Orthopedic Sports Medic Review | Dr Hutaif Sports Medic -...

The patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral closing- wedge osteotomy would not allow for adequate correction of the tibial slope. If the patient continues to experience instability following correction of the varus malalignment, reconstruction of the ACL and posterolateral corner would be appropriate at that time.

Mild traumatic brain injury is common in the adolescent child. Neuropsychological examination is widely used but, in this case, the patient is asymptomatic and has no baseline testing. There is a limited role for MRI in the recovery process of concussions. Furthermore, higher levels of physical/cognitive activity should be avoided due to their potential to increase total recovery time. In this scenario, a graduated return to activity is most appropriate thus, the next appropriate step is to start light aerobic activity.
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the radiographs at her 6-week appointment show anterior subluxation of the glenohumeral joint indicative of subscapularis insufficiency. Subscapularis repair is the next best step in management, especially in this age group, with well-fixed and well-aligned components.
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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.

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The question stem describes a patient with long-standing anterior glenohumeral joint instability. The axillary view plain radiograph shows blunting of the anterior glenoid rim. The axial cut from the MR arthrogram shows loss of anterior glenoid contour and tear and medialization of the anteroinferior labrum consistent with anterior glenohumeral joint instability. The sagittal cut shows loss of pear-shaped glenoid. With a patient describing innumerable dislocations and anterior glenoid bone loss, the best option is for coracoid transfer or Latarjet. Open or arthroscopic bankart repair does not address the bone loss. Glenoid osteotomy has been advocated for posterior shoulder instability and glenoid retroversion, which the patient does not have.

The injury mechanism and MRI scans demonstrate an isolated posterior cruciate ligament (PCL) tear. PCL injury may result in posterior translational macro-instability of the knee, but may
also result in more subtle and subclinical increases in varus and posterior tibial translation during normal gait and other activities of daily living. These changes result in increased contact stresses in the medial (due to varus forces) and patellofemoral (due to posterior forces) compartments, leading to an increased risk of degenerative chondrosis in these areas.
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Radiographs reveal a reverse Hill-Sachs lesion. This can only occur following a posterior shoulder dislocation. In this case, the patient sustained a posterior shoulder dislocation secondary to seizure activity. The dislocated shoulder is self-reduced. Seizures are a common mechanism for posterior instability because of the severe posterior muscular contractions that occur. It is important to evaluate radiographs for subtle signs of pathology. The axillary image reveals the reason for this patient's shoulder pain showing a reverse Hill-Sachs lesion.

The image depicts the medial ulnar collateral ligament of the elbow. This ligament is the primary restraint to valgus forces at the elbow. It is commonly injured in baseball pitchers. Pain with resisted wrist flexion would suggest medial epicondylitis. Pain with resisted wrist extension would suggest lateral epicondylitis. Lateral elbow pain and varus instability would suggest posterolateral rotatory instability.

Left-sided trapezial atrophy is shown in both images. Trapezial palsy is the most common cause of lateral scapula winging, a finding illustrated in the picture of the patient’s back. This is likely related to dysfunction of the spinal accessory nerve. A common scenario for injury to the spinal accessory nerve would be after a radical neck dissection. In contrast medial scapular winging is likely related to dysfunction of the serratus anterior and long thoracic nerve. Other causes of scapular winging could be direct injuries/avulsions of the serratus anterior, trapezius, and/or rhomboids.

The description and radiograph reveal a case of proximal humeral epiphysiolysis, also called Little Leaguer’s shoulder (LLS). This is an overuse condition resulting from chronic repetitive microtraumatic forces imposed on the unossified cartilage of the proximal humeral
physis. Classic radiographic findings include widening of the proximal humeral physis with increased sclerosis and/or mineralization/lucency. Many factors have been studied as possible contributors to the development of LSS, including all options presented. However, no clear relationship between body weight/height or throwing mechanics exist with LSS. It has also been claimed that the use of breaking pitches (e.g. curve balls, sliders) at an early age are a contributing factor, but this has been refuted by a number of recent studies. By far, the most important factors are the numbers of pitches thrown and the frequency of pitching. This is reflected in a number of indicators, including numbers of innings pitched, number of throwing days, numbers of pitches or pitched innings per week, month and year, and playing for multiple teams.

Images show substantial tunnel widening 17 mm on coronal and 21 mm on sagittal views. Generally, two-stage ACL revision is recommended for tunnels
>14 mm. Anterolateral ligament reconstruction or lateral-extra-articular tenodesis alone would not be adequate to restore knee stability. There is no fracture to necessitate ORIF. Bracing and return to play in a symptomatic, ACL insufficient athlete is not recommended.
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This athlete has experienced a quadriceps contusion with hemorrhage and swelling into the anterior compartment of the thigh. Initial treatment for these injuries is immobilization of the knee in flexion to reduce the amount of bleeding into the anterior compartment. Rest and anti-inflammatory medication may be used in the rehabilitation process but should not take the place of immobilization in flexion. The compartments are soft and therefore, there is no indication for fasciotomy. MRI scan of the femur may demonstrate hematoma in the anterior thigh compartment but is not required to make the diagnosis.

