ORTHOPEDIC MCQS BANK WITH ANSWER SPORT 01

1.         An 18-year-old high school football player sustains a thigh injury that results in the findings shown in Figure 1.  Initial management should consist of

 

1-         gentle passive stretching.

2-         pulsed therapeutic ultrasonography.

3-         interferential electrical stimulation.

4-         cross-fiber friction massage.

5-         resting the muscle group.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The radiograph shows myositis ossificans within the quadriceps muscle.  This condition occurs as a complication of muscle injury.  Initial treatment should include rest, ice, compression, and elevation.  While gentle active range of motion is encouraged in the functional recovery from this injury, passive stretching is contraindicated as it can enhance hemorrhage and accentuate the development of myositis ossificans.  Ultrasound is similarly contraindicated because it can enhance the development of myositis ossificans and has no proven efficacy in this patient; electrical stimulation also has no proven benefits.  Massage is contraindicated in the initial management of this injury because of its influence on increasing local blood flow. 

 

REFERENCES: Anderson JE (ed): Grant’s Atlas of Anatomy.  Baltimore, MD, Williams & Wilkins, 1978, pp 4.39-4.49.

Brumet ME, Hontas RB: The thigh, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, pp 1086-1112.

Antao NA: Myositis of the hip in a professional soccer player: A case report.  Am J Sports Med 1988;16:82-83.

Jackson DW, Feagin JA: Quadriceps contusions in young athletes: Relation of severity of injury to treatment and prognosis.  J Bone Joint Surg Am 1973;55:95-105.

2.         What is the function of the rotator cuff during throwing?

 

1-         Limits humeral head translation in the transverse plane but not in the sagittal plane

2-         Limits superior migration but not anterior and posterior translation

3-         Limits superior migration and anterior and posterior translation

4-         Provides little control of superior anterior and posterior translation

5-         Creates inferior migration with maximal contraction during acceleration

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The coupled action of the rotator cuff prevents superior migration and controls anterior and posterior translation by depressing the humeral head.

 

REFERENCES: Poppen NK, Walker PS: Normal and abnormal motion of the shoulder.  J Bone Joint Surg Am 1976;58:195-201.

Abrams JS: Special shoulder problems in the throwing athlete:  Pathology, diagnosis, and nonoperative management.  Clin Sports Med 1991;10:839-861.

3.         A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago.  She reports that symptoms worsen with athletic activities.  MRI scans are shown in Figures 2a through 2c.  What is the most likely diagnosis?

 

1-         Osteochondral fracture of the lateral femoral condyle

2-         Trabecular injury of the lateral tibial plateau

3-         Lateral meniscal tear with a parameniscal cyst

4-         Fibular collateral ligament tear

5-         Discoid lateral meniscal tear

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The MRI scans show the typical findings of a torn discoid lateral meniscus.  The average transverse diameter of the lateral meniscus is 11 or 12 mm.  A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the menicus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height.  Normally the black “bow tie” would be seen on two contiguous sagittal sections.  The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width.

 

REFERENCES: Jordan MR: Lateral meniscal variants: Evaluation and treatment.  J Am Acad Orthop Surg 1996;4:191-200.

Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging.  Philadelphia, PA, WB Saunders, 1997, pp 625-630.

4.         A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief.  The knee is stable on ligament testing.  Figure 3 shows the findings at a repeat arthroscopy.  Treatment should now include

 

1-         revision of the failing ACL reconstruction.

2-         arthroscopic lysis of adhesions and manipulation of the knee.

3-         surgical removal of hypertrophic fibrous tissue.

4-         excision of the torn medial meniscus.

5-         continued aggressive physical therapy.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has a cyclops lesion.  This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers.  The treatment of choice is excision of the nodule and, if needed, additional notchplasty.  Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.
 

REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis.  Arthroscopy 1998;14:869-876.

Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction.  Am J Sports Med 1993;4:558-564.

