Full Question & Answer Text (for Search Engines)
Question 1:
When performing anterior cruciate ligament reconstruction using a bone- patellar tendon-bone autograft fixated with interference screws, up to how many degrees of divergence between the bone plug and the screw provides mechanically acceptable initial fixation strength on the femoral side?
Options:
Correct Answer: 30°
Explanation:
Biomechanical studies have shown that up to 30° of divergence between the femoral bone plug and interference screw can be accepted without significantly compromising initial fixation strength.
Question 2:
A 20-year-old male collegiate basketball player experiences a near syncopal episode during a particularly rigorous conditioning session. Appropriate management should include:
Options:
- More intensive conditioning
- A short break, allowing the athlete to return when he feels ready
- Discontinuation of participation for 1 week
- Urgent cardiac evaluation
- Urgent neurological evaluation
Correct Answer: Urgent cardiac evaluation
Explanation:
A near syncopal episode in a young athlete may be a sign of an underlying life threatening condition. Most commonly, this is related to cardiac pathology, such as hypertrophic cardiomyopathy, idiopathic hypertrophic subaortic stenosis, or arrhythmias. These conditions require urgent medical attention as they are frequently life threatening. The athlete should not be allowed to participate until a complete medical (including cardiac) work up has been performed.
Question 3:
On a cellular level, the nutritional supplement creatine has the following effect:
Options:
- Increases water retention in cells
- Decreases water retention in cells
- C auses hydrolysis of cells
- C auses increased organelle production
- C auses decreased organelle production
Correct Answer: Increases water retention in cells
Explanation:
Creatine is a popular nutritional supplement with athletes, and has a cellular effect of increasing water retention. This effect decreases the amount of free water available to the athlete and may result in cramping and dehydration. In season use of creatine is not recommended.
Question 4:
A 20-year-old male weight-lifter complains of progressive right shoulder pain when performing bench presses. He recalls no specific injury, and physical examination reveals mild swelling and tenderness in the right acromioclavicular joint. He is otherwise healthy with no other findings or complaints. The most likely diagnosis is:
Options:
- Acromioclavicular joint dislocation
- Septic acromioclavicular joint
- Arthrosis
- Distal clavicular fracture
- Subacromial impingement syndrome
Correct Answer: Arthrosis
Explanation:
Distal clavicular osteolysis most commonly occurs in weight-lifters and is most symptomatic while performing bench presses. There is usually no history of trauma. Symptoms may be bilateral in up to 40% of patients. Treatment initially involves modification of training regimens and anti-inflammatory medications. Failing nonoperative interventions, distal clavicle excision is usually successful in alleviating symptoms.
Question 5:
When comparing open distal clavicle resection with arthroscopic distal clavicle resection for osteolysis of the distal clavicle, arthroscopic techniques:
Options:
- Less reliably resect the appropriate amount of distal clavicle
- Less reliably provide pain relief
- Have a higher complication rate
- Require a longer hospital stay
- Allow quicker return to activity
Correct Answer: Allow quicker return to activity
Explanation:
A study comparing arthroscopic and open techniques of distal clavicular resection in the treatment of osteolysis of the distal clavicle found no difference in the amount of bone resected or amount of pain relief obtained. The arthroscopic group had a shorter hospital stay, less complications, and returned to activity nearly twice as fast as the open group.
Question 6:
Osteochondritis dissecans of the elbow most commonly occurs at this location:
Options:
- Trochlea
- Olecranon
- Capitellum
- Radial head
- Coronoid
Correct Answer: Capitellum
Explanation:
Osteochondritis dissecans of the elbow is most common in adolescent and pre-adolescent individuals who participate in sports that place an excessive amount of load on the radiocapitellar joint (e.g., baseball pitching, gymnastics). Factors involved in the development of this entity include repetitive microtrauma and a tenuous capitellar blood supply. Treatment may involve arthroscopic removal of loose bodies.
