2016 Sports Medicine

Self-Assessment Examination

للاب يجار

 

 

Figure 1a	Figure 1b
Figure 2a	Figure 2b

 

CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 2

A 16-year-old boy fell while playing soccer. He said it felt like his knee buckled when he planted his leg to kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.” He could not finish the game, but was able to bear weight with a limp. He had 2 similar past episodes, but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of motion, and patella apprehension. A lateral patellar glide performed at 30 degrees of flexion was 3+. He was otherwise ligamentously stable, and there were no other noteworthy findings.

 

Question 1 of 100

What do Figures 1a and 1b reveal?

1. Medial femoral condyle physeal widening

2. An ossseous or osteochondral loose fragment

3. Osgood-Schlatter disease

4. A patella nondisplaced fracture

 

PREFERRED RESPONSE: 2- An ossseous or osteochondral loose fragment

 

Question 2 of 100

Figures 2a and 2b are this patient’s proton density fat-saturated MR images. His tibial tubercle-trochlear groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this stage should include

1. hinged knee bracing, protected weight bearing, and physical therapy.

2. anteromedialization of the tibial tubercle.

3. internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

4. arthroscopic lateral retinacular release.

 

PREFERRED RESPONSE: 3- internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

 

 

DISCUSSION

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

 

Question 3 of 100

Heat transfer from the skin to the environment when the ambient temperature exceeds 35°C primarily is attributable to

1. evaporation.

2. conduction.

3. convection.

4. radiation.

 

PREFERRED RESPONSE: 1- evaporation.

 

DISCUSSION

Heat transfer from the skin to the environment occurs through conduction, convection, evaporation, and radiation. Evaporation of sweat is the primary mechanism by which core body temperature is regulated when the ambient temperature exceeds 35°C. High humidity can inhibit the evaporation of sweat, placing athletes at increased risk for heat-related illness, which is defined as a core temperature above 40°C. Symptoms include dizziness, confusion, irritability, hyperventilation, nausea, vomiting, fatigue, and collapse. Initial treatment involves rapid cooling through immersion in cold or ice water to prevent end-stage organ failure.

 

Question 4 of 100

Which factor increases the success rate associated with all-inside lateral meniscal repair?

1. Concomitant anterior cruciate ligament (ACL) reconstruction

2. Concomitant medial meniscus repair

    

    

3. Older patient age

4. Varus knee alignment

 

PREFERRED RESPONSE: 1- Concomitant anterior cruciate ligament (ACL) reconstruction

 

DISCUSSION

Decreased patient age, neutral alignment, and a concomitant ACL tear are associated with improved success rates of meniscal repair. Meniscus tears on the contralateral side of the knee and articular cartilage defects are not associated with improved healing rates.

 

RESPONSES FOR QUESTIONS 5 THROUGH 6

1. Physical therapy and a home exercise program

2. Corticosteroid injection

3. Arthroscopic debridement

4. Microfracture

5. Osteochondral autograft transplantation (OAT)

Match the treatment above with the clinical scenario below

 

Question 5 of 100

A 16-year-old female basketball player has a 4-week history of anterior knee pain during practice. She also notes pain while sitting at her desk in class and pain while going down stairs. An examination reveals mild patellofemoral crepitus with no patellar apprehension and normal patellar tracking. Radiographs are unremarkable. MR imaging reveals no chondral or osteochondral lesions of the patella or trochlear groove.

1. Physical therapy and a home exercise program

2. Corticosteroid injection

3. Arthroscopic debridement

4. Microfracture

5. Osteochondral autograft transplantation (OAT)

 

 

PREFERRED RESPONSE: 1- Physical therapy and a home exercise program

 

Question 6 of 100

A 20-year-old college soccer player comes for an evaluation 6 months after an injury during which he landed awkwardly from a jump. Although physical therapy, ice, and activity modification have helped him return to baseline motion, strength, and swelling, he continues to have lateral knee pain. He also notes a popping sensation on the lateral side of his knee with activity. A Lachman test, anterior and posterior drawer tests, a pivot shift test, and McMurray test findings are all negative. MR images reveal a 12-mm x 15-mm osteochondral defect in the lateral femoral condyle with full-thickness cartilage loss and approximately 4 mm of subchondral bone loss.

1. Physical therapy and a home exercise program

2. Corticosteroid injection

3. Arthroscopic debridement

4. Microfracture

5. Osteochondral autograft transplantation (OAT)

 

PREFERRED RESPONSE: 5- Osteochondral autograft transplantation (OAT)

 

DISCUSSION

Patellofemoral pain in a young athlete without patellar instability or a chondral or osteochondral defect often can be managed with nonsurgical treatment such as physical therapy and a home exercise program. Microfracture surgery is associated with good short-term results for younger athletes. Patients with no history of prior surgery, primary chondral rather than osteochondral lesions, and lesions smaller than 2 cm have experienced the best results. Microfracture surgery performed for chondral lesions of the central aspect of the medial femoral condyle is associated with worse results. Decreased activity levels over time of patients who undergo microfracture surgery are a concern. OAT provides good outcomes and return-to-sports rates for athletic people who are younger and have lesions smaller than 2 cm. Patients with lesions on the lateral femoral condyle have better success rates. Both microfracture surgery and OAT provide better results for chondral defects than osteochondral defects. OAT is associated with better results than microfracture for medium-sized lesions between 2 cm and 4 cm, while autologous chondrocyte implantation yields better improvement for patients with defects larger than 4 cm. All of the surgical techniques listed for articular cartilage repair are associated with better outcomes for patients younger than age 30.

 

 

Figure 7

 

 

Question 7 of 100

Figure 7 is the MR image of a 43-year-old man who has left shoulder pain with a traumatic rotator cuff tear after a fall. An examination reveals active forward elevation at 120 degrees and positive Yergason and lift-off test results. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

1. Rotator cuff repair and biceps tenodesis

2. Rotator cuff repair and loose body removal

3. Latissimus dorsi transfer

4. Bankart repair

 

PREFERRED RESPONSE: 1- Rotator cuff repair and biceps tenodesis

 

DISCUSSION

 

 

Video 7 for reference

 

 

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.

The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

 

Question 8 of 100

Augmentation of a Broström repair with the mobilized lateral portion of the extensor retinaculum (Gould modification) is expected to produce

1. higher risk for iatrogenic nerve injury.

2. decreased ankle range of motion 6 weeks after surgery.

3. no significant biomechanical difference in initial ankle stability.

4. a significantly lower incidence of osteoarthritis on long-term follow-up.

 

PREFERRED RESPONSE: 3- no significant biomechanical difference in initial ankle stability.

 

DISCUSSION

 

 

Multiple biomechanical studies have investigated the contribution of the Gould modification with the Broström anatomic repair for chronic ankle instability. No studies to date have demonstrated a statistically significant difference in initial ankle stability with inclusion of the Gould modification or augmentation of the repair with a mobilized lateral portion of the extensor retinaculum. No clear association exists between the Broström-Gould repair technique and risk for nerve injury, postsurgical range of motion, or incidence of osteoarthritis on long-term follow-up.

 

 

 

 

Figure 9

 

CLINICAL SITUATION FOR QUESTIONS 9 THROUGH 13

Figure 9 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding.

 

Question 9 of 100

The injured structure is composed of an

1. anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.

2. anterolateral bundle that is tight in extension and a posteromedial bundle that is tight in flexion.

    

    

3. anteromedial bundle that is tight in flexion and a posterolateral bundle that is tight in extension.

4. anteromedial bundle that is tight in extension and a posterolateral bundle that is tight in flexion.

 

PREFERRED RESPONSE: 1- anterolateral bundle that is tight in flexion and a posteromedial bundle that is tight in extension.

 

Question 10 of 100

Left untreated, injury to this structure most likely will lead to degenerative changes in

1. medial and lateral compartments.

2. medial and patellofemoral compartments.

3. lateral and patellofemoral compartments.

4. the patellofemoral compartment only.

 

PREFERRED RESPONSE: 2- medial and patellofemoral compartments.

 

Question 11 of 100

If the patient chooses surgical reconstruction, he should be advised that, when compared to a transtibial technique, the tibial inlay technique has been shown to provide

1. stronger initial graft fixation.

2. more anatomic positioning of tibial fixation.

3. more natural knee kinematics during deep flexion.

4. more graft protection during cyclic loading.

 

PREFERRED RESPONSE: 4- more graft protection during cyclic loading.

 

Question 12 of 100

 

 

This patient elects nonsurgical treatment and later experiences persistent instability. Examination reveals an asymmetric Dial test finding and a varus thrust during ambulation. Which osteotomy and correction appropriately addresses this chronic instability pattern?

1. Distal femoral/opening lateral wedge osteotomy

2. Distal femoral/closing lateral wedge osteotomy

3. High tibial osteotomy; opening medial wedge with increased tibial slope

4. High tibial osteotomy; closing lateral wedge with decreased tibial slope

 

YOUR RESPONSE: 4- High tibial osteotomy; closing lateral wedge with decreased tibial slope

 

Question 13 of 100

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

1. accessory incisions.

2. use of tapered drill bits.

3. use of oscillating drills.

4. greater knee extension.

 

PREFERRED RESPONSE: 4- greater knee extension.

 

DISCUSSION

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, 1 major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading.

In Question 12, the scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-

 

 

producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag.

Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

 

Question 14 of 100

A patient underwent a right hip arthroscopy, CAM resection, and labral repair while positioned supine on a fracture table with a perineal post. The leg was in traction for 4 hours, and no intrasurgical complications were noted. At the 2-week follow-up appointment, the patient was experiencing numbness and tingling in the perineum on the surgical side and noted pain predominantly while sitting. What is the likely cause of these symptoms?

