

Question 69

A 24-year-old soccer player sustains a high ankle sprain. On examination, he has a positive squeeze test and external rotation stress test. Which ligament is the primary restraint to anterior translation of the distal fibula relative to the tibia?

Explanation

The anterior inferior tibiofibular ligament (AITFL) is the most commonly injured structure in a syndesmotic 'high ankle' sprain. It serves as the primary restraint to anterior translation and external rotation of the distal fibula.

Question 70

A 23-year-old male athlete presents with a focal, symptomatic 4.5 cm squared osteochondral defect on the medial femoral condyle. MRI reveals 6 mm of subchondral bone loss. Which of the following is the most appropriate surgical treatment?

Explanation

For large osteochondral defects (>2-3 cm squared) involving significant subchondral bone loss, Osteochondral Allograft Transplantation (OCA) is the treatment of choice. MACI and ACI are indicated for large purely chondral defects without deep bony involvement.

Question 71

Which bundle of the posterior cruciate ligament (PCL) is considered the primary restraint to posterior tibial translation at 90 degrees of knee flexion?

Explanation

The PCL consists of two main bundles: the anterolateral (AL) and posteromedial (PM) bundles. The anterolateral bundle is thicker, stronger, and tightens in flexion, making it the primary restraint to posterior translation at 90 degrees.

Question 72

A 35-year-old water skier falls and sustains a proximal hamstring avulsion. The tear involves the 'conjoined tendon' of the hamstring complex. Which muscles form this specific tendinous structure at the ischial tuberosity?

Explanation

The conjoined tendon of the proximal hamstring complex consists of the long head of the biceps femoris and the semitendinosus. The semimembranosus has a distinct, more lateral and anterior footprint on the ischial tuberosity.

Question 73

A 30-year-old professional basketball player suffers an acute Achilles tendon rupture. When discussing operative versus non-operative management utilizing early functional rehabilitation, what does the current evidence suggest regarding outcomes?

Explanation

Recent high-level evidence shows that non-operative management with early functional weight-bearing rehabilitation protocols yields re-rupture rates equivalent to surgical repair, while avoiding surgical risks like infection and wound breakdown.

Question 74

A 28-year-old female runner complains of deep anterior hip pain. An AP pelvic radiograph demonstrates the 'crossover sign'. This radiographic finding is indicative of which pathoanatomical condition?

Explanation

The crossover sign occurs when the anterior wall of the acetabulum crosses lateral to the posterior wall on an AP pelvis radiograph. It is the hallmark radiographic sign of focal or global acetabular retroversion, a form of pincer impingement.

Question 75

A 20-year-old cyclist sustains a displaced midshaft clavicle fracture. Which of the following radiographic parameters is the strongest indication for operative fixation to prevent nonunion and functional deficit?

Explanation

Shortening of the clavicle greater than 2 cm alters the shoulder girdle mechanics and significantly increases the risk of symptomatic nonunion and persistent weakness, making it a strong indication for operative fixation.

Question 76

During a physical examination of a patient with suspected anterior shoulder instability, the examiner applies a posterior-directed force to the humeral head while the arm is abducted to 90 degrees and externally rotated. A sudden release of the posterior force reproduces the patient's apprehension. What is this test called?

Explanation

The Surprise test (or anterior release test) is performed after the Jobe relocation test by abruptly removing the posterior stabilizing force. A positive test is the return of apprehension and is highly specific for anterior instability.

Question 77

A 19-year-old female undergoes medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. Postoperatively, she reports severe medial knee pain and stiffness in flexion. Radiographs indicate that the femoral tunnel is positioned too proximal and anterior relative to Schöttle's point. What is the primary biomechanical consequence of this specific graft malposition?

Explanation

Femoral tunnels placed too proximal and anterior to Schöttle's point result in a graft that becomes excessively tight in flexion. This limits knee flexion and drastically increases medial patellofemoral contact pressures.

Question 78

A 24-year-old hockey player undergoes hip arthroscopy for symptomatic femoroacetabular impingement (FAI). During osteochondroplasty of the cam lesion at the head-neck junction, the surgeon must be careful to avoid over-resection. Resecting more than what percentage of the femoral neck diameter substantially increases the risk of a post-operative femoral neck fracture?

Explanation

Biomechanical studies have demonstrated that resecting more than 30% of the femoral neck diameter during cam osteochondroplasty significantly decreases the load-to-failure. This greatly increases the risk of an iatrogenic femoral neck fracture.