The MRI scan shows a full-thickness cartilage defect. When treated with a marrow stimulation technique, such as a microfracture, the reparative tissue is fibrocartilage. Unlike hyaline cartilage, which is composed of only type 2 collagen, fibrocartilage is composed of both type 1 and type 2 collagen.
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The patient has glenohumeral osteoarthritis based on the radiograph. His examination demonstrates limited motion and no significant rotator cuff pathology – full strength with external rotation, negative belly press, and no pseudoparalysis. Of all the
hoices, an anatomic TSA would be the most appropriate treatment option. Hemiarthroplasty does not address glenoid pathology and provides inferior pain relief and function, compared with TSA. A reverse shoulder arthroplasty is utilized for patients with degenerative shoulder changes in conjunction with irreparable rotator cuff pathology. Shoulder arthroscopy with debridement and biceps tenodesis is not appropriate for those with severe degenerative changes of the shoulder.
Correct answer : A 12

images show a flap tear of the medial meniscus (Figure 2), anterior cruciate ligament tear (Figure 3), and a full thickness articular cartilage defect (Figure 5). Other less likely causes of a double PCL sign include intermeniscal ligament, meniscofemoral ligaments, loose bodies, osteophytes, and fracture fragments.
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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.
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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 D correctly describes the pathomechanics that result in the audible clunk heard during the pivot-shift maneuver. Responses A and B are incorrect because they describe the medial tibial plateau, which is not part of the pathomechanics of the pivot shift. Response C is incorrect because in extension, the lateral tibial plateau is subluxated, not reduced.
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The MRI reveals an osteochondritis dissecans (OCD) lesion that is unstable and has a large osseous component. OCDs are acquired lesions of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and
establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. 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 for 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. In this patient, the fragment is unstable and therefore stabilization of the fragment with internal fixation would be the best treatment option.

The clinical vignette demonstrates an unstable left ankle syndesmotic injury, also known as a “high ankle sprain”. The distal tibiofibular syndesmosis comprises five structures: the anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, the interosseous membrane, the interosseous ligament, and the inferior transverse ligament.
This injury commonly occurs secondary to a forced external rotation motion of the foot. Stable grade 1 strains without diastasis on stress radiographs can be treated with a period of non-weight bearing followed by physical therapy. Unstable injuries, grade 2 and 3, which demonstrate diastasis on external rotation stress radiographs, are commonly treated operatively. Fixation constructs commonly include screw fixation, suture button fixation, or a hybrid combination technique. Naqvi and associates demonstrated more accurate syndesmotic reduction with suture button fixation versus screw fixation. Syndesmotic malreduction has been shown to be an important independent predictor of decreased clinical outcomes. Andersen and associates demonstrated higher AOFAS scores and diminished syndesmotic widening at radiographic follow-up at 2 years with suture button fixation. In a systematic review, Zhang and associates demonstrated higher AOFAS scores, diminished need for implant removal (3.7% vs 40.2%), diminished implant failure, and lower rates of malreduction (1% vs 12%). Thornes and associates demonstrated a faster return to work following suture button fixation versus screw fixation.

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the
nd prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.
Correct answer : B

The MRI scans reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root 18
repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in “Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role in the setting of a reparable meniscal root tear.

The information and image provided describe a throwing athlete with a complete tear of his ulnar collateral ligament (UCL) of the elbow. Numerous techniques have been described for UCL reconstruction, and at this time, optimal graft choice and fixation methods have not been established. Most studies show no.
major differences in outcome between gracilis autograft palmaris autograft, and allograft. Similarly, no clear advantage has been established when comparing use of bone tunnels with interference screws, tunnels with a docking technique, modified docking techniques, and combination
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approaches. Use of a muscle-splitting approach, rather than muscle detachment, appears to improve outcomes, with a larger percentage of patients reporting excellent results and a lower rate of postoperative ulnar neuropathy. With regard to the ulnar nerve itself, routine transposition is no longer indicated in patients such as this with no preoperative neurologic symptoms, as limited handling of the nerve is associated with improved patient-reported outcomes and lower rates of postoperative neuropathy

Concussions can be defined as a traumatically induced transient disturbance of brain function. There is currently no consensus regarding the definition of a concussion, nor is a there a defined biomechanical threshold of a concussion. Concussions occur when either linear and/or rotational forces are transmitted to the brain. A complex disturbance in neurometabolic activity follows. Until normal metabolic activity is restored, a second injury can result in worsening metabolic changes and significant cognitive defects. Given this reasoning, under no circumstances should an athlete be allowed same-day return to physical activity. In terms of return to play, studies have shown that strict rest may actually delay recovery and prolong symptoms. Most studies recommend a 24 to 48 hour period of symptom limited cognitive and physical rest, followed by sub-symptom threshold light aerobic activity.
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chronic exertional compartment syndrome is commonly seen in running athletes and causes a constellation of lower leg pain, weakness and/or
numbness/paresthesias. It is an exercise-induced condition that is thought to result from muscle swelling during activity and
resultant hypoperfusion to the muscles and nerves within the compartment. The description of this patient, with symptoms in the anterior and lateral areas of her lower legs and the foot slap that she describes, indicates symptoms localized to the anterior and lateral compartments as opposed to posterior compartment symptoms. The anterior and lateral compartments would have been released in this patient. The structure seen lays between two released muscular compartments over the intermuscular septum and is the superficial peroneal nerve, which pierces the fascia 10 to 12 cm proximal to the tip of the lateral malleolus.
The structure that would cause medial leg numbness would be injury to the saphenous nerve. Her symptom description is not consistent with posterior compartment syndrome, and these compartments would not have been released at the time of surgery. The structure is not a blood vessel.

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, and loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction. Active shoulder elevation <90° in the presence of full passive motion is termed pseudoparalysis. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve. This patient's sensory examination suggests that the axillary nerve is intact. Cervical radiculopathy is less common after shoulder dislocation but has been reported. Conflicting evidence exists regarding the contribution of the long head of the biceps tendon to glenohumeral stability. One study reported minimal electromyographic activity in the biceps during ten basic shoulder motions.
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The National Collegiate Athletic Association's health and safety guidelines regarding concussion management recommend no return to play on the same day of an injury. In particular, athletes sustaining a concussion should not return to play the same day as their injury. Before resuming exercise, athletes must be asymptomatic or returned to baseline symptoms at rest and have no symptoms with cognitive effort. They must be off of medications that could mask or alter concussion symptoms. Neurocognitive testing can be a helpful tool in determining brain function even after all symptoms of concussion have resolved. With a comparison baseline test, this evaluation, in conjunction with a physician's examination, may reduce risk for second impact syndrome. The athlete's clinical neurologic examination findings (cognitive, cranial nerve, balance testing) must return to baseline before resuming exercise. Research has shown that among youth athletes, it may take longer for tested functions to return to baseline (compared with the recovery rate in adult athletes). Brain MRI scan has no role in evaluating athletes for return to play in this situation.