1. Traction injury to the sciatic nerve

2. Traction injury to the femoral nerve

3. Compression injury to the pudendal nerve

4. Direct injury to the lateral femoral cutaneous nerve

 

PREFERRED RESPONSE: 3- Compression injury to the pudendal nerve

 

DISCUSSION

Although all of these responses are known complications related to hip arthroscopy, the symptoms of perineal numbness and pain associated with prolonged traction time indicate a compression injury to the pudendal nerve against the perineal post used to provide counter traction. Perineal numbness usually occurs on the surgical side, with pain in the area of the anus to the penis/clitoris. Pain is predominantly experienced while sitting, but is relieved when sitting on a toilet. Pain can be relieved with a diagnostic pudendal nerve block. This injury is not unique to hip arthroscopy; it also is described in the trauma literature. To prevent compression-type injuries, a well-padded post larger than 9 cm in diameter should be positioned against the medial thigh. Traction force should be kept to a minimum and the

 

 

extremity positioned in slight abduction. Continuous traction time should not exceed 2 hours, with intermittent traction used during prolonged procedures.

 

Figure 15a	Figure 15b

 

Question 15 of 100

Figures 15a and 15b are intrasurgical photographs from the posterolateral viewing portal that were taken at the beginning and end of a right shoulder arthroscopic procedure performed on a 54-year-old man. This technique demonstrates superior results compared to traditional arthroscopic techniques when evaluating which outcome?

1. Time to healing

2. Retear rate

3. Functional outcome scores

4. Postsurgical pain scores

 

PREFERRED RESPONSE: 2- Retear rate

 

DISCUSSION

The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the 2 techniques.

 

 

 

 

Figure 16

 

CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 17

Figure 16 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop," and then he needed help walking off the field. His knee is visibly swollen.

 

Question 16 of 100

Knee range of motion is between 0 degrees and 70 degrees. What is the most appropriate treatment option?

1. Open reduction and internal fixation of the lateral condyle

2. Microfracture of the chondral defect

3. Immediate anterior cruciate ligament (ACL) reconstruction

4. Delayed ACL reconstruction

 

PREFERRED RESPONSE: 4- Delayed ACL reconstruction

 

Question 17 of 100

 

 

The patient has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they “want to get the therapy over with as fast as possible” to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared to nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

1. increased laxity.

2. increased risk for graft failure.

3. no differences in long-term results.

4. lower Knee Injury and Osteoarthritis Outcome Scores (KOOS).

 

PREFERRED RESPONSE: 3- no differences in long-term results.

 

DISCUSSION

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibia plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated vs nonaccelerated rehabilitation programs have demonstrated no significant differences in longterm results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

 

Question 18 of 100

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side, but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

1. Calcified transverse scapular ligament

2. Parsonage-Turner syndrome

3. Spinoglenoid notch cyst

4. Quadrilateral space syndrome

 

 

PREFERRED RESPONSE: 3- Spinoglenoid notch cyst

 

DISCUSSION

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

 

Figure 19a	Figure 19b

 

Question 19 of 100

A 25-year-old woman has lower leg pain during exercise without numbness, tingling, or weakness. The symptoms resolve by the following day. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19a (Table 1). She undergoes anterior compartment fasciotomy with complete resolution of symptoms. Two years later, she has recurrent pain and tightness with exercise. Radiographs, a technetium bone scan, and noninvasive vascular study findings are normal. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19b (Table 2). What is the most likely etiology for her recurrent symptoms?

1. Misdiagnosis

2. Hematoma formation

3. Postsurgical fibrosis

4. Failure to recognize involvement of other compartments

 

 

PREFERRED RESPONSE: 3- Postsurgical fibrosis

 

DISCUSSION

Exertional compartment syndrome involves an increase in compartment pressure caused by exercise or sports activity that restricts blood flow in the compartment, resulting in pain with continued activity. Compartment pressures of at least 15 mm Hg measured at rest, at least 30 mm Hg measured 1 minute after exercise, and at least 20 mm Hg measured 5 minutes after exercise are diagnostic. Surgical fasciotomy for exertional compartment syndrome is successful for the majority of patients, but recurrence rates as high as 20% have been reported. Scar formation within the fascial defect can result in recurrent symptoms and/or nerve entrapment, and recurrence is typically observed after an initial symptom-free period. In a series of 18 patients, recurrent symptoms occurred at a mean of 23.5 months after the index procedure. Other potential causes of recurrence include inadequate fascial release, failure to recognize involvement of other compartments, nerve compression, and misdiagnosis. Surgical complications after fasciotomy include hemorrhage leading to excessive fibrosis, neurovascular injury, and hematoma or seroma formation.

 

Question 20 of 100

A 16-year-old swimmer has right shoulder pain with activity. She describes the continued sensation that her shoulder is “loose.” She has been in physical therapy for 7 months to work on strengthening the muscles around her shoulder and scapula. She denies being able to voluntarily dislocate her shoulder. Upon examination, you can feel the humeral head slide over the glenoid rim both anteriorly and posteriorly with the load and shift test. She has a grade III sulcus sign. What is the most appropriate next step?

1. Arthroscopic superior labrum anterior to superior repair

2. Arthroscopic Bankart repair

3. Latarjet procedure

4. Capsulorrhaphy

 

PREFERRED RESPONSE: 4- Capsulorrhaphy

 

DISCUSSION

Nonsurgical treatment with activity modification and physical therapy is generally considered the first-line approach for young athletes with multidirectional instability (MDI) of the shoulder. Physical therapy focuses on exercises to strengthen the scapular stabilizers and rotator cuff muscles and restore scapulohumeral rhythm. Although a definitive length of time

 

 

to assess physical therapy failure is not known, many surgeons believe that a patient with MDI should undergo at least 6 months of physical therapy and activity modification before considering surgery. Although an open inferior capsular shift has historically been considered the gold standard for surgical treatment for MDI, studies have shown good success rates for arthroscopic capsulorrhaphy. Arthroscopy can allow a surgeon to assess all intra-articular structures and address a patient’s particular problem based on arthroscopic findings.

 

Figure 24a	Figure 24b

 

CLINICAL SITUATION FOR QUESTIONS 21 THROUGH 25

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow.

 

Question 21 of 100

 

 

Which type of contraction of the involved muscle most likely resulted in this lineman's injury?

1. Eccentric

2. Concentric

3. Isometric

4. Isokinetic

 

PREFERRED RESPONSE: 1- Eccentric

 

Question 22 of 100

The most substantial functional deficit that may develop if no surgical treatment is provided is

1. elbow flexion strength.

2. elbow supination strength.

3. lack of terminal extension at the elbow.

4. decrease of elbow pronation strength.

 

PREFERRED RESPONSE: 2- elbow supination strength.

 

Question 23 of 100

The athlete decides to undergo surgery. Which complication is most commonly associated with surgical repair of this injury?

1. Posterior interosseous nerve (PIN) palsy

2. Infection

3. Lateral antebrachial cutaneous neuropraxia (LABCN)

4. Symptomatic heterotopic ossification

 

PREFERRED RESPONSE: 3- Lateral antebrachial cutaneous neuropraxia (LABCN)

 

 

Question 24 of 100

The athlete undergoes repair of the injury, and postsurgical radiographs are shown in Figures 24a and 24b. At his first postsurgical visit he reports no pain but describes weakness in his hand and decreased sensation over his lateral forearm. Upon examination, he has decreased 2-point discrimination over the lateral forearm and an inability to actively extend his thumb and fingers at the metacarpophalangeal joints. He can extend at the finger interphalangeal joints. He can extend his wrist weakly, and it deviates radially as he extends. His distal sensation is intact. Considering his examination findings, which 2 nerves are injured?

1. PIN and radial nerve

2. PIN and LABCN

3. Median nerve and LABCN

4. Radial nerve and LABCN

 

PREFERRED RESPONSE: 2- PIN and LABCN

 

Question 25 of 100

After the athlete undergoes the appropriate treatment of the postsurgical complication and recovers without further incident, which muscle most likely will be last to experience return of function?

1. Extensor indicis proprius (EIP)

2. Extensor digiti quinti (EDQ)

3. Extensor digitorum communis (EDC)

4. Extensor carpi ulnaris (ECU)

 

PREFERRED RESPONSE: 1- Extensor indicis proprius (EIP)

 

DISCUSSION

This patient sustained an eccentric contracture (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors have the highest

 

 

potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed.

The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared to the 2-incision technique. The most troubling complication for most surgeons is the development of a PIN palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABC nerve injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button.

Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The EIP is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC followed by the ECU, EDQ, and, finally, the EIP.

 

RESPONSES FOR QUESTIONS 26 THROUGH 27

1. Anterior tibial artery

2. Posterior tibial artery

3. Superficial peroneal nerve

4. Deep peroneal nerve

Match the neurovascular structure at risk (listed above) with the compartment undergoing fasciotomy (listed below).

 

Question 26 of 100

Lateral compartment

1. Anterior tibial artery

2. Posterior tibial artery

3. Superficial peroneal nerve

4. Deep peroneal nerve

 

PREFERRED RESPONSE: 3- Superficial peroneal nerve

 

Question 27 of 100

Deep posterior compartment

1. Anterior tibial artery

2. Posterior tibial artery

3. Superficial peroneal nerve

4. Deep peroneal nerve

 

PREFERRED RESPONSE: 2- Posterior tibial artery

 

DISCUSSION

The structures at risk are the anterior tibial artery and deep peroneal nerve in the anterior compartment, superficial peroneal nerve in the lateral compartment, sural nerve in the superficial posterior compartment, and posterior tibial nerve and posterior tibial and peroneal arteries and veins in the deep posterior compartment.

 

Figure 28a	Figure 28b

 

Question 28 of 100

Figures 28a and 28b are the MR images of a 30-year-old man who has right shoulder pain and difficulty throwing a football. His history includes a shoulder injury from a skiing accident 2 years ago. He has not had a recent shoulder injury. Which shoulder motion is most likely to demonstrate weakness?