Question 7:
When examining an individual for suspected posterior instability of the glenohumeral joint, a posteriorly directed force is applied with the arm in this position:
Options:
- Abduction, external rotation
- Abduction, internal rotation
- Adduction, internal rotation
- Forward flexion, internal rotation
- Forward flexion, external rotation
Correct Answer: Forward flexion, internal rotation
Explanation:
The appropriate position for testing posterior stability of the glenohumeral joint is 90° of forward flexion and internal rotation.
Question 8:
Patellar tendinitis is associated with:
Options:
- Pain at the insertion of the patellar tendon on the tibia
- Pain at the insertion of the patellar tendon on the patella
- Lateral knee pain during downhill running
- Locking and popping of the knee during activity
- "Giving way" of the knee during activity
Correct Answer: Pain at the insertion of the patellar tendon on the tibia
Explanation:
Activities such as basketball, soccer, volleyball and track require repeated impact with the ground. This leads to micro-trauma, resulting in degeneration of the tendon and focal inflammation. Pain at the inferior pole of the patella is usually isolated with palpation along the tip of the kneecap.
Question 9:
Patellar tendinitis:
Options:
- Is most frequently diagnosed in patients over 40 years old.
- Occurs at the superior pole of the patella.
- Frequently has consistent radiographic changes that are pathognomonic to the condition.
- Leads to fibrinoid necrosis and mucinous degeneration in the deep fibers of the tendon origin at the inferior pole of the patella.
- Occurs at the insertion of the patellar tendon into the tibia.
Correct Answer: Is most frequently diagnosed in patients over 40 years old.
Explanation:
The deep fibers of the patellar tendon are less elastic and more susceptible to stresses that create the micro-traumatic damage. This repetitive stress leads to the focal degeneration and chronic inflammation.C orrect Answer: Leads to fibrinoid necrosis and mucinous degeneration in the deep fibers of the tendon origin at the inferior pole of the patella.
Question 10:
Septic arthritis of the knee within 4 weeks following anterior cruciate ligament (AC L) reconstruction using bone-patellar tendonbone autograft should initially be treated with:
Options:
- C ulture-specific intravenous antibiotics
- C ulture-specific intravenous antibiotics and surgical irrigation with graft retention
- C ulture-specific intravenous antibiotics and surgical irrigation with graft removal
- Culture-specific intravenous antibiotics, surgical irrigation with graft removal, and immediate revision reconstruction
- C ulture-specific intravenous antibiotics, surgical irrigation with graft removal, and delayed revision reconstruction
Correct Answer: C ulture-specific intravenous antibiotics
Explanation:
In a recent study that surveyed surgeons with expertise in AC L reconstruction surgery, 85% of surgeons selected culture-specific intravenous antibiotics and surgical irrigation of the joint with graft retention as initial treatment for the infected patellar tendon autograft. Sixty-four percent of surgeons chose this regimen as treatment for the infected allograft.
Question 11:
In the setting of chronic anterior cruciate ligament (AC L) deficiency, which of the following meniscal tear patterns is most common:
Options:
- Peripheral posterior horn tears of the medial meniscus
- Peripheral posterior horn tears of the lateral meniscus
- Peripheral anterior horn tears of the medial meniscus
- Peripheral anterior horn tears of the lateral meniscus
- C entral posterior horn tears of the medial meniscus
Correct Answer: Peripheral posterior horn tears of the medial meniscus
Explanation:
Medial meniscal tears account for approximately 45% of acute tears and 70% of chronic tears in patients with AC L insufficiency. Peripheral posterior horn tears of the medial meniscus are the most common type of tear associated with chronic AC L deficiency.
