Full Question & Answer Text (for Search Engines)
Question 1:
A 13-year-old female competitive gymnast has had pain in her lumbar spine and anterior thighs for 9 weeks. It has become significant enough to limit her activities. Radiographs of her lumbar and thoracic spine are normal and iliac crests show that she is not skeletally mature. Physical examination is essentially normal with no long tract or nerve tension signs present. What is the next appropriate step in a diagnostic work up:
Options:
- Magnetic resonance image (MRI) of lumbar spine
- C omputed tomography (C T) scan of lumbar spine
- C T of thoracic spine
- MRI of thoracic spine
- Technetium bone scanning
Correct Answer: Technetium bone scanning
Explanation:
This athlete most likely has spondylolysis of the lumbar spine. Repetitive hyperextension of the lumbar spine with stress concentrated at the pars interarticularis can lead to stress fractures especially in the fourth or fifth lumbar vertebrae. Spondylolysis is the most common bony injury in the athlete's spine. The most sensitive way to delineate this injury is with technetium bone scanning. C T and MRI are not as helpful in the diagnosis or treatment of spondylolysis, unless the patient has frank radicular symptoms.
Question 2:
The posterior cruciate ligament sustains from 85% to 100% of the load of a posterior directed force at 90º of flexion. Which fibers of the ligament are responsible for this:
Options:
- Anterolateral bundle
- Anteromedial bundle
- Posteromedial bundle
- Posterolateral bundle
- Anterolateral and posteromedial equally
Correct Answer: Anterolateral bundle
Explanation:
The posterior cruciate ligament is the primary restraint to posterior tibial translation, sustaining the majority of force across the knee at 90º of flexion. The PC L has two functional components, an anterolateral portion, and a posteromedial portion. These two "bundles" are named according to their insertions. The anterolateral bundle is tight in flexion and is biomechanically superior to the posteromedial bundle. For this reason, "one bundle techniques" attempt to reproduce the anterolateral bundle.
Question 3:
A fourteen-year-old little league pitcher has lateral elbow pain that is worsened by throwing. Plain radiographs demonstrate fragmentation of the capitellum with no evidence of a loose body. A presumptive diagnosis of osteochondritis dissecans of the capitellum has been made. He has undergone rest, followed by physical therapy over the past three months. Now range of motion is from 30 to 120, and pain is present when attempting to throw. The next appropriate step is:
Options:
- Extension Dyna-Splint at night time
- Aggressive range of motion with physical therapy and iontophoresis
- Rest until skeletal maturity is reached, and further re-evaluation
- Arthroscopy of the elbow with debridement of defect
- Open reduction and internal fixation of capitellar fracture
Correct Answer: Arthroscopy of the elbow with debridement of defect
Explanation:
This patient has osteochondritits dissecans of the capitellum from pitching. OC D of the capitellum differs from Panner's disease, which is a osteochondrosis of the capitellum which occurs at a younger age (7-12) and is less symptomatic. Initial treatment of osteochondritis dissecans of the capitellum is rest and occasional splinting. Arthroscopy is indicated for both detached lesions and those who have failed conservative therapy. The entire joint should be a assessed, loose fragments removed and the subchondral bone of the defect is debrieded to a healthy vascular bed.
Question 4:
The primary stabilizer of the elbow to valgus stress is:
Options:
- The posterior bundle of the medial collateral ligament
- The anterior bundle of the medial collateral ligament
- The transverse bundle of the medial collateral ligament
- The inferior bundle of the medial collateral ligament
- The superior bundle of the medial collateral ligament
Correct Answer: The anterior bundle of the medial collateral ligament
Explanation:
The medial collateral ligament complex of the elbow consists of three parts: the anterior, posterior, and transverse segments or bundles. The anterior bundle is the most distinct portion. The posterior bundle/segment is a thickening of the capsule and notable only at 90 degrees of flexion. The transverse component or ligament of C ooper appears to contribute little to elbow stability. There are no inferior or superior bundles.