1. Shoulder abduction

2. Shoulder internal rotation

3. Shoulder external rotation

4. Shoulder adduction

 

PREFERRED RESPONSE: 3- Shoulder external rotation

 

DISCUSSION

Figure 29

 

The MR images reveal a large paralabral cyst extending into the spinoglenoid notch. This cyst can be expected to compress the branch of the suprascapular nerve to the infraspinatus. Compression of this branch could lead to weakness in the infraspinatus, which would manifest as external rotation weakness. Shoulder abduction would be unaffected because the axillary and main suprascapular nerves would be intact. Shoulder internal rotation and adduction would be unaffected because the subscapularis and pectoralis would be unaffected.

 

 

 

 

 

Question 29 of 100

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. Which phase of the throwing cycle shown in Figure 29 will most likely reproduce his symptoms?

1. B

2. C

3. D

4. E

 

PREFERRED RESPONSE: 2- C

 

DISCUSSION

This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle. In windup, very little elbow torque is required. In early cocking, the arm is getting loaded, and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

 

CLINICAL SITUATION FOR QUESTIONS 30 THROUGH 33

A 42-year-old man has a 4-month history of right shoulder pain. He denies any specific injury that initiated his symptoms. He says that his pain is worse when reaching overhead or lifting an object across his body. He describes his pain as being located along the front of his shoulder, although he occasionally feels the pain on the side of his neck. Upon examination, you find mild tenderness to palpation at his acromioclavicular (AC) joint. Radiographs show osteophytes and narrowing of the AC joint.

 

Question 30 of 100

Which examination test is most specific for pain related to AC joint osteoarthritis?

1. Pain when the shoulder is brought into 90 degrees of forward flexion and maximal adduction across the body

2. Pain when the shoulder is brought into 90 degrees of forward flexion while you internally rotate the shoulder

3. Pain when the shoulder is brought into forward elevation while your hand stabilizes the scapula

    

    

4. Pain when the patient resists downward pressure while the arm is in 90 degrees of abduction and in the scapular plane

 

PREFERRED RESPONSE: 1- Pain when the shoulder is brought into 90 degrees of forward flexion and maximal adduction across the body

 

Question 31 of 100

The patient inquires about nonsurgical treatment for his AC joint arthritis. You should advise him that

1. physical therapy is of little use because of his substantial degenerative changes.

2. a corticosteroid injection may help to control symptoms, although access to the joint is challenging.

3. 4 weeks of sling immobilization will likely provide the best long-term relief of symptoms.

4. he should strongly consider surgical treatment because nonsurgical options rarely provide relief.

 

PREFERRED RESPONSE: 2- a corticosteroid injection may help to control symptoms, although access to the joint is challenging.

 

Question 32 of 100

What is the most common complication associated with distal clavicle resection for AC joint osteoarthritis?

1. AC joint instability

2. Persistent pain

3. Nerve injury

4. Arthritis recurrence

 

PREFERRED RESPONSE: 2- Persistent pain

 

Question 33 of 100

 

 

After performing an open distal clavicle excision and resecting 15 mm of distal clavicle, which potential concern for shoulder function could result?

1. Persistent pain attributable to inadequate resection

2. Complex regional pain syndrome

3. Fracture

4. AC joint instability

 

PREFERRED RESPONSE: 4- AC joint instability

 

DISCUSSION

AC joint arthritis often is marked by pain along the anterior and superior aspects of the shoulder. It can occasionally radiate into the trapezius and the anterolateral neck region. A patient may have tenderness to palpation directly at the AC joint or pain with the cross-body adduction stress test and the O'Brien active compression test. During the cross-body adduction test, this patient has pain when the examiner lifts his arm in 90 degrees of forward flexion and maximally adducts it across his body. Although the cross-body adduction test is the most sensitive provocative test for AC joint osteoarthritis at 77%, the O’Brien active compression test has been shown to be most specific at 95%.

Physical therapy, rest, activity modification, and other nonsurgical treatments might not reverse osteoarthritis changes at the AC joint, but these interventions can often help improve pain, range of motion, and function. A corticosteroid injection into the AC joint may be an option if nonsurgical treatments do not work, although Wasserman and associates demonstrated that only 44% of AC joint injections accurately entered the joint.

Persistent pain is the most common complication following distal clavicle excision. Although the exact amount of distal clavicle that should be resected is a topic of debate, resection of 10 mm or more of the distal clavicle may lead to instability of the AC joint, especially if the AC capsule is sectioned.

 

 

 

 

Figure 34

 

Question 34 of 100

making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice a “clunk” within the knee. What is the most likely biomechanical basis for the “clunk”?

1. In extension with internal rotation/valgus force, the medial tibial plateau is subluxated; with flexion, the medial tibial plateau reduces

2. In extension with internal rotation/valgus force, the medial tibial plateau is reduced; with flexion, the medial tibial plateau subluxates

3. In extension with internal rotation/valgus force, the lateral tibial plateau is reduced; with flexion, the lateral plateau subluxates

4. In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces

 

PREFERRED RESPONSE: 4- In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces

 

DISCUSSION

 

 

This patient sustained an isolated anterior cruciate ligament (ACL) injury based upon the mechanism described and examination findings. The finding that produces the “clunk” is the pivot-shift maneuver, which is positive in a knee with an incompetent ACL. With an ACL-deficient knee in full extension and internal rotation, the lateral tibial plateau subluxates anteriorly. As the knee is flexed, the lateral tibial plateau slides posteriorly into a reduced position, causing an audible clunk. Response 4 correctly describes the pathomechanics that result in the audible clunk heard during the pivot-shift maneuver. Responses 1 and 2 are incorrect because they describe the medial tibial plateau, which is not part of the pathomechanics of the pivot shift. Response 3 is incorrect because in extension, the lateral tibial plateau is subluxated, not reduced.

 

 

 

 

Figure 35

 

Question 35 of 100

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

1. Arthroscopic or open reduction and internal fixation with possible bone grafting

2. Arthroscopic chondroplasty

3. No weight-bearing activity for 6 weeks and then re-evaluate

4. Retrograde subchondral drilling without fixation

 

 

 

PREFERRED RESPONSE: 1- Arthroscopic or open reduction and internal fixation with possible bone grafting

 

DISCUSSION

The MR image shows an osteochondritis dissecans (OCD), which is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help to identify the lesion and establish the physes status. MRI is useful for assessing potential for the lesion to heal with nonsurgical treatment. This lesion is unstable, considering the fluid line between the OCD and the underlying normal bone. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary to address unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular surface restored whenever possible.

 

Question 36 of 100

A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). He plans a 60-degree anteromedialization to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?

1. Grade III chondrosis of the proximal patella

2. Caton-Deschamps ratio of 1:1

3. Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm

4. Q angle of 17 degrees

 

PREFERRED RESPONSE: 1- Grade III chondrosis of the proximal patella

 

DISCUSSION

TTO is a common treatment for patellofemoral instability. The angle of correction must be customized to each patient’s anatomy. For this patient, the orthopaedic surgeon plans an osteotomy that will both anteriorize and medialize the tubercle. This will consistently result in

 

 

a change of patellofemoral kinematics and contact pressures. Medialization decreases lateral and increases medial patellofemoral contact pressures, and anteriorization shifts contact pressures from distal to proximal. Significant anteriorization may not be desired in a patient with proximal patellar chondrosis unless a concomitant chondral procedure is performed as well. The patellar height (Caton-Deschamps ratio) is normal, precluding the need for distalization but not medialization. The TT-TG distance, at more than 20 mm, is a strong indication for osteotomy. The Q angle, although a less precise indicator of malalignment, is also elevated and would be considered an indication for osteotomy.

 

Figure 39a	Figure 39b

 

 

Figure 39c	Figure 39d

 

 

Figure 40a

Figure 40b

 

CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 41

A healthy, active 18-year-old man has acute-onset right knee pain and an inability to fully extend his knee following an attempt to stand from a seated position yesterday. He sustained a noncontact injury to his right knee while playing basketball 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction with bone-patella-tendon-bone autograft and medial meniscus repair. He sustained another noncontact injury to the same knee 8 months later and underwent a revision ACL reconstruction using soft-tissue allograft and revision medial meniscus repair. He reports multiple episodes of “giving way” of his knee, but no pain prior to yesterday’s acute injury.

 

Question 37 of 100

Which risk factor is associated with the highest rate of recurrent ACL rupture following reconstruction?

1. Family history of ACL rupture

2. Patient age

3. Type of graft used

4. A supervised accelerated rehabilitation program

 

PREFERRED RESPONSE: 2- Patient age

 

Question 38 of 100

The patient underwent a primary meniscal repair using a second-generation all-inside meniscal repair system. In the setting of concomitant ACL reconstruction, which medial meniscus repair healing rate is appropriate to quote when use of these devices is discussed?

1- 45%

2- 55%

3- 65%

4- 85%

 

PREFERRED RESPONSE: 4- 85%

 

 

 

Question 39 of 100

Figures 39a through 39d are this patient’s radiographs and sagittal MR images. An examination reveals a painful knee with limited motion from 10 degrees shy of full extension to 100 degrees of knee flexion. He has a positive Lachman test result and negative Dial test result. A pivot shift cannot be performed because of his lack of motion. What is the best next treatment step?

1. Arthroscopic revision ACL reconstruction

2. Arthroscopic revision medial meniscus repair

3. Arthroscopic debridement of a cyclops lesion

4. Arthroscopic-assisted revision ACL reconstruction with partial medial meniscectomy

 

PREFERRED RESPONSE: 4- Arthroscopic-assisted revision ACL reconstruction with partial medial meniscectomy

 

Question 40 of 100

Presurgical radiographs and MR images are shown in Figures 39a through 39d. The patient undergoes a second revision ACL reconstruction with a soft-tissue allograft. Postsurgical radiographs are shown in Figures 40a and 40b. Assuming there is a well-tensioned graft in each scenario, the new tunnel placement likely will result in improvement of which examination maneuver?