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The patient has sustained an injury to the musculocutaneous nerve, which is at risk during a coracoid transfer procedure. The terminal branch of this nerve is the lateral antebrachial cutaneous nerve of the forearm. The axillary nerve provides sensation to the lateral arm. The median nerve provides sensation more distally. The radial nerve is not likely to be injured with a coracoid transfer procedure; if it is, the injury would result in numbness near the wrist.in the posterior forearm.

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.

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.

Based upon large multicenter studies and registries including the MARS group and Danish registry, re-tear rates after revision ACL reconstruction are higher when allograft is used as compared with autograft. Sport function, as assessed by the IKDC, is better with the use of autograft. Furthermore, no differences in retear rates or function have been shown between soft tissue and bone patellar tendon bone autograft.
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This study represents a randomized clinical trial with two groups. However, the sample size is small, increasing the risk for type II error, or false-negative findings. Increasing the number of patients in each group would lead to increased power, thereby reducing the risk of a type II error. A type I error is the rejection of a true null hypothesis (false-positive). A randomized trial reduces the risk of selection bias as patients are assigned to groups in a random fashion. Recall bias occurs when participants do not accurately remember previous events or experiences from the past.

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation; this must be avoided by careful attention to initial resting position and station of the knee.

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 wind up, 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.
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The radiographs show a large cam lesion on the anterosuperior aspect of the femoral head, and this is confirmed by high alpha angle (76). Cam and pincer lesions commonly cause labral tears and lead to femoroacetabular impingement. After failure of nonoperative treatment, surgery involves hip arthroscopy, labral repair or debridement, rim trimming (resection of acetabulum), and femoral osteochondroplasty. A periacetabular osteotomy is the preferred surgery in dysplastic patients. Dysplasia is defined as undercoverage of the femoral head, typically a center-edge angle <25/. Reverse periacetabular osteotomy is used for a true retroverted acetabulum. Lastly, open dislocation is the preferred method when the hip deformity is too severe to treat arthroscopically or when the femoral head is significantly overcovered by the acetabulum (center-edge angle >40).
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A 50-year-old right-hand dominant man presents after a traumatic fall on an outstretched right upper extremity. Based upon the MRI scans shown in Figures 1 and 2, what examination test would be abnormal?
A. Belly press
B. Hornblower's test
C. External rotation strength
D. Empty can test
A fall on an outstretched upper extremity can commonly result in a traumatic rotator cuff tear. The images require appropriate interpretation of an acute subscapularis tendon rupture with medial subluxation of the biceps tendon. Subscapularis tendon tears result in a positive belly press or lift-off test. Hornblower's tests for external rotation strength with the arm abducted 90° (teres minor weakness). Empty can tests supraspinatus strength. External rotation strength with the arm at the side tests for infraspinatus weakness.
Correct answer : A

The MRI scan and surgical video are showing an example of a posterior medial meniscal root tear/avulsion. Many studies have shown successful treatment of these tears with repair using various techniques and minimal progression to osteoarthritis (OA). Most studies exclude patients with high BMI. Brophy and associates demonstrated in their series that high BMI was associated with higher rates of clinical OA and need for subsequent surgery.
Multiple studies in the literature demonstrate good results with a variety of techniques. A valgus alignment in this setting would be considered protective, as opposed to a varus alignment >5°, which has also been associated with worse outcomes. The vascularity of the meniscus is consistently poor throughout most of its volume, including the root, and is not considered to be significantly different from person to person and should affect all root repairs equally.

In younger active patients, tendon transfer is considered a preferable treatment option. The patient has failed a course of nonoperative management. Subacromial decompression may offer pain relief but may not be advisable in a patient with rotator cuff deficient shoulder. A total shoulder arthroplasty requires functionality of the supraspinatus and infraspinatus. A reverse total shoulder is an option to alleviate pain and perhaps improve forward flexion height and strength; however, reverse arthroplasty would not improve external rotation in this patient, and there is concern for longevity of the implant in younger patient populations.
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Type-II errors, or beta errors, occur when the null hypothesis is accepted and should have been rejected. An underpowered study is at risk of this type of error. Power is defined as 1-probability of a type-II (beta error), and this is generally set at a level of 80% for most studies. The type-II error occurs when a study concludes that there is no association between the studied variables when in fact one exists. The type-I error, or alpha error, is defined as rejecting the null hypothesis when it should have been accepted. Alpha errors occur when a study suggests an association does exist when in reality it does not. Selection bias occurs when proper randomization is not achieved and therefore, the study cohort is not representative of the population intended to be analyzed.

TO 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 32
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.

The patient has exertional heat exhaustion (EHE). In cases of exertional heat illness with elevated core body temperature, it is critical to differentiate between EHE and exertional heat stroke (EHS). Patients suffering from EHE often complain of dizziness, nausea, cramping and headache. Vital signs can show mild tachycardia and normal to low blood pressure. EHS is defined by elevated core body temperature >40°C (104°F) and organ failure. Rapid cooling is critical in the setting of EHS, but not EHE. In the setting of EHE, the patient should be placed in a cool, shaded area and given fluids. Studies suggest that the presence of carbohydrate (<8%) in combination with electrolytes mildly promotes fluid retention better than drinking water alone.