Question 12:
All of the following are reported complications following the surgical treatment of medial epicondylitis except:
Options:
- Ulnar neuritis
- Injury to the medial antebrachial cutaneous nerve
- Permanent flexor mass weakness
- Injury to the posterior interosseous nerve (PIN)
- Injury to the ulnar collateral ligament (UC L)
Correct Answer: Injury to the medial antebrachial cutaneous nerve
Explanation:
The potential complications associated with the surgical treatment of medial tendon injuries primarily involve the structures surrounding the medial epicondyle. The most frequent complications involve the ulnar nerve. Careful dissection through the subcutaneous tissues must be performed so that the medial antebrachial cutaneous nerve can be isolated and protected. Extensive release of the flexor-pronator mass can lead to permanent flexor weakness, as well as detachment of the UC L from the medial epicondyle. The PIN is located on the lateral side of the elbow and its injury is not a reported complication associated with medial epicondylar debridement.
Question 13:
In valgus extension overload of the elbow, impingement occurs between which of the following structures:
Options:
- Ulnar nerve and ulnar collateral ligament
- Posteromedial olecranon process and posteromedial olecranon fossa
- Posterolateral olecranon process and radial head
- C oronoid process and radial head
- Posteromedial olecranon process and ulnar nerve
Correct Answer: Posteromedial olecranon process and posteromedial olecranon fossa
Explanation:
Valgus extension overload is unique to the throwerâ s elbow. Valgus extension overload of the elbow involves attenuation and creep in the ulnar collateral ligament that transfers compressive forces to the lateral compartment of the elbow at the radiocapitellar joint. In the posterior elbow compartment, the valgus moment creates contact between the posteromedial aspect of the olecranon process and the posteromedial olecranon fossa.
Question 14:
Anteroposterior displacement of the acromion on the clavicle is most strongly resisted by which of the following structures:
Options:
- The conoid ligament
- The acromioclavicular ligaments
- The osseous articulation of the acromion on the clavicle
- The acromioclavicular meniscus
- The trapezoid ligament
Correct Answer: The acromioclavicular ligaments
Explanation:
During high loads, the coracoclavicular ligaments (conoid and trapezoid ligament) resist vertical and compressive loads across the acromioclavicular joint. The conoid ligament is the strongest ligament resisting downward movement of the scapula relative to the clavicle. The acromioclavicular ligaments maintain alignment of the joint in the axial plane.
Question 15:
Causes of distal clavicular osteolysis include all of the following except:
Options:
- Rheumatoid arthrosis
- Diabetes mellitus
- Sarcoidosis
- Hyperparathyroidism
- Repetitive microtrauma
Correct Answer: Diabetes mellitus
Explanation:
Osteolysis of the distal clavicle has been associated with various conditions. Among the most common causes is repetitive microtrauma from activities such as weight lifting, gymnastics, and swimming. Other causes include rheumatoid arthrosis and hyperparathyroidism. The diagnosis of sarcoidosis should be considered in bilateral cases. Diabetes mellitus has not been associated with this condition.
Question 16:
Which of the following describes the correct relationship between the suprascapular nerve and the suprascapular vessels as they pass through the suprascapular notch:
Options:
- The suprascapular nerve, artery, and vein all pass below the transverse scapular ligament.
- The suprascapular nerve, artery, and vein all pass superficially to the transverse scapular ligament.
- The suprascapular nerve passes superficially to the transverse scapular ligament while the artery and vein pass deep to it.
- The suprascapular nerve and artery pass deep to the transverse scapular ligament while the suprascapular vein passes superficially to it.
- The suprascapular nerve passes deep to the transverse scapular ligament while the suprascapular artery and vein pass above it.
Correct Answer: The suprascapular nerve, artery, and vein all pass below the transverse scapular ligament.
Explanation:
The suprascapular nerve is a branch of the upper trunk of the brachial plexus at Erbs point. The suprascapular nerve receives branches primarily from the fifth cervical nerve root. The nerve follows the omohyoid muscle laterally and passes beneath the anterior border of the trapezius muscle to the upper border of the scapula where it joins the suprascapular artery. It passes through the suprascapular notch deep to the transverse scapular ligament. The artery and vein pass superficial to the ligament and join the nerve distally in the suprascapular fossa. After innervating the supraspinatus muscle, the nerve passes around the lateral free margin of the scapular spine (spinoglenoid notch) to innervate the infraspinatus muscle.