1. Dial test

2. Pivot shift

3. Anterior drawer

4. Posterior drawer

 

PREFERRED RESPONSE: 2- Pivot shift

 

Question 41 of 100

The patient returns 4 days after surgery and says he has noticed a red, swollen knee since yesterday. He reports a fever of 38.0°C since last evening and denies traumatic injury. He has an erythematous knee with a large, tense effusion; his range of motion is limited; and the surgical incisions are not draining. Radiographs taken in the office show no change from the

 

 

immediate postsurgical images. Aspiration in the office returns 50 cc of cloudy, blood-tinged synovial fluid, and analysis of the fluid reveals a white blood cell count of 92000 (reference range 4500-11000 /µL). Which bacteria is most commonly responsible for this clinical scenario?

1. Staphylococcus epidermidis

2. Staphylococcus aureus (S. aureus)

3. Propionibacterium acnes (P. acnes)

4. Beta-hemolytic Streptococcus

 

 

 

PREFERRED RESPONSE: 1- Staphylococcus epidermidis DISCUSSION

 

Video 39 for reference

 

 

This patient has a history of failed primary and revision ACL reconstructions, both times with medial meniscus repairs. The clinical scenario suggests a recurrent ACL injury with a recurrent medial meniscus tear that is now locked. The most critical risk factor for ACL reconstruction is age younger than 20 years. The meniscal repair success rate using an all-inside device is between 80% and 90%. Traditionally, it was believed that healing rates were

 

 

higher in ACL reconstruction, but current literature demonstrates a similar rate of healing associated with ACL reconstruction and no reconstruction of stable knees.

The images show a vertical femoral tunnel resulting from this patient’s prior reconstruction and revision. The MR images reveal a locked bucket-handle tear of the medial meniscus, and the examination shows a positive Lachman test finding attributable to ACL graft failure. In the setting of a young individual who has failed 2 meniscal repairs, a third repair is not indicated. In addition to a revision ACL reconstruction to stabilize the knee, a partial medial meniscectomy is indicated. An attempt at revision medial meniscus repair would be indicated if the technique were poor in the first attempt, but a failed repair otherwise should indicate the need for partial meniscectomy. The postsurgical images reveal a much more anatomic position of the femoral tunnel that should provide better rotational control of the knee, thereby improving the pivot shift (compared to the vertical femoral tunnel).

This patient has an obvious postsurgical infection based on the timing, examination, and results of the aspiration. In multiple studies of septic arthritis following ACL reconstruction, the most common pathogen was coagulase-negative staph (Staphylococcus epidermidis), followed by S. aureus. If S. aureus is the causative pathogen, the rate of necessary graft removal is higher because of the aggressive nature of this specific bacteria.

 

Question 42 of 100

Which sterilization method is expected to produce the most degradation of an allograft used for anterior cruciate ligament reconstruction?

1. Deep freezing

2. Supercritical CO2 treatment

3. Gamma irradiation with 1.2 Mrad

4. Chlorhexidine gluconate 4% cleansing

 

PREFERRED RESPONSE: 2- Supercritical CO2 treatment

 

DISCUSSION

A biomechanical study compared unprocessed, irradiated (2.0 Mrad-2.8 Mrad), and supercritical CO2-treated soft-tissue allografts and demonstrated a 27% to 36% decrease in stiffness of the supercritical CO2-treated grafts. No significant difference was found between the irradiated and untreated soft-tissue allografts. Low-dose (1.0 Mrad-1.2 Mrad) gamma irradiation of bone-patellar-tendon-allograft has been shown to produce a 20% decrease in graft stiffness. Deep freezing or cleansing with 4% chlorhexidine gluconate does not appear to adversely affect the biomechanical properties of the allograft tissue.

 

 

 

Figure 43a	Figure 43b

 

CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46

Figures 43a and 43b are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable.

 

Question 43 of 100

Which provocative maneuver is most likely to reproduce pain for this patient?

1. Forward flexion, abduction, and internal rotation

2. Forward flexion, abduction, and external rotation

3. Forward flexion, adduction, and internal rotation

4. Forward flexion, adduction, and external rotation

 

PREFERRED RESPONSE: 3- Forward flexion, adduction, and internal rotation

 

 

Question 44 of 100

Which of the 4 muscles of the rotator cuff provides the most resistance to this patient's direction of instability?

1. Subscapularis

2. Supraspinatus

3. Infraspinatus

4. Teres minor

 

PREFERRED RESPONSE: 1- Subscapularis

 

Question 45 of 100

The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus and Beighton sign findings, and radiographs show 5 degrees of glenoid retroversion. What is the most appropriate surgical plan?

1. Arthroscopic infraspinatus tenodesis

2. Arthroscopic posterior labral repair

3. Arthroscopic capsular shift and rotator interval closure

4. Posterior glenoid opening-wedge osteotomy

 

PREFERRED RESPONSE: 2- Arthroscopic posterior labral repair

 

Question 46 of 100

What is the most likely complication after surgical treatment in this scenario?

1. Recurrent instability

2. Degenerative joint disease

3. Shoulder stiffness

4. Axillary nerve injury

 

PREFERRED RESPONSE: 3- Shoulder stiffness

 

 

 

DISCUSSION

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, and internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through as seen in this patient.

The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The 4 muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the 4 rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation.

This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Brighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion, a posterior opening-wedge osteotomy is appropriate.

The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability and degenerative joint disease.

 

Question 47 of 100

Which study is most useful for diagnosis of exertional compartment syndrome?

1. MRI

2. Arterial Doppler

3. Static compartment pressures

4. Exertional compartment pressures

 

PREFERRED RESPONSE: 4- Exertional compartment pressures

 

 

DISCUSSION

The most sensitive study in the diagnosis of exertional compartment syndrome is intracompartmental pressures taken at rest (compared to pressures taken immediately after exercise). MRI often can reveal nonspecific muscle edema in exertional compartment syndrome, but this is usually not diagnostic. Arterial Doppler studies are usually unremarkable unless they are taken after exercise, in which case these findings may be abnormal.

 

Figure 48a	Figure 48b

Figure 48c	Figure 48d

Figure 48e	Figure 48f

 

CLINICAL SITUATION FOR QUESTIONS 48 THROUGH 50

Figures 48a through 48f reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures.

 

Question 48 of 100

What is the most appropriate treatment?

1. Distal femoral varus osteotomy

2. Autologous chondrocyte implantation (ACI)

3. Fresh osteochondral allograft (OCA) transplantation

4. Arthroscopic microfracture

 

PREFERRED RESPONSE: 3- Fresh osteochondral allograft (OCA) transplantation

 

Question 49 of 100

In comparison to the lamina splendens, the deep zone of hyaline cartilage contains

1. larger-diameter collagen fibrils arranged perpendicular to the joint surface and a higher concentration of proteoglycans.

    

    

2. larger-diameter collagen fibrils arranged parallel to the joint surface and a higher concentration of proteoglycans.

3. smaller-diameter collagen fibrils arranged perpendicular to the joint surface and a lower concentration of proteoglycans.

4. smaller-diameter collagen fibrils arranged parallel to the joint surface and a lower concentration of proteoglycans.

 

PREFERRED RESPONSE: 1- larger-diameter collagen fibrils arranged perpendicular to the joint surface and a higher concentration of proteoglycans.

 

Question 50 of 100

Which factor has the most negative influence on the success of knee osteochondral allograft transplantation?

1. Mechanical axis malalignment

2. Blood-type matching of the host and donor

3. Sex of the donor

4. Failed previous cartilage procedure

 

PREFERRED RESPONSE: 1- Mechanical axis malalignment

 

DISCUSSION

The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would increase the contact pressure in the medial compartment and worsen the situation.

The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface. In contrast, the deep zone contains the largest-diameter

 

 

collagen fibrils, oriented perpendicular to the joint surface, and the highest concentration of proteoglycans.

 

Figure 51a	Figure 51b

 

 

 

 

Video 54 this video is uploaded at

 

CLINICAL SITUATION FOR QUESTIONS 51 THROUGH 54

Figures 51a and 51b are the radiographs of an 18-year-old football linebacker who was involved in a tackle and fell onto an outstretched left arm. He had immediate pain and deformity of his left elbow.

 

Question 51 of 100

Which mechanism of injury across the elbow leads to this type of dislocation?

1. Axial compression, forearm supination, valgus stress

2. Axial compression, forearm supination, varus stress

3. Axial compression, forearm pronation, valgus stress

4. Axial distraction, forearm pronation, varus stress

 

PREFERRED RESPONSE: 1- Axial compression, forearm supination, valgus stress

 

Question 52 of 100

The patient is in the emergency department, and the orthopaedic surgeon is performing a closed reduction under conscious sedation. Following the reduction, what is the most stable position in which to splint the arm to prevent further subluxation?

1. Elbow flexion, supination

    

    

2. Elbow flexion, pronation

3. Elbow extension, supination

4. Elbow extension, pronation

 

PREFERRED RESPONSE: 2- Elbow flexion, pronation

 

Question 53 of 100

The elbow is successfully reduced in the emergency department and placed in a splint.

What is the most appropriate next step in this evaluation?

1. MRI

2. CT scan

3. Electromyography

4. Radiographs

 

PREFERRED RESPONSE: 4- Radiographs

 

Question 54 of 100

No fractures were identified and the patient was treated nonsurgically in a range-of-motion brace. Two months later, he continued to experience elbow pain and was unable to return to sports. He regained motion and strength with physical therapy, there was no gross instability with varus or valgus testing, and he had a negative moving-valgus stress test. The orthopaedic surgeon performed an examination under anesthesia in the operating room (Video 54). Which anatomic structure is injured?