The MRI scans show a distal biceps tendon avulsion with significant retraction. When addressing these injuries, a single-incision approach has been associated with an increased risk of lateral antebrachial cutaneous nerve injury. A two-incision approach has been associated with an increased risk of heterotopic ossification, second surgeries and posterior interosseous nerve injury.
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The MRI reveals a large full thickness supraspinatus tear. A large, prospective study showed that physical therapy can be effective in the treatment of atraumatic full-thickness rotator cuff tears. Patient expectations regarding the role of rehabilitation were the strongest predictor of surgery. Other
factors associated with surgery were higher activity level and not smoking. Anatomic features of the rotator cuff tear and the severity of patient’s reported pain did not predict failure of nonoperative treatment. Patients who have low expectations regarding the effectiveness of physical therapy are more likely to fail nonoperative treatment.

The MRI scans show a full-thickness tear of the supraspinatus, infraspinatus, subscapularis and medial subluxation of the long head of biceps tendon. Teres minor appears intact on the images. Although the tear of the subscapularis is not as well-visualized, medial subluxation of the long head of biceps is reliably correlated with a subscapularis tear.

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
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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.

Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in adolescent athletes who participate in running or jumping sports. The condition occurs primarily before or during peak growth and is characterized by a tight Achilles tendon, a positive squeeze test, and tenderness over the calcaneal apophysis. Pain is localized to the heel and exacerbated by running. Os trigonum syndrome involves posterior ankle impingement and is commonly associated with ballet dancers. Gastrocnemius strain typically causes pain more proximally at the myotendinous junction. The Thompson test is performed with the patient lying prone on the examination table. Absence of ankle plantar flexion when the examiner squeezes the calf constitutes a positive test and is indicative of Achilles rupture.

The patient is suffering from heat stroke due to the neurologic changes noted by confusion (can not state the date). This is a medical emergency and should be treated with immediate cold-water ice bath immersion and temperature monitoring with a rectal thermometer. Administration of IV fluids is controversial and is not first-line treatment for heat stroke. Transport to a hospital should be delayed until immediate cooling has been achieved and rectal temperature begins to decrease.

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The images are consistent with herpes gladiatorum. This condition is caused by herpes simplex type 1 and occurs in 2% to 7% of wrestlers. It is spread via direct skin contact and is generally seen on the head, neck and shoulders. The lesions are characterized by fluid-filled blisters on an erythematous base. Return to play is permitted after the patient has been treated for 5 days with anti-viral medications, no new lesions are seen within 72 hours and previous active lesions have scabbed over.

The patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral osteoarthritis without significant lateral laxity and thrust.
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This patient has sustained a Lisfranc fracture dislocation of the forefoot. To fully restore foot function, an open reduction and internal fixation should be performed to anatomically reduce this dislocation. Closed reduction is unlikely to restore normal foot biomechanics and would likely result in delayed arthritis and joint incongruity. Posterior splint immobilization, CAM walker ambulation, and in situ percutaneous pinning will not adequately reduce the fracture and restore normal function to the foot.

The arthroscopic images and the patient's history are consistent with a bucket handle tear of the medial meniscus. The ACL graft is intact and well- vascularized as shown in the arthroscopic image. The morphology of the meniscus and that the images are one of a left knee allows the determination that this is a tear of the medial and not the lateral meniscus. The image of the reduced bucket handle medial meniscus tear reveals plastic deformation and a large overlapping peripheral remnant that would make the possibility of healing after revision medial meniscus repair unlikely or suboptimal. The best treatment option for this patient is partial medial meniscectomy.
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This patient has likely sustained an isolated PCL injury. The examination is consistent with a grade II injury to the PCL. In patients with isolated PCL injuries, such as this scenario, the best initial option is nonsurgical treatment and return to play as symptoms subside and strength improves. Physical therapy and delayed PCL reconstruction is not the
ecause this patient can likely be treated without surgery. The absence of valgus laxity and negative dial testing findings suggest that an injury to the posteromedial and posterolateral corners has not occurred. Initial nonsurgical treatment is indicated for this patient. If he completes rehabilitation and experiences persistent disability with anterior and/or medial knee discomfort or senses the knee is "loose," PCL reconstruction should be considered at that time.
Correct answer : A

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The MRI scan shows medial subluxation of the biceps tendon. Biceps tenotomy has been an effective treatment option for patients with large to massive rotator cuff tears when the tear is irreparable and pain is the main symptom. There is no evidence of a loose body on the MRI. Patients with severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer. Reverse total shoulder arthroplasty is an option in patients with cuff tear arthropathy and pseudoparalysis.