Question 17:
All of the following factors have been used to explain why exertional compartment syndrome is more common in the lower leg when compared to the upper arm except:
Options:
- Muscle straining that occurs in the lower leg seldom occurs in the upper arm.
- Muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined to the compartment of the upper extremity.
- The brachialis fascia is less taut than the crural fascia.
- The brachialis fascia yields more to increased intracompartmental pressure as compared to the crural fascia.
- The pulse pressure of the lower extremity is greater than that of the upper extremity.
Correct Answer: The pulse pressure of the lower extremity is greater than that of the upper extremity.
Explanation:
There are several reasons that have been offered as to why upper arm compartment syndromes are so rare. First, the brachialis fascia is less taut and contains less rigid ligaments than the fascia in the lower leg. Second, the brachialis fascia yields more to increased intracompartmental pressure as compared to the fascia of the lower leg. Third, the muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined enough to develop into a compartment syndrome. Finally, muscle stresses that occur in the lower leg during events such as prolonged march seldom occur in the arm.
Question 18:
During arthroscopic repair of the lateral meniscus using an "outside-in technique," the most important way to prevent damage to the peroneal nerve is to:
Options:
- Fully extend the leg during the repair
- Keep the knee flexed at least to 90° while performing the repair
- Make a large incision to identify the nerve
- Repair of the lateral meniscus should be done only with intra-articular arrows to prevent injury to the peroneal nerve
- Repair of the lateral meniscus should be done only with an inside-out technique to prevent injury to the peroneal nerve
Correct Answer: Keep the knee flexed at least to 90° while performing the repair
Explanation:
The most important consideration in arthroscopic repair of the lateral meniscus is to avoid injuring the peroneal nerve. This is done best by using an outside-in technique and flexing the knee to 90° while passing the needles. With flexion of the knee, the peroneal nerve falls posterior to the joint line. It is important to remember to keep the needles anterior to the biceps.
Question 19:
A 20-year old female collegiate swimmer has suffered from pain in her right shoulder and inability to compete for the last 9 months. She has been diagnosed with multidirectional instability. Physical therapy for 7 months has failed, and she wishes to swim competitively again. Assuming the diagnosis is correct, the next step should be:
Options:
- Bankhart capsulolabral repair
- Posterior capsular shift
- Bristow procedure (coracoid process transfer)
- Inferior capsular shift
- Superior capsular shift
Correct Answer: Inferior capsular shift
Explanation:
Initial treatment of multidirectional instability is with rehabilitation. These patients, who have loose capsules, often rely on dynamic stabilizing mechanisms rather than tight ligamentous constraint. If surgery is to be performed, the procedure of choice is the inferior capsular shift, originally described by Neer. It reduces the volume of the glenohumeral joint inferiorly, anteriorly, and posteriorly by equalizing capsular tightness on all three sides.
Question 20:
How is an anterior drawer test performed to evaluate the competence of the anterior talofibular ligament in a patient with a possible ankle sprain:
Options:
- Knee bent, ankle dorsiflexed
- Knee bent, ankle neutral
- Knee bent, ankle plantar flexed
- Knee extended ankle neutral
- Knee extended ankle plantar flexed
Correct Answer: Knee bent, ankle dorsiflexed
Explanation:
The anterior drawer test should be performed with the patient sitting, the knee bent, and the ankle plantar flexed in a position of comfort. Flexing the knee relaxes the gastrocnemius. Plantar flexion relaxes the peroneals. The tibia is braced with one hand and the hindfoot is gently brought forward. The amount of anterior translation is compared between feet.