Question 79

A 22-year-old collegiate baseball pitcher is undergoing ulnar collateral ligament (UCL) reconstruction. Which specific component of the UCL is the primary restraint to valgus stress during the late cocking phase of throwing, and what are its correct anatomical attachments?

Explanation

The anterior band of the anterior bundle of the UCL is the primary restraint to valgus stress between 30 and 120 degrees of flexion. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle of the ulna.

Question 80

A 62-year-old male laborer presents with a massive, irreparable posterosuperior rotator cuff tear without glenohumeral arthritis (Hamada Grade 1). A lower trapezius tendon transfer is planned to restore external rotation. Which nerve provides the primary motor innervation to the muscle being transferred?

Explanation

The lower trapezius is innervated by the spinal accessory nerve (Cranial Nerve XI). It is increasingly utilized for tendon transfers in irreparable posterosuperior rotator cuff tears due to its favorable line of pull that mimics the infraspinatus.

Question 81

You are performing a double-bundle posterior cruciate ligament (PCL) reconstruction using an Achilles tendon allograft. To accurately recreate native knee biomechanics, how should the anterolateral (AL) and posteromedial (PM) bundles be tensioned during graft fixation?

Explanation

The native anterolateral (AL) bundle is taut in flexion, whereas the posteromedial (PM) bundle is taut in extension. Therefore, during double-bundle reconstruction, the AL bundle is fixed at 90 degrees of flexion and the PM bundle is fixed in near full extension.

Question 82

During an acute anterior cruciate ligament (ACL) reconstruction in a 25-year-old athlete, a peripheral tear of the posterior horn of the medial meniscus at the meniscocapsular junction (Ramp lesion) is identified. What is the primary biomechanical consequence of leaving this lesion unrepaired?

Explanation

Ramp lesions disrupt the posterior medial meniscocapsular attachments, which act as important secondary restraints to anterior tibial translation. Failure to repair them during ACL reconstruction leads to significantly increased anterior tibial translation and persistent pivot-shift kinematics.

Question 83

A 28-year-old overhead athlete undergoes repair of a type II SLAP tear. Six months postoperatively, he presents with severe stiffness and a clinically significant loss of external rotation with the arm at the side. Entrapment or overtightening of which capsuloligamentous structure during the anchor placement is most likely responsible?

Explanation

Loss of external rotation after a SLAP repair is frequently caused by placing anchors too far anteriorly to the biceps root. This inadvertently captures and overtightens the superior glenohumeral ligament (SGHL) and the anterosuperior capsule.

Question 84

A 30-year-old cyclist sustains an acute Type V acromioclavicular (AC) joint dislocation and undergoes anatomical reconstruction using a free tendon graft. To accurately recreate the native coracoclavicular (CC) ligaments, what is the correct orientation of the clavicular bone tunnels?

Explanation

The native conoid ligament inserts on the posteromedial aspect of the distal clavicle, while the trapezoid ligament inserts more anterolaterally. Anatomical reconstruction techniques mirror this native footprint orientation to optimize biomechanical stability.

Question 85

A 35-year-old male sustains a traumatic knee dislocation resulting in ACL, PCL, and posterolateral corner (PLC) tears (Schenck KD III-L). He has normal distal pulses (ABI > 0.9) but exhibits a dense, complete foot drop. What is the most appropriate management regarding his peroneal nerve injury during his planned multiligament knee reconstruction at 3 weeks post-injury?

Explanation

In a multiligament knee injury with concomitant peroneal nerve palsy, exploration and neurolysis are indicated at the time of the PLC reconstruction to assess the zone of injury and prevent local tethering. Definitive repair, grafting, or nerve transfers are typically delayed if function fails to return after several months.

Question 86

A 21-year-old basketball player presents with a 4.5 cm² full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle. He has failed conservative management and requires surgical intervention. Which of the following procedures is most appropriate to provide hyaline-like cartilage for a defect of this magnitude?

Explanation

Autologous chondrocyte implantation (ACI) is indicated for large (> 2-3 cm²), symptomatic full-thickness chondral defects in young, active patients, and it has been proven to regenerate hyaline-like cartilage. Microfracture and OATS are generally reserved for smaller defects (< 2 cm²).

Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

Orthopedic Sport Review | Dr Hutaif Sports Medicine Rev -...

Key Takeaway

Orthopedic Sport Review | Dr Hutaif Sports Medicine Rev -...

Chapter Index