Iliotibial band syndrome (ITBS) is a common cause of lateral knee pain in runners. Potential etiologies for the pain include repetitive friction, compression, and bursal inflammation. An Ober test is used to assess iliotibial band tightness. With the patient lying on the unaffected side, the affected leg is abducted and extended. The test result is positive if the examiner is unable to adduct the leg from this position. An MRI scan can be helpful in making the diagnosis, but a negative MRI scan does not rule out ITBS. Studies have reported increased signal intensity on T2-weighted images deep to the iliotibial band adjacent to the lateral epicondyle, with thickening of the iliotibial band. Nonsurgical treatment is most appropriate initially and involves activity modification, ice, anti-inflammatory medications, and stretching. Corticosteroid injection to the iliotibial bursa is also an option to treat acute pain. After the initial inflammation improves, a strengthening program is started. Multiple surgical procedures have been described for recalcitrant cases, including iliotibial band excision, Z-lengthening, and iliotibial band bursectomy.
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The increase in available options for fixation regarding distal biceps tendon repair has led to an abundance of literature comparing various surgical techniques over the past 20 years. Distal biceps tendon tears most commonly occur in the dominant extremity of males in their 40s. Nonoperative management leads to a 40% loss of supination strength and a 30% loss in flexion strength. The injury frequently occurs during eccentric contraction of the biceps muscle. The tendon insertion is comprised of both the long- and short- head insertions. The short head inserts distally on the radial tuberosity acting as a better flexor, whereas, the long head inserts on the apex of the radial tuberosity acting as a better supinator.
Prud’homme-Foster and associates demonstrated that a more anatomic reconstruction on the ulnar aspect of the radial tuberosity is essential to restore maximal supination strength. Both single- and dual-incision techniques
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have demonstrated excellent outcomes; however, each has been shown to have a unique complication profile, which should be taken into consideration when considering operative intervention.
In a meta-analysis, Amin and associates demonstrated that lateral antebrachial cutaneous neuropraxia is the most common complication of the single-incision technique and heterotopic ossification was the most common complication of the dual-incision technique. The complication rate following single-incision technique is higher than that of the dual-incision technique secondary to the high frequency of lateral antebrachial cutaneous nerve neuropraxia.
In a study of complications over 784 procedures, Dunphy and associates demonstrated higher rates of posterior interosseus nerve palsy, heterotopic bone formation and reoperation with the dual-incision technique. There was no significant difference in tendon rerupture rates. Biomechanical studies have demonstrated increased pullout strength with the use of a cortical suspensory button versus transosseous bone tunnels or suture anchors.

The case and radiograph describe a chronic anterior tibial stress fracture with radiographic evidence of the "dreaded black line". Both tibial IM nailing and compression plating are acceptable treatment options in the high-level athlete and are associated with a high rate of return to sport. Compression plating results in a higher rate of symptomatic hardware (20%) as compared with tibial IM nailing. Time to radiographic union may be faster with compression plating. This may be due to the mechanical advantage of neutralizing tensile forces and fracture micromotion. Plating avoids disruption of the knee extensor mechanism and the anterior knee pain associated with IM nailing. There are several reports of fracture completion after tibial IM nailing, requiring revision open reduction and internal fixation.

Internal impingement is the direct contact of the undersurface of the posterior supraspinatus on the posterosuperior labrum in late cocking during the typical throwing motion. This can result in labrum tearing, undersurface rotator cuff tearing or both in their respective locations (as illustrated in Figure 2). Anterior glenohumeral instability (or microinstability) can happen in the setting of throwing for many years as the anterior capsule stretches in the throwing position. This is thought to be exacerbated by posterior capsule tightness that can occur from repetitive microtrauma and scarring during the latter stages of throwing. Posterior instability and subacromial impingement are not typical pathology in the thrower's shoulder and are not exemplified in the throwing motion or arthroscopic images.

The MRI scan 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.

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The clinical vignette describes a 13-year-old boy with Little Leaguers’ shoulder. This is an injury to the proximal humerus growth plate specifically involving the hypertrophic zone of the physis. This condition is considered a Salter-Harris 1 injury to the proximal humerus physis and most commonly affects male throwing athletes ages 11 to 16. The proximal humerus growth plate closes between the ages of 18 to 21. The mechanism of injury involves microtrauma to the growth plate from exposure to excessive rotational torque and distraction forces during the late cocking; early acceleration and deceleration phases of throwing, respectively. High pitch counts have been implicated as risk factors for injury. The diagnosis is frequently made clinically; however, radiographs of the shoulder may reveal widening of the proximal humeral physis in comparison with the contralateral side. Treatment includes cessation of throwing for 3 to 6 months. The patient should be asymptomatic prior to return to a throwing program. Physical therapy and a program of guided return to throwing that enforces proper pitching mechanics can be helpful during a return to play. Following established pitch counts and allowing for appropriate rest before throwing can help to prevent future recurrence.

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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.

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.
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The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of the rotator cuff tendons. Although the radiographs do not reveal any obvious signs of rotator cuff failure, the patient had had an open Bankart 20 years ago. The integrity of the subscapularis tendon following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to consider. Range of motion and infraspinatus strength do not affect the decision-making process, assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which arthroplasty to use.
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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 definitively proven to increase risk for ACL tears.

All responses represent findings that may be associated with chronic UCL insufficiency. Responses A and C 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
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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.

The MRI scan is consistent with an episode of patellar instability with concomitant bruising of the medial patellar facet and lateral femoral condyle. The medial patellofemoral ligament appears torn and attenuated. Kita and associates reported that severe
trochlear dysplasia is the most important predictor of residual patellofemoral instability after isolated medial patellofemoral ligament reconstruction. An increased TT-TG affected outcomes of patients with type D trochlear dysplasia (Dejour classification). Wagner and associates also found that high degrees of trochlear dysplasia correlate with poor clinical outcome due to graft overload in dysplastic situations. Other studies by Nelitz and associates and Matsushita and associates have also suggested that TT-TG distance did not reliably correlate with clinical outcome. Tibial slope would not affect recurrent patellar instability.

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the patient has a symptomatic cartilage lesion of his medial femoral condyle, which has not responded to nonsurgical measures, and he failed a prior arthroscopy with debridement. Based on his examination and imaging, he is ligamentously stable, has normal mechanical alignment, and has intact menisci, making him a candidate for a cartilage restoration procedure. The accompanying MRI also indicates subchondral bone involvement with increased T2 signal underlying the cartilage defect. Osteochondral allograft is the only choice that addresses both the cartilage defect, as well as compromised subchondral bone. Depending on lesion size, osteochondral autograft transfer may also be considered, but this is not presented as an
hoice.
Given the radiographic finding of neutral mechanical alignment, bracing would be less effective, and the patient has already tried extensive physical therapy. Lack of malalignment also excludes tibial osteotomy as a preferred answer choice. Microfracture is best for small cartilage lesions without significant bone marrow involvement.
Correct answer : C

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The MRI scans reveal a root tear of the medial meniscus. Studies demonstrate that this tear pattern greatly increases the tibiofemoral contact forces. These forces, and meniscal extrusion, worsen with increasing flexion.