Question 5:
A collegiate football player sustains a direct blow to his anterior shoulder. Physical examination reveals ecchymosis over the anterior shoulder and painful range of motion. Radiographs include an anteroposterior, scapular Y and an axillary lateral. The radiographs show the humeral head to be located with an isolated fracture at the base of the coracoid process. Treatment should consist of:
Options:
- Screw fixation of the coracoid base
- Airplane type splinting at 90º of abduction for 6 weeks, followed by progressive range of motion
- Sling immobilization with gradual progressive range of motion
- Costoclavicular screw fixation
- Costoclavicular ligament reconstruction
Correct Answer: Sling immobilization with gradual progressive range of motion
Explanation:
Acute isolated fracture of the coracoid base is almost invariably treated conservatively with the expectation of a good result. If the acromioclavicular joint is sound, the basal fracture is splinted by the costoclavicular ligaments, and displacement is minimal. Treatment with a sling for comfort is sufficient. Pendulum exercises are encouraged. Overhead elevation is restricted for 4-6 weeks to allow healing. Return to sports can occur after healing of the fracture and return to full, painless range of motion. This usually requires 6 to 8 weeks.
Question 6:
The infraspinatus is strengthened best by which exercise:
Options:
- External rotation at 70º of elevation
- Internal rotation at 70º of elevation
- External rotation at 0º of elevation
- Internal rotation at 0º of elevation
- Scapular elevation with internal humeral rotation
Correct Answer: External rotation at 70º of elevation
Explanation:
The infraspinatus is primarily responsible for external rotation, humeral head depression, and posterior approximation at lower elevations, whereas the teres minor functions at higher elevations. Therefore, external rotation with the arm near the side of the body is optimal for strengthening the infraspinatus. External rotation at approximately 70º is more appropriate for strengthening the teres minor.
Question 7:
When comparing male and female competitive athletes, what can be said regarding anterior cruciate ligament injuries:
Options:
- Females have a lower relative risk for anterior cruciate ligament (AC L) injuries.
- Females have an increased relative risk for AC L injuries.
- Males and female competitive athletes have equal risk for injuries.
- A comparison is difficult to make due to the different sports played by each sex.
- There have been no studies examining this association as it may be construed as sexist.
Correct Answer: Females have a lower relative risk for anterior cruciate ligament (AC L) injuries.
Explanation:
It has been shown that competitive female athletes have an increased relative risk for anterior cruciate ligament injury in college sports as well as during military training. Possible causative factors have been suggested (body movement, muscular strength, joint laxity, limb alignment, notch dimensions, effects of estrogen), but none have been proven as of yet.
Question 8:
The most common location for a meniscal cyst is:
Options:
- Middle third of the lateral meniscus
- Middle third of the medial meniscus
- Posterior horn of the lateral meniscus
- Anterior horn of the lateral meniscus
- Anterior horn of the medial meniscus
Correct Answer: Middle third of the lateral meniscus
Explanation:
Mensical cysts are rather uncommon and occur most frequently in the middle third of the lateral meniscus. They are less common in the medial meniscus, where they tend to occur in the posterior horn. They are often associated with horizontal, cleavage type tears of the meniscus. Lateral cysts tend to be smaller and are localized to the joint line, where medial cysts can be large and may dissect through the capsule.
Question 9:
If a distal biceps tendon avulsion is not repaired or reconstructed, what is the likely result:
Options:
- Loss of 90% of flexion an 20 % of supination strength
- No loss of flexion strength and 40% loss of supination strength
- 20% loss of flexion strength and no loss of supination strength
- No significant clinical deficit will occur
- 20% loss of flexion and 40% loss of supination strength
Correct Answer: 20% loss of flexion strength and no loss of supination strength
Explanation:
Untreated distal biceps rupture results in a loss of about 20% flexion and 40% supination strength.
Question 10:
The best clinical test for diagnosis of an anterior cruciate ligament (AC L) rupture is:
Options:
- Anterior drawer
- Pivot shift
- Losee
- Lachman
- Single leg hop
Correct Answer: Lachman
Explanation:
The Lachman test provides the best predictive value of all clinical tests for diagnosis of an anterior cruciate ligament rupture. The diagnosis of a complete AC L rupture can be reliably made clinically without the added expense of a preoperative magnetic resonance image.