1. Medial ulnar collateral ligament (UCL) (anterior bundle)

2. Medial UCL (posterior bundle)

3. Lateral UCL

4. Annular ligament

 

PREFERRED RESPONSE: 3- Lateral UCL

 

 

DISCUSSION

Ninety percent of elbow dislocations occur in a posterolateral direction. O’Driscoll and associates described the mechanism of injury in posterolateral elbow dislocations in 1992, reporting that they occur most typically after a fall onto an outstretched arm. As the arm hits the ground it causes axial compression, forearm supination, and valgus load across the elbow. The triceps fires, pulling the olecranon posterior; the forearm supinates while simultaneous shoulder internal rotators fire; and the elbow falls into valgus. These 3 mechanisms cause the elbow to subluxate and dislocate posterolaterally. The elbow is most stable following posterolateral dislocation in a flexed and pronated position. The elbow is least stable in extension and supination. Simple dislocation often can be treated nonsurgically, while fracture dislocation will usually necessitate surgical intervention. The video shows the elbow pivot-shift test, which evaluates for posterolateral rotatory instability. A positive test finding elicits apprehension and, in this case, radial head subluxation and confirms an insufficient lateral UCL.

 

Question 55 of 100

A 19-year-old collegiate lacrosse player has bilateral lower extremity pain during training runs and practice sessions. She says her pain is only associated with activity, always begins 4 to 5 minutes into an activity, and resolves within 10 minutes after activity cessation. She reports a feeling of numbness and tingling in her first- and second-toe web space with continued activity. She has no pain while at rest and has tried nonsteroidal anti-inflammatory drugs, ice baths, and rehabilitation techniques with her athletic trainers without experiencing noticeable changes. Which test has the highest specificity and sensitivity for the pathology suspected?

1. MRI of the affected tibia

2. Palpation of the affected leg compartments during activity

3. Compartment pressure monitoring 1 and 5 minutes into the activity

4. Compartment pressure monitoring continuously during the activity

 

PREFERRED RESPONSE: 4- Compartment pressure monitoring continuously during the activity

 

DISCUSSION

Chronic exertional compartment syndrome (CECS) is an uncommon cause of pain that is most often encountered in athletes or military populations. The diagnosis is suggested by pain after the start of the activity with resolution of symptoms when the activity stops. Traditionally, the diagnosis was established by measuring intracompartment pressures at 1 and 5 minutes of

 

 

activity. Roscoe and associates have shown that using continuous pressure monitoring during the activity until pain forces subjects to stop provides higher sensitivity and specificity than the traditional diagnostic technique. Palpating the leg is not as sensitive or specific as direct pressure monitoring. Although certain changes can be seen on MRI in CECS, this is not the diagnostic study of choice.

 

 

 

 

Figure 56

 

Question 56 of 100

Figure 56 is the MR image of a 20-year-old Division I baseball pitcher who has a 1-month history of medial elbow pain in his throwing arm. He also notes a decrease in both control and

 

 

pitching velocity. An examination reveals tenderness at the medial epicondyle that is exacerbated with valgus elbow stress. The strongest indication for ulnar collateral ligament (UCL) reconstruction is

1. progressive ulnar neuropathy.

2. a decision to enter the Major League Baseball (MLB) draft.

3. pain with resisted wrist flexion.

4. failure to improve after prolonged nonsurgical treatment.

 

PREFERRED RESPONSE: 4- failure to improve after prolonged nonsurgical treatment.

 

DISCUSSION

All responses represent findings that may be associated with chronic UCL insufficiency. Responses 1 and 3 reflect injury to the UCL itself. In most patients, particularly young patients, UCL reconstruction should not be considered until an appropriate trial of nonsurgical measures has failed. This trial should include, at a minimum, 6 weeks of throwing abstinence followed by rehabilitation to address pitching mechanics and shoulder motion deficits and core strengthening. Although the decision to enter the MLB draft may influence surgical decision making, a pitcher with a 1-month history of elbow symptoms should attempt nonsurgical therapy before making a surgical decision that is not based on clinical data.

 

Question 57 of 100

A coach of 3 football teams—the B team, junior varsity team, and varsity team—wants to study the average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-yard dash times for the athletes on 1 team are different from those on the other teams?

1. Independent 2-sample t test

2. Analysis of variance (ANOVA)

3. Chi-square test

4. Fisher’s exact test

 

PREFERRED RESPONSE: 2- Analysis of variance (ANOVA)

 

DISCUSSION

 

 

Data collected in research studies fall into 1 of 2 categories—continuous or discrete. Continuous data can be displayed on a curve. Examples include height, weight, and time recorded in a 40-yard dash. Discrete data represent data that fall into specific categories such as gender or the presence or absence of a risk factor.

ANOVA is used to determine statistical significance in mean values of continuous data when there are more than 2 independent samples. The 2-sample t test compares mean values of continuous data between 2 independent groups. The Chi-square test and Fisher's exact tests are tests used to analyze discrete data.

 

RESPONSES FOR QUESTIONS 58 THROUGH 61

1. Paresthesias in the fourth and fifth digits

2. Numbness on the lateral side of the forearm

3. Heterotopic ossification

4. Posterolateral rotatory instability of the elbow

5. Medial antebrachial cutaneous neuroma

For each surgical case described below, match the most likely related complication listed above.

 

Question 58 of 100

2-incision distal biceps repair

1. Paresthesias in the fourth and fifth digits

2. Numbness on the lateral side of the forearm

3. Heterotopic ossification

4. Posterolateral rotatory instability of the elbow

5. Medial antebrachial cutaneous neuroma

 

PREFERRED RESPONSE: 3- Heterotopic ossification

 

Question 59 of 100

Single-incision distal biceps repair

1. Paresthesias in the fourth and fifth digits

2. Numbness on the lateral side of the forearm

    

    

3. Heterotopic ossification

4. Posterolateral rotatory instability of the elbow

5. Medial antebrachial cutaneous neuroma

 

PREFERRED RESPONSE: 2- Numbness on the lateral side of the forearm

 

Question 60 of 100

Arthroscopic lateral epicondylitis debridement

1. Paresthesias in the fourth and fifth digits

2. Numbness on the lateral side of the forearm

3. Heterotopic ossification

4. Posterolateral rotatory instability of the elbow

5. Medial antebrachial cutaneous neuroma

 

PREFERRED RESPONSE: 4- Posterolateral rotatory instability of the elbow

 

Question 61 of 100

Ulnar collateral ligament (UCL) reconstruction using a modified Jobe technique

1. Paresthesias in the fourth and fifth digits

2. Numbness on the lateral side of the forearm

3. Heterotopic ossification

4. Posterolateral rotatory instability of the elbow

5. Medial antebrachial cutaneous neuroma

 

PREFERRED RESPONSE: 1- Paresthesias in the fourth and fifth digits

 

DISCUSSION

Certain complications are more strongly associated with the approach and surgical procedure for elbow pathology. With a 2-incision distal biceps repair, heterotopic ossification

 

 

with a radial-ulnar synostosis is a concern. This complication can be minimized through irrigation of bone debris and care to avoid dissection between the radius and ulna. With a single-incision distal biceps repair, the lateral antebrachial cutaneous nerve is retracted during the procedure. Numbness on the lateral side of the forearm is common, although often temporary. During arthroscopic debridement for lateral epicondylitis, injury to the radial UCL can occur, leading to posterolateral rotatory instability of the elbow. The modified Jobe technique for UCL reconstruction typically involves an ulnar nerve transposition during the procedure. Numbness and tingling in the fourth and fifth digits are concerns when this procedure is performed.

 

Question 62 of 100

A 17-year-old high school football player sustains a neck injury in a game. During the initial on-field assessment, the team physician removes his helmet, and the athlete is log-rolled to the supine position while the physician manually stabilizes his cervical spine. An examination demonstrates tenderness to palpation over the cervical spine and neurologic deficits in bilateral upper and lower extremities. Shoulder pads prohibit proper placement of a hard cervical collar, and the athlete is immobilized on a spine board and transported to the emergency department via ambulance. Comprehensive evaluation in the emergency department reveals a bilateral facet dislocation of C5 on C6. The on-field intervention most likely to cause a neurologic injury is

1. failure to place a hard cervical collar.

2. helmet removal prior to examination.

3. transfer to a spine board prior to transport.

4. log-rolling the athlete to the supine position.

 

PREFERRED RESPONSE: 2- helmet removal prior to examination.

 

DISCUSSION

Complete immobilization of the cervical spine is critical for athletes with a suspected cervical spine or spinal cord injury. The spinal cord in the subaxial spine is especially sensitive to motion, and removal of protective gear such as the helmet and shoulder pads presents an unacceptable risk for progressive neurologic injury in the setting of a potentially unstable cervical spine injury. Removal of the face mask alone is typically performed to improve access to an athlete's airway. Protective equipment often prevents proper placement of a hard cervical collar, and the spine board offers a variety of options for safe cervical spine immobilization of helmeted athletes without a hard cervical collar. The log-roll and lift-and-slide techniques

 

 

allow for the safe transfer of an athlete to a spine board while maintaining appropriate manual stabilization of the cervical spine.

 

Question 63 of 100

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

1. Female athletes with valgus knee alignment and small femoral notch width

2. Female athletes with valgus knee alignment and large ACL width

3. Male athletes with valgus knee alignment and small ACL width

4. Male athletes with varus knee alignment and small femoral notch width

 

PREFERRED RESPONSE: 1- Female athletes with valgus knee alignment and small femoral notch width

 

DISCUSSION

ACL tears are several times more common among women than men. Women who land from jumps in increased valgus and external rotation are at particularly increased risk for ACL tears. Women have smaller notch widths and a smaller ACL cross-sectional area than men, but these factors have not been proven to increase risk for ACL tears.

 

 

 

 

 

Figure 64

 

 

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67

Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

 

Question 64 of 100

What is the most likely cause of this patient’s pain?

1. Femoroacetabular impingement (FAI)

2. Osteoarthritis of the sacroiliac joint

3. Intra-articular loose body

4. Trochanteric bursitis

 

PREFERRED RESPONSE: 1- Femoroacetabular impingement (FAI)

 

Question 65 of 100

The patient participates in physical therapy for 8 weeks with his team’s trainer but notes little improvement. What is the most appropriate next diagnostic step to determine the cause of his pain?