The principal contraindications to valgus-producing HTO include (1) lateral compartment degenerative joint disease, (2) loss of a significant portion of the lateral meniscus, (3) symptomatic patellofemoral degenerative joint disease,
(4) nonconcordant pain (ie, patellofemoral pain with medial compartment osteoarthritis), (5) smoking, (6) patient unwillingness to accept the anticipated cosmetic appearance of the desired amount of angular correction, and (7) inflammatory arthritis.

The one overriding principle regarding the return to any collision sport, as Torg and associates has described, is that the athlete be "neurologically intact, asymptomatic, and pain-free and have full strength and full cervical range of motion". Forces exerted on the cervical spine can be absorbed by the "elasticity of the intervertebral disk, the mobility of the spine itself, and the impact of absorbing capabilities of the cervical paravertebral musculature". The C1 and C2 levels (atlanto-occipital level) control movement of the skull and articulate the large motion movements. Specifically, partial or complete 56
congenital fusion of the atlas to the base of the occiput results in progressive cord compression by the posterior lip of the foramen magnum. It can result in sudden death.
A cervical disk herniation that was previously treated nonsurgically and is not causing cord compression in the currently asymptomatic patient is not a contraindication to return to collision sports. Spina bifida occulta is common (10-20% of healthy individuals). It is typically an incidental finding and does not result in neurologic problems. If individuals have a healed anterior, lateral or posterior disk herniation that is treated nonsurgically and they are currently asymptomatic, then there is no contraindication to participation in contact sports. If they require a diskectomy and fusion and they have a solid/healed fusion, are asymptomatic and neurologically intact with full and pain-free range of motion, then there is no contraindication to return to collision sports. An acute disk herniation, a disk herniation with associated pain or neurologic symptoms, or the presence of cord compression or loss of normal lordosis are all contraindications.

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have been shown to be strongly correlated with this pathology, nor as specific to this pathology.
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The MRI scans reveal an acute ACL rupture with pivot shift contusions in the lateral tibiofemoral compartment and a bucket handle tear of the medial meniscus. Additionally, there is likely a radial tear of the lateral meniscus at the anterior horn/body junction (Figure 4). Figure 1 shows a bucket handle tear of the medial meniscus with the posterior horn displaced anteriorly. Figure 3 shows a double posterior cruciate ligament sign. Figure 2 shows the ACL tear and Figure 4 shows the pivot shift contusions. There is no evidence of PCL injury on examination or imaging.

Heat illness encompasses a wide spectrum of disorders, including heat edema, cramps, heat exhaustion and heat stroke. Of these, heat stroke is the most serious and dangerous and involves the body’s loss of the ability to self- regulate core body temperature. Although most heat illness findings may be nonspecific and include headache, nausea, dizziness or fatigue, the defining difference between heat stroke and other forms of heat illness is a core (i.e. rectal) body temperature of >40°C (>104°F) associated with central nervous system disturbances. While immediate and rapid cooling should be started regardless, any symptoms of neurologic dysfunction including seizures, confusion or disorientation, warrant transport of the athlete to an emergency department or other referral center.

There are numerous risk factors for ACL reconstruction failure. These include increased tibial slope, younger age, higher activity level, increased preoperative hyperextension and increased preoperative instability (increased Lachman/pivot shift). In this case, the patient had increased hyperextension, and a normal tibial slope and inclination angle. Of the
hoices, hyperextension is her most identifiable risk factor for potential ACL graft failure. Correct answer : A

This player has experienced a “stinger” or “burner”, which results from a transient stretch or compression of the nerves emanating from the brachial plexus. This player experienced complete resolution of symptoms quickly and had a normal physical examination immediately after the injury. As this was the player’s first stinger, he may return to the game without restriction. Multiple stingers would warrant further neurologic work-up. With a normal physical examination, cervical immobilization is not necessary.
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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.

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In patients with painful AC joint osteoarthritis undergoing surgery for concomitant rotator cuff tear, several well-designed studies and meta- analyses have shown that distal clavicle excision does not improve pain, function, shoulder range of motion or decrease need for revision surgery compared with rotator cuff repair alone.

The musculocutaneous nerve enters the conjoint tendon distal to the coracoid. Excessive retraction on the conjoint tendon during the deltopectoral incision can lead to neuropraxia of the Musculo- cutaneous nerve. This would lead to biceps weakness and weakness with elbow flexion. During this approach, it is not recommended to retract with significant tension on the conjoint tendon.

The structure shown is the posterolateral bundle of the anterior cruciate ligament (ACL). This bundle is optimally positioned in the knee to resist rotatory forces during terminal knee extension. "Resist anterior translation during knee flexion" best describes the anteromedial bundle. "Resist rotatory loads during knee flexion" is unlikely because the posterolateral bundle is tightest during knee extension. The posterior cruciate ligament, not the ACL, functions to resist posterior translation.

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The low likelihood that common symptoms associated with meniscal body injury will manifest in patients with root tears makes clinical diagnoses challenging. For instance, patients with a posterior root tear injury may experience joint line pain, but the absence of mechanical symptoms such as locking or catching is probable. Meniscal root tears are also not typically associated with an inciting traumatic event. MRI has become increasingly used in the diagnosis of meniscal root tears. Telltale signs of a root tear include the presence or absence of a ghost sign, which is the absence of an identifiable meniscus in the sagittal plane or high signal replacing the normal dark meniscal signal. The posterior meniscus is seen in sagittal MRI view in all images up to the one that shows the PCL. The posterior root of the medial meniscus attaches anterior to the posterior cruciate ligament (PCL).