Question 11:
The reason a patient with an acute rupture of the anterior cruciate ligament will usually have a hemarthrosis is due to disruption of what main blood supply to the ligament:
Options:
- Lateral superior geniculate artery
- Medial superior geniculate artery
- Middle geniculate artery
- Medial inferior geniculate artery
- Lateral inferior geniculate artery
Correct Answer: Middle geniculate artery
Explanation:
The major blood supply to the anterior cruciate ligament arises from the ligamentous branches of the middle genicular artery, with minor contribution from the terminal branches of the medial and lateral inferior genicular arteries. The AC L is covered in a synovial fold that is richly supplied by the middle geniculate artery.
Question 12:
A football player is down and unconscious after making a tackle. He is found lying supine. What initial management should be undertaken on the playing field:
Options:
- Remove helmet, place cervical collar, check for breathing, place on spine board
- Remove chinstrap only, check for breathing, place on spine board
- Remove helmet and shoulder pads, hold cervical traction and place on spine board
- Check breathing with helmet and chinstrap buckled, if airway problems are noted, remove facemask only, place on spine board
- Place on spine board immediately, check breathing once secured, with helmet on and chinstrap buckled, if airway problems noted, remove under in-line traction and assess further
Correct Answer: Check breathing with helmet and chinstrap buckled, if airway problems are noted, remove facemask only, place on spine board
Explanation:
Prevention of further injury is the single most important objective in this patient. While maintaining immobilization of the head and neck check for airway, breathing and pulses (ABC ), followed by level of consciousness. The chin strap and helmet fastened will support the head and neck, and keep it aligned with the body, thereby reducing the risk of spinal cord injury associated with unstable fractures and dislocations. The face mask must be removed from the helmet before rescue breathing can ensue.
Question 13:
A 30-year-old competitive body builder felt a severe pain in his proximal humerus after performing a bench press exercise. He has significant ecchymoses over the anterior aspect of his proximal arm and axilla. There is significant limitation of motion due to pain, with pain to palpation over the insertion of the pectoralis major and the axilla. A magnetic resonance image showed more than 80% avulsion of the pectoralis major from the humerus. What treatment should this patient undergo:
Options:
- Subscapularis transfer
- Primary repair of the tendon to bone through drill holes or with anchors
- Wait until swelling decreases and range of motion returns to normal, then perform a primary repair
- No treatment is necessary, the patient will have functional results with rehabilitation
- Semitendinosis augmentation with repair of the pectoralis tendon through drill holes once swelling and motion are normal
Correct Answer: Primary repair of the tendon to bone through drill holes or with anchors
Explanation:
A complete rupture of the pectoralis insertion demands early surgical treatment in the active athlete. Results of late repair are inferior when compared with primary repair. The tendon is either sutured to bone or anchors are placed to augment repair. Results of those with surgery within one week of injury have been shown to be superior compared to those with delayed surgery or no surgery.
Question 14:
When making an anteromedial portal for ankle arthroscopy, which structure is most "at risk" for injury:
Options:
- The superficial peroneal nerve
- The dorsalis pedis artery
- The extensor hallucis longus
- The posterior tibial nerve
- The saphenous vein
Correct Answer: The saphenous vein
Explanation:
The anteromedial portal is adjacent to the saphenous vein, and injury may occur if care is not taken when creating the portal. A nick in the skin is made and then blunt hemostats are used to spread in line with the neurovascular structures to decrease the likelihood of injury. The anterolateral portal is associated with injury to the superficial peroneal nerve. The anterior-central portal is associated with injury to the dorsalis pedis artery.
Question 15:
Fibrinous degradation in which muscle insertion most commonly characterizes lateral epicondylitis or tennis elbow:
Options:
- Extensor carpi radialis brevis
- Extensor carpi radialis longus
- Extensor carpi ulnaris
- Brachioradialis
- Extensor digitourm longus complex
Correct Answer: Extensor carpi radialis brevis
Explanation:
Degeneration at the extensor muscle group insertion to the lateral epicondyle, primarily the extensor carpi radialis brevis, can be a result of overuse or poor technique in racket sports. Tenderness to palpation at the insertion of the extensor carpi radialis brevis and pain with resisted wrist extension are common findings.