1. Diagnostic arthroscopy of the hip

2. Hip bone scan

3. Hip MRI arthrogram

4. Hip ultrasound

 

PREFERRED RESPONSE: 3- Hip MRI arthrogram

 

Question 66 of 100

 

 

Further workup confirms an anterosuperior tear of the acetabular labrum and prominence of the acetabulum. What is the most likely location of a chondral injury associated with these findings?

1. Posterosuperior acetabulum

2. Posteroinferior acetabulum

3. Femoral head above the fovea

4. Femoral head below the fovea

 

PREFERRED RESPONSE: 2- Posteroinferior acetabulum

 

Question 67 of 100

The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intrasurgically, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

1. Debridement of the labral tear plus bony resection of the pincer lesion

2. Debridement of the labral tear and no bony resection of the pincer lesion

3. Femoral neck osteoplasty plus labral repair using suture anchor

4. Resection of the bony pincer lesion plus labral repair using suture anchor

 

PREFERRED RESPONSE: 4- Resection of the bony pincer lesion plus labral repair using suture anchor

 

DISCUSSION

 

 

 

 

Video 67 for reference

 

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown.

The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. An ultrasound may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasound is not commonly used to diagnose labral pathology.

Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

 

Question 68 of 100

 

 

A 26-year-old weight lifter has had increasing pain in his left shoulder for 4 months. His symptoms do not improve with nonsurgical treatment that included activity modification, anti-inflammatory medication, and corticosteroid injections. He undergoes arthroscopic distal clavicle excision with resection of the distal 2.5 cm of clavicle. Three months after surgery, he reports persistent pain and popping in his shoulder. An examination demonstrates anterior and posterior instability of the distal clavicle without gross deformity. Radiographs are unremarkable. What is the most likely cause of distal clavicle instability after surgery?

1. Release of the coracoacromial ligament

2. Use of an arthroscopic rather than open technique

3. Overresection of the distal clavicle

4. Treatment with corticosteroid injections before surgery

 

PREFERRED RESPONSE: 3- Overresection of the distal clavicle

 

DISCUSSION

Overresection of the distal clavicle can result in disruption of the acromioclavicular ligamentous complex, which inserts at an average of 22.9 mm from the distal clavicle. A comparison of arthroscopic and open distal clavicle excision demonstrated less pain in the arthroscopic group, with no difference in patient satisfaction or shoulder function between groups. Injuries to the conoid and trapezoid ligaments occur with high-grade acromioclavicular separations, resulting in superior migration of the distal clavicle relative to the acromion. Release of the coracoacromial ligament typically is not performed during distal clavicle excision.

Figure 69a	Figure 69b

Figure 69c	Figure 69d
Figure 69e

 

Question 69 of 100

The radiographic finding indicated by the arrow in Figure 69a is most commonly associated with which arthroscopic image?

1. Figure 69b

2. Figure 69c

3. Figure 69d

4. Figure 69e

 

 

PREFERRED RESPONSE: 2- Figure 69c

 

DISCUSSION

The Segond fracture, first described in cadaveric dissections by Paul Segond in 1879, is a lateral capsular avulsion fracture occurring just distal to the lateral tibial plateau. It is associated with tears of the anterior cruciate ligament in more than 75% of cases. Radiographically, this “lateral capsular sign” is easily identified on a standard anteroposterior view of the affected knee, but it also may be seen on a CT scan or MRI.

In 2013, a distinct, lateral capsular ligament known as the anterolateral ligament (ALL) was described. The ligament originates on the lateral femoral epicondyle and inserts on the anterolateral tibia. Claes and associates showed that the ALL inserts in the region on the proximal tibia from which Segond fractures consistently avulse, suggesting that a Segond fracture is actually a bony avulsion of the ALL.

 

 

 

 

Figure 70

 

Question 70 of 100

Figure 70 is the radiograph of a 14-year-old girl with increasing posterior ankle pain, especially during pointe technique exercises. Nonsurgical measures such as modification, stretching, and injection have been unsuccessful. Which nerve is most vulnerable to injury during endoscopic excision of this lesion?

 

 

1. Sural

2. Deep peroneal

3. Medial plantar

4. Posterior tibial

 

PREFERRED RESPONSE: 1- Sural

 

DISCUSSION

The pathology is that of posterior ankle impingement, which is secondary to a symptomatic os trigonum. Endoscopic excision necessitates posteromedial and posterolateral ankle portals. Although plantar numbness has been described as a relatively common postsurgical complication, the neurovascular structure most commonly injured is the sural nerve.

 

Figure 71a	Figure 71b

 

Question 71 of 100

Figures 71a and 71b/ are the MR images of a 65-year-old man who dislocated his shoulder.

What is his most likely chief symptom?

1. Numbness in the anterior aspect of his shoulder

    

    

2. Recurrent instability

3. Difficulty raising his arm

4. Biceps muscle deformity

 

PREFERRED RESPONSE: 3- Difficulty raising his arm

 

DISCUSSION

This patient has a massive rotator cuff tear resulting in disruption of the transverse force couple between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles provide dynamic shoulder stability throughout active elevation. Loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction and external rotation, which results in difficulty raising an arm. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve that supplies sensation to the lateral aspect of the shoulder, not the anterior aspect. Recurrent instability is uncommon unless there is a labral tear or massive subscapularis tear. The biceps muscle is not viewed in the MR images, and a complete proximal biceps tendon rupture would be uncommon in the setting of an anterior shoulder dislocation.

 

Figure 72a	Figure 72b

 

 

Figure 72c	Figure 72d
Figure 72a

 

CLINICAL SITUATION FOR QUESTIONS 72 THROUGH 75

Figures 72a through 72e are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0 degrees

 

 

to 90 degrees and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

 

Question 72 of 100

What is the underlying cause of the pathology noted in the figures?

1. Genetic mutation

2. Recurrent trauma

3. Shallow intercondylar notch

4. Congenital abnormality

 

PREFERRED RESPONSE: 4- Congenital abnormality

 

Question 73 of 100

Based on the pathology noted, which finding may be found on plain knee radiographs?

1. Shallow trochlear groove

2. Squaring of the lateral femoral condyle

3. Deepening of the sulcus terminalis

4. Medial joint space narrowing

 

PREFERRED RESPONSE: 2- Squaring of the lateral femoral condyle

 

Question 74 of 100

What other finding may be noted in patients with this diagnosis?

1. Symmetric knee pathology

2. Excessive joint laxity

3. Recurrent patella instability

4. Extra-articular manifestations

 

PREFERRED RESPONSE: 1- Symmetric knee pathology

 

Question 75 of 100

Treatment should include

1. anterior cruciate ligament reconstruction with lateral meniscus repair.

2. partial lateral meniscectomy with saucerization.

3. lateral meniscus transplant.

4. protected weight bearing with referral for genetic testing.

 

PREFERRED RESPONSE: 2- partial lateral meniscectomy with saucerization.

 

DISCUSSION

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

 

 

Figure 76

 

 

Question 76 of 100

Figure 76 is the MR image of a 16-year-old high school football player who sustained a traumatic dominant shoulder dislocation during a game. On-field reduction was unsuccessful. The shoulder is reduced in the emergency department, and the player and his family followup in clinic. Which factor is most associated with failure of surgical treatment in this scenario?

1. Dominant shoulder

2. Age

3. Size of lesion

4. Periosteal stripping

 

PREFERRED RESPONSE: 2- Age

 

DISCUSSION

The MR image reveals a Bankart lesion. Arthroscopic Bankart repair failure likelihood is increased by numerous factors. Age, number of recurrences, and bony defects are most associated with failure of arthroscopic repair. Shoulder dominance, amount of periosteal

 

 

stripping, and difficulty of reduction do not correlate with increased recurrence risk following surgery.

 

CLINICAL SITUATION FOR QUESTIONS 77 THROUGH 79

A 17-year-old volleyball player has a 3-month history of gradually worsening right shoulder pain. She describes a vague sensation of her shoulder “popping out of place” and weakness associated with overhead activities. She has intermittent generalized paresthesias in her right upper extremity, and she has discontinued participation in sports as a result of her symptoms. Glenohumeral range of motion is symmetric bilaterally. Empty can test findings are negative with full strength of the supraspinatus. An active compression test is negative, and sulcus sign findings are positive. An anterior apprehension test produces pain that is unrelieved with a relocation test. A cervical spine examination is unremarkable.

 

Question 77 of 100

Which examination finding most likely is present?

1. Lateral scapular winging

2. Positive Mayo shear test

3. Grade 3 instability on an anterior load-and-shift test

4. Scapulothoracic dyskinesia

 

PREFERRED RESPONSE: 4- Scapulothoracic dyskinesia

 

Question 78 of 100

Treatment with muscle strengthening exercises for the rotator cuff and scapular stabilizers most likely will result in

1. diminished pain and improved stability.

2. glenohumeral joint dislocation.

3. progression of neurologic symptoms.

4. normal muscle activation and motion patterns.

 

PREFERRED RESPONSE: 1- diminished pain and improved stability.

 

 

Question 79 of 100

The patient does not improve with 1 year of rehabilitation exercises. MR arthrography reveals a normal glenoid labrum and rotator cuff. Surgical treatment should consist of

1. rotator interval closure.

2. thermal capsulorrhaphy.

3. arthroscopic capsular plication.

4. suprascapular nerve decompression.

 

PREFERRED RESPONSE: 3- arthroscopic capsular plication.