Varus and valgus deformities are contributing factors for unilateral osteoarthritis. Leg alignment is a driving force in the management of weight distribution in the knee, and the HTO is biomechanically designed to realign the weight-bearing line (WBL) in the coronal plane. HTO shifts load in the tibial plateau away from the arthritic compartment toward the healthy compartment. Reducing tibiofemoral load and decreasing thrust moment arms in the affected compartment of the knee joint lessens pain and slows progression of osteoarthritis.

The radiographs reveal a high-riding humeral head with an acromiohumeral interval of 1 mm. This indicates a chronic long-standing rotator cuff tear. There is further evidence of arthritic change with grade 4 Hamada findings. The only surgery with predictable outcomes for massive tear, high-riding humeral head and severe arthritis is RSA.
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The radiographs reveal a displaced proximal humerus fracture in a skeletally immature patient. There is tremendous remodeling potential, and similar outcomes are seen in both operative and nonoperative treatment. Worse outcomes are seen with older patients, as the remodeling potential decreases. In a study of 32 pediatric proximal humeral fractures, subgroup analysis of the nonoperative cases showed that, for every 1-year increase in age at initial injury, the odds of a less than desirable outcome increased by a factor of 3.81.

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Bone marrow aspirate has been shown to have higher concentrations of IL-1ra versus both leukocyte-rich and leukocyte-poor platelet-rich plasma. IL-1 is a potent proinflammatory cytokine. IL-1ra blocks binding of IL-1 to its receptor and therefore, serves an anti-inflammatory role.

Recently, there has been much excitement and interest in the use of biologic injections for orthopaedic injuries including tendinopathies, rotator cuff tears, muscle injuries, articular cartilage lesions, sprains and osteoarthritis. PRP is a preparation of human plasma taken from a blood sample of a patient. Through centrifugation, the platelets and plasma are separated from other blood components, and the concentration of platelets is increased. It is not completely clear how PRP works; however, these platelets contain a variety of growth factors, which many believe will aid in the healing of ailments. Though various studies may show limited evidence of their efficacy, there certainly is no conclusive evidence. In particular, clinical trials on the efficacy of PRP in the setting of rotator cuff tears have shown equivocal results.

Multiple factors need to be considered in the setting of the acutely dislocated knee, but beyond the joint being located, the vascular status of the knee needs to be established to avoid an ischemic limb and possibility of amputation. While palpation for pulses certainly can be performed, an ABI should be performed first in this setting. The patient should be supine and ideally Doppler ultrasonography should be used to detect the pulse. ABI <0.9 has been demonstrated to be 100% sensitive and 100% specific for vascular injury (Mills and associates). Selective angiography can be employed if ABI measures indicate a possible injury. ABI measurements can be affected by existing distal arterial sclerosis or calcification, which would not be expected in this young patient. If pulses are absent or other hard ischemic signs are present, ABI can be foregone for operating room (OR) angiography or an equivalent study to determine the exact location of the vascular injury.
A missed compartment syndrome in the setting of a knee dislocation can be a devastating event leading to ischemia and limb dysfunction or tissue death leading to need for amputation. If a suspected compartment syndrome exists, compartment pressures can be measured directly after ABI, and if needed, compartments can be released in the OR in conjunction with vascular repair (if required). Urgent stabilization can also be done in the OR at the time of vascular repair but is not the most important priority in this setting. Angiograms can be performed in the OR to reduce warm ischemia time if ABI measures are concerning, with vascular repair if indicated. This has been superseded by CT-arteriogram in many trauma centers, which can be performed just prior to OR if indicated.
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The patient is exhibiting a motor mononeuropathy that does not follow a radicular pattern. In the absence of a space-filling lesion, e.g., a paralabral cyst at the suprascapular notch or, more commonly, at the spinoglenoid notch (which this patient does not have on MRI), at this time, the patient’s diagnosis is most consistent with neuralgic amyotrophy (NA) - i.e Parsonage-Turner syndrome. NA is reported to be quite rare, with a range of about 20 to 30 cases in 100,000 individuals. Although a hereditary form exists, it is much rarer (and severe), with most cases being idiopathic. Causes are unknown but generally it is thought to be autoimmune in nature and can be triggered by viral illness, as well as other noninfectious triggers..
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Presentation is variable but most commonly affects males and nerves emanating from the upper trunk of the brachial plexus. Typically, the nerves affected are motor and usually, it is a unilateral presentation. The process is usually self-limiting within a 6-month period, but residual deficits can be seen as far out as 3 years from initial presentation. MRI is very sensitive to inflammation in the affected muscles and EMG is typically abnormal along the specific nerve affected. Typically, the best treatment in this time frame is benign neglect, with physical therapy helpful in maintaining range of motion of the affected joint (usually the shoulder) and treatment of the periscapular muscles that are usually being overused to establish function in the affected limb.
Physical examination and these supporting studies differentiate this condition from cervical radiculopathies. An arthroscopic or open decompression of the suprascapular notch may be indicated if no improvement is seen within 6 months of onset of symptoms

The axillary nerve is at most risk in this area of the glenohumeral joint as it passes adjacent to and just inferior to the 6 o’clock position. Although performing capsular shifts within and up to 1 cm from the glenoid rim is generally considered safe, taking large amounts of capsule (>1 cm) in this region in an effort to tighten the capsule can inadvertently damage the nerve as it crosses there.
The musculocutaneous nerve does not cross in this region, although it can be injured during dissection around the coracoid, such as in arthroscopic Latarjet procedures. The musculocutaneous nerve branches to the lateral cutaneous nerve and provides sensory innervation to the lateral aspect of the forearm.
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The suprascapular nerve crosses superior and posterior to the glenoid and is at greatest risk during transglenoid screw placement in the anteroposterior directions. The suprascapular nerve innervates the supraspinatus and the infraspinatus. The radial nerve courses behind the humeral shaft and can be damaged during bicortical fixation in the anterior to posterior direction in this region. A radial nerve palsy would result in wrist extension weakness.