Question 16:
A patient underwent bone-patellar-bone anterior cruciate ligament reconstruction. Postoperative radiographs show the femoral tunnel has been placed too far anteriorly. What is the most likely clinical result of anterior placement of the femoral tunnel:
Options:
- Limited extension
- Anterior instability
- Anterior knee pain
- Limited flexion
- Posterior instability
Correct Answer: Limited extension
Explanation:
A femoral tunnel that has been placed too anterior will limit extension. Numerous studies have shown the most common technical mistake intraoperatively is placement of either the tibial or the femoral tunnel, or both, too far anteriorly. Either of these aberrant placements may cause impingement of the graft and thus promote formation of a large lump of fibrous tissue, known as a Cyclops lesion. This lesion forms anterior to the graft, potentially blocking extension of the knee.
Question 17:
During a wrist arthroscopy in a basketball player who has ulnar-sided wrist pain, the articular disk of the triangular fibrocartilage complex is observed. A probe is inserted and the disk is free floating without tension, (a negative "trampoline test"). What does this signify:
Options:
- Flexor carpi ulnaris subluxation
- Distal radioulnar joint disruption
- Scapholunate instability
- Tear in either the central or peripheral portion of the TFC C
- Ulnar abutment syndrome
Correct Answer: Tear in either the central or peripheral portion of the TFC C
Explanation:
A probe should be used to test the integrity of the articular disc of the TFC C . This disk should be fairly taught, similar to a trampoline. When the articular disk is floppy and floating without tension, a tear in either the central or peripheral portion must be suspected.
Question 18:
A football player has suffered a concussion. It is his first such injury. He suffered loss of consciousness for about 30 seconds and was confused after for 45 minutes. He is now fully asymptomatic at the end of the football game (1 hour after injury). When should he return to play:
Options:
- The next day
- After one month if computed tomography (C T) scan of the brain is negative
- In 1 week
- He should sit out the rest of the season.
- The next day, if C T scan of the brain is negative
Correct Answer: In 1 week
Explanation:
This patient has suffered a grade 2, or moderate concussion. These patients may return to play after one week if asymptomatic. Grade 1: No LOC , posttraumatic amnesia <30 minutes; return to play when symptoms resolve Grade 2: LOC <5 minutes or posttraumatic amnesia >30 minutes; return to play after one week if asymptomatic. Grade 3: LOC >5 minutes, or posttraumatic amnesia >24 hours; minimum delay of 1 month, then may return if asymptomatic.
Question 19:
A collegiate tennis player has undergone surgery for recalcitrant tennis elbow (lateral epicondylitis). He now complains of clicking, catching, and "slipping out of joint" of the elbow. Examination reveals a positive "pivot shift" test of the elbow with normal motion. Radiograph examination is normal. The primary stabilizer of the elbow that is damaged in this patient giving rise to his symptoms of posterolateral rotatory instability is:
Options:
- Lateral ulnar collateral ligament
- Annular ligament
- Medial collateral
- Posterior capsule of the elbow
- Common extensor muscle attachment to the lateral epicondyle
Correct Answer: Lateral ulnar collateral ligament
Explanation:
This patient has incompetence of the lateral ligamentous constraint to the elbow. The most common causes for this injury are previous dislocations and iatrogenic approaches to the lateral elbow. Up to 25% of cases of failed tennis elbow surgery are associated with lateral ligamentous insufficiency. The lateral ulnar collateral ligament has been shown to be the primary restraint to posterolateral instability of the elbow.
Question 20:
A 56-year-old competitive triathelete fell off his bicycle and sustained a traumatic anterior shoulder dislocation. The dislocation was reduced in the emergency room. No associated fractures were noted. A magnetic resonance image examination would be judicious in this patient to:
Options:
- Assess the capsuloligamentous integrity of the shoulder
- Assess for glenoid labrum tears
- Assess the integrity of the articular cartilage
- Assess the integrity of the rotator cuff
- Evaluate the bone for occult fractures
Correct Answer: Assess the integrity of the articular cartilage
Explanation:
Rotator cuff tears may accompany anterior and inferior glenohumeral dislocations. The frequency of this complication increases with age. In patients older than 40 years incidence exceeds 30%; in patients older than 60 years, the incidence exceeds 80%. Shoulder ultrasound, arthrography or MRI is indicated in patients over 40 years of age, with a shoulder dislocation. Prompt repair of these lesions is usually indicated.