 

DISCUSSION

This patient has multidirectional instability (MDI). Symptoms are typically of insidious onset with nonspecific sports-related pain during the second or third decade of life. The etiology of MDI involves a patulous inferior capsular complex, but, in isolation, this lesion may not produce symptoms. Patients with MDI have abnormal patterns of rotator cuff muscle activity that is not restored with nonsurgical treatment. Symptomatic patients with MDI also demonstrate increased rates of abnormal scapular kinematics. The prevalence of MDI is higher among overhead athletes. The sulcus sign is an examination finding that produces a visible dimple inferior to the lateral border of the acromion with application of inferior traction on the arm. Generalized hyperlaxity or a connective tissue disorder may be present. Physical therapy for strengthening of the rotator cuff and scapular stabilizers remains the recommended initial treatment. Rehabilitation should continue for at least 6 months (and possibly much longer). Motivated patients frequently report diminished pain and improved stability with strengthening exercises. If nonsurgical measures fail to provide adequate relief, arthroscopic capsular plication is a viable treatment option, with high rates of return to play among properly selected patients. Thermal capsulorrhaphy has a high failure rate and poses potential for serious complications, including chondrolysis and thermal injury to the axillary nerve. Closure of the rotator interval has not been definitively shown to enhance stability or improve outcomes for patients with MDI.

 

 

Figure 80a	Figure 80b

 

Question 80 of 100

Figures 80a and 80b are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test result, trace effusion, and range of motion from 0 to 85 degrees of knee flexion. Which factor is most contributory to his examination findings?

1. Incorrect graft choice

2. Improper tunnel position

3. Tibial graft-tunnel mismatch

    

    

4. Poor femoral fixation

 

PREFERRED RESPONSE: 2- Improper tunnel position

 

DISCUSSION

Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

 

Figure 81a	Figure 81b

 

 

Figure 81c	Figure 81d

 

CLINICAL SITUATION FOR QUESTIONS 81 THROUGH 84

Figures 81a through 81d are the MR images of a 25-year-old man with left knee pain after a motorcycle collision. He has palpable pedal pulses with an ankle-brachial index of 0.95. Neurologic examination findings of the injured extremity are normal.

 

Question 81 of 100

Based on Figures 81a through 81d, which structures are injured?

1. Anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL)

2. ACL, PCL, and medial collateral ligament

3. ACL and lateral collateral ligament

4. ACL, PCL, and posterolateral corner (PLC)

 

PREFERRED RESPONSE: 4- ACL, PCL, and posterolateral corner (PLC)

 

Question 82 of 100

Surgical treatment within 3 weeks of injury offers which advantage over delayed surgical treatment?

1. Increased rate of return to work

    

    

2. Higher subjective outcome scores

3. Less residual anterior knee instability

4. Reduced need to undergo a second surgery

 

PREFERRED RESPONSE: 2- Higher subjective outcome scores

 

Question 83 of 100

Which factor is most closely associated with increased risk for surgical complications in this scenario?

1. Age

2. Morbid obesity

3. Injury mechanism

4. Time to surgery

 

PREFERRED RESPONSE: 2- Morbid obesity

 

Question 84 of 100

Surgical arthroscopy performed 1 week after injury presents increased risk for

1. deep venous thrombosis.

2. popliteal artery dissection.

3. complex regional pain syndrome.

4. compartment syndrome.

 

PREFERRED RESPONSE: 4- compartment syndrome.

 

DISCUSSION

The MR images show injuries to the ACL, PCL, and PLC consistent with a knee dislocation. The optimal timing of surgery after multiligament knee injury remains unclear. Two systematic reviews demonstrated superior clinical outcome scores after early treatment, including higher mean Lysholm scores and a higher percentage of good/excellent International

 

 

Knee Documentation Committee scores. Early treatment was associated with increased residual anterior knee instability but no difference in posterior instability, varus laxity, or valgus laxity. Although numbers were limited, the average range of motion and rate of extension loss of at least 5 degrees was similar between groups. More patients in the early-treatment group demonstrated a higher rate of flexion loss of 10 or more degrees and an increased need to undergo a second procedure to address arthrofibrosis, including manipulation under anesthesia and arthrolysis. Return to work did not significantly differ between groups, but return to sports was lower in the early-treatment group. Evidence demonstrates a higher rate of low-energy mechanisms resulting in multiligament knee injury and an increased odds ratio for complications among obese (= 30 degrees kg/m2 patients, including wound complications and neurovascular injury. The complication rate increased 9.2% for every 1-point increase in body mass index. There is no association between complication rate and age, injury mechanism, or timing of surgery. Orthopaedic surgeons performing arthroscopy during the early postinjury period must be mindful of the extensive soft-tissue damage present in these patients, including potential capsular defects. Use of high-pressure irrigation can lead to substantial fluid extravasation into the thigh or lower leg compartments, placing patients at increased risk for compartment syndrome. In addition to avoiding high-pressure irrigation, some orthopaedic surgeons have advocated the creation of generous capsular incisions during portal establishment to allow for ready egress of irrigation fluid from the portal sites rather than into soft tissues.

 

RESPONSES FOR QUESTIONS 85 THROUGH 88

1. Excessive medial placement of coracoid autograft

2. Excessive lateral placement of coracoid autograft

3. Excessive inferior dissection during the procedure

4. Excessive retraction and dissection of the medial portion of the conjoint tendon

A 20-year-old right-hand-dominant football player sustained a traumatic shoulder dislocation during a tackle. He has had multiple recurrent dislocations, and radiographs reveal anterior glenoid bone loss. He underwent a Latarjet procedure. Match the most likely complication described below with the surgical error listed above.

 

Question 85 of 100

The patient sustains a recurrent dislocation.

1. Excessive medial placement of coracoid autograft

2. Excessive lateral placement of coracoid autograft

3. Excessive inferior dissection during the procedure

4. Excessive retraction and dissection of the medial portion of the conjoint tendon

 

PREFERRED RESPONSE: 1- Excessive medial placement of coracoid autograft

 

Question 86 of 100

The patient is unable to actively elevate his arm and has atony of the deltoid.

1. Excessive medial placement of coracoid autograft

2. Excessive lateral placement of coracoid autograft

3. Excessive inferior dissection during the procedure

4. Excessive retraction and dissection of the medial portion of the conjoint tendon

 

PREFERRED RESPONSE: 3- Excessive inferior dissection during the procedure

 

Question 87 of 100

Two years after undergoing the procedure, the patient develops shoulder crepitus, and radiographs reveal arthritis.

1. Excessive medial placement of coracoid autograft

2. Excessive lateral placement of coracoid autograft

3. Excessive inferior dissection during the procedure

4. Excessive retraction and dissection of the medial portion of the conjoint tendon

 

PREFERRED RESPONSE: 2- Excessive lateral placement of coracoid autograft

 

Question 88 of 100

The patient has weakness with elbow flexion and has numbness down the anterior lateral aspect of the forearm.

1. Excessive medial placement of coracoid autograft

2. Excessive lateral placement of coracoid autograft

3. Excessive inferior dissection during the procedure

4. Excessive retraction and dissection of the medial portion of the conjoint tendon

 

PREFERRED RESPONSE: 4- Excessive retraction and dissection of the medial portion of the conjoint tendon

 

DISCUSSION

The Latarjet procedure was initially described in 1959 as a modification of the Bristow procedure. It has been used as a primary procedure to address instability, but is used more commonly for patients with instability and glenoid bone loss. In 2000, Burkhart and associates reported a 67% failure rate of the Bankart procedure in patients with an inverted pear-shaped glenoid (glenoid bone loss) or an engaging Hill-Sachs lesion, with a suggestion that a bone graft procedure would be optimal in this population. Complications following the Latarjet procedure have been reported as high as 25%, with the majority attributable to nerve injury, recurrent instability, and arthritis. Many of these complications are likely secondary to surgical technique. A coracoid graft that is placed too laterally or with prominent screws will overhang the glenoid and lead to early degenerative glenohumeral arthritis. A coracoid graft placed too medially can lead to recurrent instability secondary to an ineffective subscapularis sling and bone block. A coracoid graft placed inferiorly indicates dissection close to the axillary nerve, which can place tension on the axillary nerve or cause injury from direct trauma. After harvesting the coracoid graft, the surgeon must find the musculocutaneous nerve as it enters the conjoint tendon on the medial surface about 5 cm distal to the coracoid. Excessive dissection or retraction can lead to musculocutaneous nerve palsy.

 

Question 89 of 100

A 27-year-old man has recurrent right shoulder instability. He first dislocated his shoulder in college while playing rugby and was treated nonsurgically. Since then, he has sustained nearly 1 dozen dislocations and says that his shoulder always feels “loose.” The shoulder recently dislocated in his sleep and while he was putting on clothes. Which factor is a contraindication to an arthroscopic soft-tissue repair?

1. A 270-degree labral tear

2. His intention to continue contact sport activities

3. Anterior bony loss measuring 30% of inferior glenoid width

4. An inferior glenohumeral ligament avulsion (HAGL) lesion

 

PREFERRED RESPONSE: 3- Anterior bony loss measuring 30% of inferior glenoid width

 

DISCUSSION

There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Although some studies suggest that open stabilization may result in lower recurrence rates in contact athletes, this approach is now under scrutiny. Extensive labral involvement (posterior labral involvement in this scenario) is likely more accessible via arthroscopic methods. Although HAGL lesions may be more easily accessible via an open approach (particularly for inexperienced arthroscopists), numerous authors describe successful repair via arthroscopic techniques. Among these responses, the strongest indication for an open approach, including possible bony transfer, is high-grade glenoid bone loss. Although the critical amount of bone loss is a topic of debate, most surgeons and authors suggest a cutoff of 20% to 25%.

 

 

 

 

Figure 90

 

CLINICAL SITUATION FOR QUESTIONS 90 THROUGH 92

Figure 90 is the radiograph of a 14-year-old pitcher who plays in a year-round baseball program and has vague pain in his dominant shoulder. The pain occurs with throwing, and it has been worsening for 2 months. Pain typically occurs during the late cocking phase of throwing. He has no tenderness of the rotator cuff and 5/5 rotator cuff strength. His arc of motion is symmetric between his dominant and nondominant arms. The sulcus sign is negative.

 

 

Question 90 of 100

What is the most likely diagnosis?