This patient has a complete distal biceps rupture, as evidenced by history, examination and imaging. Surgical repair is typically recommended in otherwise healthy patients to restore supination strength of the forearm. Surgical repair can be undertaken using either a single- or dual-incision approach. The single-incision approach is associated with injury to the lateral
antebrachial cutaneous nerve, whereas the dual-incision approach carries an increased risk of radioulnar synostosis. Tendon retear and radial nerve injury, while possible, are less common.
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The images show a bucket handle medial meniscus tear, which is likely responsible for the block to motion. Therefore, surgery should be recommended with a meniscus repair if possible. Physical therapy or knee aspiration/manipulation under anesthesia is not the best definitive treatment.

Controversy exists regarding optimal treatment of an athlete with a shoulder instability event that has occurred during the competitive season. In the absence of large bony Bankart lesion or significant glenoid or humeral bone loss, particularly in athletes who are not involved in contact sports or throwing, return to sport may be attempted following a course of rehabilitation, provided the patient is asymptomatic following sports-specific drills. However, there is a significant risk of recurrence following nonoperative treatment in patients <20 years, and athletes should be counseled appropriately. Although motion-limiting braces may be associated with subjective improvement in stability, no studies have demonstrated a decreased rate of dislocation associated with bracing.

The history and physical examination describe a patient with an acute ACL rupture and MCL tear. The images are consistent with an acute midsubstance ACL rupture and distal MCL avulsion with proximal retraction/Stener-type lesion. Distal MCL avulsions that retract proximal to the pes anserine tendons have poor healing potential, and failure to treat these injuries typically results in persistent instability that requires delayed reconstruction. The patient demonstrates range of motion from 3° to 120° and only a trace effusion. The best treatment is immediate ACL reconstruction and MCL repair.

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This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of long-standing groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable to those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described 5 patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Infectious mononucleosis presents with fever, pharyngitis, fatigue and lymph node enlargement. It is common among individuals in their teens and early twenties. Participation in contact activities during an acute illness with unresolved splenomegaly increases the risk of splenic rupture. Evidence- based return to play criteria recommend that a patient may return to full- contact activities 4 weeks after the onset of their symptoms with resolution of splenomegaly. An ultrasonography of the spleen can help confirm that the spleen has returned to normal size.
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Complete radial tears of the meniscus body are analogous to root avulsions from a biomechanical standpoint. The complete tears significantly decrease contact area and increase mean contact pressure. This altered weight distribution is not well handled by subchondral bone. Although meniscal loss puts more stress on the ACL and PCL, it is still not a likely mechanism for injury. Although lateral meniscal tear is possible it is not the most likely outcome.

The clinical scenario describes an athlete with chronic exertional leg pain. The differential is large, and there is much overlap in clinical symptoms between different potential diagnoses. The most common overall cause would be medial tibial stress syndrome (MTSS), but in this situation, MTSS is unlikely given the location of her pain and the absence of bony tenderness,
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which is typically along the posteromedial tibia in MTSS. Persistent MTSS is usually evaluated with bone scan or MRI to confirm the diagnosis and to assess for occult stress fracture. Angiography is useful primarily in cases of suspected popliteal artery entrapment, which is a dynamic exercise-related vascular phenomenon. Here, the description of pain in the anterior and/or lateral compartments, the multi-year history, and the predictable time-course for onset and relief of symptoms all strongly suggest a diagnosis of exercise- induced compartment syndrome, also called exertional compartment syndrome. MRI and bone scan are likely to be negative; definitive diagnosis can only be made through direct measurement of compartment pressures before, during and after exercise.

The patient's MRI scan reveals peroneal tendon dislocation. This is a relatively uncommon condition that tends to occur in young, athletic individuals frequently in the setting of a high-grade lateral ankle ligament sprain. The mechanism of injury is
thought to be a rapid forced dorsiflexion of the foot while in an inverted position leading to reflexive contraction of the peroneal tendons. This can lead to a disruption of the superior peroneal retinaculum and subsequently peroneal tendon subluxation or dislocation. Continued subluxation may lead to longitudinal split tears, particularly within the peroneal brevis tendon. Acute injuries in recreational athletes with reducible tendons may be treated with cast immobilization. Elite athletes with an acute injury may be treated with a 77
primary repair of the superior retinaculum; however, chronic injuries may require a fibular groove deepening procedure to reliably stabilize the tendons.

While in the ABER position in the MRI machine, the MRI technician aligns the cut lines along the axis of the humerus and perpendicular through the glenoid, from superior to inferior. According to this, one might assume that the humerus would be seen in a sagittal plane and the glenoid in an axial plane. However, while the glenoid
does stay fixed in an axial plane, the humerus is externally rotated, resulting in a coronal view of the proximal humerus. All of the other options do not depict the anatomic relationship of the humerus and glenoid properly while in the ABER sequence.

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The sternoclavicular joint has a low rate of injury. Usually, it is associated with motor vehicle collision or contact sports. Traumatic sternoclavicular joint injuries are classified from grade I to grade III in ascending severity. Posterior dislocation can be life-threatening, and ATLS protocol and rapid transport to the emergency department is recommended. This injury can be diagnosed by listening for upper airway obstruction or a noticeable change in voice quality as posterior dislocation of the clavicular head obstructs airflow.

The POL originates just distal and posterior to the adductor tubercle, giving it an origin distinct from that of the superficial medical collateral ligament, which originates just proximal and posterior to the medial femoral epicondyle. Distally, the POL has three readily identifiable arms: the superficial, central and capsular arms. The central, or tibial, arm is the largest and thickest of the three arms and forms the main portion of the POL, comprising most of the ligament’s femoral attachment.
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