1. Proximal humeral epiphysiolysis

2. Internal impingement with internal rotation deficit

3. Rotator cuff tendinitis

4. Biceps tendinitis

 

PREFERRED RESPONSE: 1- Proximal humeral epiphysiolysis

 

Question 91 of 100

Initial treatment should consist of

1. arthroscopic labral repair

2. rest and physical therapy

3. immobilization in external rotation

4. closed reduction and percutaneous pinning.

 

PREFERRED RESPONSE: 2- rest and physical therapy

 

Question 92 of 100

What is the most likely contributory factor to this patient's problem?

1. Throwing curveballs

2. Year-round throwing

3. Poor calcium intake

4. Shoulder laxity

 

PREFERRED RESPONSE: 2- Year-round throwing

 

DISCUSSION

 

 

Proximal humeral epiphysiolysis (little leaguer’s shoulder) is an overuse condition of the proximal humeral physis. Patients report diffuse pain that is worse with throwing. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Factors that contribute to the condition include excessive throwing, improper throwing mechanics, and muscle-tendon imbalance. Radiographic findings typically are normal but may indicate subtle widening of the proximal humeral physis, and, in more severe cases, metaphyseal demineralization or fragmentation. Surgical fixation is not required for healing. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms. Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to throwing is implemented until the patient’s condition returns to baseline. This protocol has a long-term success rate exceeding 90%. Pitching coaches should evaluate throwing mechanics and maintain pitch counts. The most common cause of this condition is overuse, as is seen in pitchers who throw all year. Internal rotation deficit and internal impingement is typically a finding in older athletes without open physes. This patient had no evidence of rotation deficit upon examination, making this diagnosis unlikely.

 

Question 93 of 100

A 17-year-old African American high school football player is in the afternoon session of an August “2-a-day” practice. He tells his trainer he is experiencing weakness, dizziness, and nausea. The ambient temperature is 31°C with a relative humidity of 70%. An examination by the team trainer reveals a body temperature of 39°C and headache, chills, confusion, and disorientation. What is the most likely diagnosis?

1. Sickle-cell crisis

2. Heat exhaustion

3. Heatstroke

4. Dehydration

 

PREFERRED RESPONSE: 3- Heatstroke

 

DISCUSSION

Heat exhaustion and heatstroke are both forms of heat illness during which the body is unable to self-regulate internal temperature. The hallmarks of heatstroke are altered mental status and/or core temperature higher than 40°C. Heat exhaustion may be marked by nausea, vomiting, headache, dizziness, chills, and excessive sweating, but there are no mental status

 

 

changes. In heatstroke, sweating can often slow or cease as dysregulation worsens. Simple dehydration would not result in mental status changes or elevated core temperature. Sickle-cell crisis is marked by extreme pain, with location depending on the site of crisis. Four main patterns are common: bone, chest, abdominal, or joint crises. Sickle-cell crisis can be precipitated by dehydration, although it also can occur as a result of cold exposure.

 

 

 

 

Figure 94

 

Question 94 of 100

Figure 94 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. After injury to the structure as indicated by the asterisks, which examination test most likely will demonstrate an abnormal finding?

1. Lachman test

2. Pivot-shift test

3. Posterior drawer test

4. Posterolateral (PL) drawer test

 

PREFERRED RESPONSE: 2- Pivot-shift test

 

 

DISCUSSION

The structure shown is the PL bundle of the anterior cruciate ligament (ACL), which is tight near terminal knee extension. Biomechanical analysis suggests the PL bundle provides a greater degree of rotational stability than the anteromedial bundle. The pivot-shift test evaluates for rotational instability of the ACL, while the Lachman test assesses anterior-posterior stability. The posterior drawer and PL drawer test findings are positive after a posterior cruciate ligament tear and PL corner injury, respectively.

 

RESPONSES FOR QUESTIONS 95 THROUGH 98

1. Axillary nerve injury

2. Musculocutaneous nerve injury

3. Radial nerve injury

4. Glenoid fracture

5. Loss of reduction

6. Deltoid detachment

7. Chondrolysis

8. Recurrent instability

9. Propionibacterium acnes (P. acnes) infection

10. Staphylococcus epidermidis

11. Staphylococcus aureus

Select the complication listed above that is most commonly associated with the shoulder arthroscopy scenarios described below.

 

Question 95 of 100

Arthroscopic capsular release of the shoulder through the anteroinferior and posteroinferior axillary pouch

1. Axillary nerve injury

2. Musculocutaneous nerve injury

3. Radial nerve injury

4. Glenoid fracture

5. Loss of reduction

6. Deltoid detachment

7. Chondrolysis

    

    

8. Recurrent instability

9. Propionibacterium acnes (P. acnes) infection

10. Staphylococcus epidermidis

11. Staphylococcus aureus

 

PREFERRED RESPONSE: 1- Axillary nerve injury

 

Question 96 of 100

Use of an intra-articular glenohumeral bupivacaine pump for postsurgical pain control

1. Axillary nerve injury

2. Musculocutaneous nerve injury

3. Radial nerve injury

4. Glenoid fracture

5. Loss of reduction

6. Deltoid detachment

7. Chondrolysis

8. Recurrent instability

9. Propionibacterium acnes (P. acnes) infection

10. Staphylococcus epidermidis

11. Staphylococcus aureus

 

PREFERRED RESPONSE: 7- Chondrolysis

 

Question 97 of 100

Use of a 5 o’clock portal in an arthroscopic Bankart repair

1. Axillary nerve injury

2. Musculocutaneous nerve injury

3. Radial nerve injury

4. Glenoid fracture

5. Loss of reduction

    

    

6. Deltoid detachment

7. Chondrolysis

8. Recurrent instability

9. Propionibacterium acnes (P. acnes) infection

10. Staphylococcus epidermidis

11. Staphylococcus aureus

 

PREFERRED RESPONSE: 1- Axillary nerve injury

 

Question 98 of 100

A common infection organism that occurs after shoulder arthroscopy, it rarely is seen in infections of the lower extremity

1. Axillary nerve injury

2. Musculocutaneous nerve injury

3. Radial nerve injury

4. Glenoid fracture

5. Loss of reduction

6. Deltoid detachment

7. Chondrolysis

8. Recurrent instability

9. Propionibacterium acnes (P. acnes) infection

10. Staphylococcus epidermidis

11. Staphylococcus aureus

 

PREFERRED RESPONSE: 9- Propionibacterium acnes (P. acnes) infection

 

DISCUSSION

Shoulder arthroscopy is becoming increasingly popular. Although it is a safe procedure, it is not without potential complications. Neurovascular injury is possible after creation of standard arthroscopic portals. Particularly, creation of anteroinferior portals puts the axillary nerve at risk. Creation of an inferior “5 o’clock” (right shoulder) portal has been proven

 

 

particularly dangerous and should be avoided. Similarly, considering the axillary nerve’s proximity to the inferior capsule, arthroscopic release of the capsule in the area also puts the nerve at risk for injury.

Bupivacaine has been shown to be chondrotoxic, and several reports have linked the use of intra-articular bupivacaine pumps to postsurgical chondrolysis of the shoulder. Deep infections are rare complications after arthroscopy, with incidence reported to range between 0 and 3.4% in the literature. The shoulder is particularly susceptible to P. acnes, a gram-positive, microaerophilic, nonspore-forming bacillus that is predominant in the pilosebaceous follicles that are most prevalent in the head, neck, and thorax. P. acnes, however, is not a common organism isolated from infections of the knee and lower extremity.

 

Question 99 of 100

A 19-year-old collegiate middistance runner has a 4-year history of bilateral leg pain. Pain begins within 10 minutes after starting to run and is described as a “tightness and cramping in the front of the legs.” Symptoms resolve within 15 to 20 minutes of running cessation. A presumptive diagnosis of exercise-induced compartment syndrome (EICS) is made, and the patient elects to undergo compartmental pressure testing. What is the strongest indication for elective fasciotomy of the anterior compartment?

1. Resting anterior compartment pressure of 13 mm Hg

2. Numbness/tingling of the plantar foot during the exercise portion of the test

3. 1-minute postexercise anterior compartment pressure of 42 mm Hg

4. 5-minute postexercise anterior compartment pressure of 19 mm Hg

 

PREFERRED RESPONSE: 3- 1-minute postexercise anterior compartment pressure of 42 mm Hg

 

DISCUSSION

This clinical scenario describes a patient with EICS, marked by a nonphysiologic rise in muscle compartment pressure during exercise. Pressure testing is the best currently accepted method of diagnosis. Most physicians use the following criteria for diagnosis: resting pressure higher than 15 mm Hg, 1-minute postexercise pressure higher than 30 mm Hg, or 5-minute postexercise pressure higher than 20 mm Hg. Only 1-minute postexercise anterior compartment pressure of 42 mm Hg meets these criteria. Neurologic symptoms in the plantar foot would imply involvement of the posterior compartments and would not support the diagnosis of anterior compartment involvement.

 

 

 

Figure 100

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Question 100 of 100

Figure 100 is the MR image of a 19-year-old man who sustains recurrent anterior shoulder dislocations. The lesion shown occupies approximately 10% of the articular surface. What is the most appropriate treatment?

1. Open distal tibial allograft reconstruction

2. Open reduction and internal fixation (ORIF) with cannulated screws

3. Arthroscopic coracoid transfer

4. Arthroscopic repair incorporating the bony component

 

PREFERRED RESPONSE: 4- Arthroscopic repair incorporating the bony component

 

DISCUSSION

The MR image shows a bony Bankart lesion involving less than 20% of the glenoid joint surface. One series reported high success rates after arthroscopic treatment when the defect was incorporated into the repair. Anterior bony deficiencies occupying more than 25% to 30% of the glenoid joint surface treated with soft-tissue repair only are associated with high

 

 

recurrence rates. In these patients, an open or arthroscopic coracoid transfer or distal tibial allograft reconstruction should be considered. ORIF has been reported for treatment of large acute glenoid rim fractures, but is not recommended for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.