5.         The major blood supply to the cruciate ligaments arises from which of the
following structures?

 

1-         Superior genicular artery

2-         Middle genicular artery

3-         Inferior genicular artery

4-         Infrapatellar fat pad

5-         Intramedullary vessels

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The major blood supply to the cruciate ligaments arises from the ligamentous branches of the middle genicular artery.  Few terminal branches of the inferior genicular artery contribute to the blood supply.  The synovial plexus and sheath covering the cruciate ligaments are also supplied by branches of the middle genicular artery.  The blood supply to the cruciate ligaments is predominately of soft-tissue origin.  There is no significant osseous vascular contribution to the ligaments.

 

REFERENCES: Arnoczky SP: Anatomy of the anterior cruciate ligament.  Clin Orthop 1983;172:19-25.

Arnoczsky SP: Blood supply to the anterior cruciate ligament and supporting structures.  Orthop Clin North Am 1985;16:15-28.

6.         In the anterior cruciate ligament (ACL)-deficient knee, which of the following variables has the highest correlation with the development of arthritis?

 

1-   Duration of time since the injury

2-   Patient age

3-   Additional ligament injury

4-   Degree of laxity

5-   Meniscal integrity

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Ample evidence supports an increased rate of degenerative arthritis in the ACL-deficient knee.  Several variables play a role in the development of the arthritis, but the integrity of the meniscus has been shown to be the single most important factor. 

 

REFERENCES: O’Brien WR: Degenerative arthritis of the knee following anterior cruciate ligament injury: Role of the meniscus.  Sports Med Arthroscopy Rev 1993;1:114-118.

Fetto JF, Marshall JL: The natural history and diagnosis of anterior cruciate ligament insufficiency.  Clin Orthop 1980;147:29-38.  

McDaniel WJ Jr, Dameron TB Jr: The untreated anterior cruciate ligament rupture.  Clin Orthop 1983;172:158-163.

7.         A 20-year-old football player has immediate pain in the midfoot and is unable to bear weight after an opposing player lands on the back of his plantar flexed foot.  AP and lateral radiographs are shown in Figures 4a and 4b.  Management should consist of

 

1-         closed reduction and a non-weight-bearing cast.

2-         closed reduction and a weight-bearing cast.

3-         closed reduction and percutaneous pinning.

4-         open reduction and casting.

5-         open reduction and internal fixation.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The history and radiographs indicate a Lisfranc fracture-dislocation of the foot.  The radiographs show the classic “fleck sign,” which is an avulsion of the Lisfranc ligament from the base of the second metatarsal.  Most authors recommend open reduction and internal fixation of this injury.  Closed reduction can be attempted, but anatomic reduction is unlikely because of the interposed bone fragments and soft tissues.  Standard radiographs are not reliable in identifying 1 to 2 mm of subluxation of the tarsometatarsal joint.  The tarsometatarsal joint has a poor tolerance to even mild subluxation, and the resulting decrease in joint contact area increases the likelihood of posttraumatic arthritis.  Open reduction with the joint visible allows more anatomic reduction and internal fixation of larger osteochondral fragments or excision of smaller interposed fragments.

 

REFERENCES: Bellabarba C, Sanders R: Dislocations of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, vol 2, pp 1539-1558.

Murphy GA: Fractures and dislocations of the foot, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9.  St Louis, MO, Mosby, 1998, vol 2, pp 1956-1960.

8.         What effect does deep freezing have on allograft tissue?

 

1-         Causes no deleterious clinical effect on ligamentous grafts

2-         Causes a less deleterious effect on cartilage than on ligamentous grafts

3-         Causes degradation of the extracellular matrix

4-         Allows for preservation of cells with tissue

5-         Eliminates the chance of human immunodeficiency virus (HIV) transmission

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Deep freezing is the simplest and most widely used method of ligament allograft storage.  All cells in the tissue are destroyed with the freezing.  However, for this reason, it is not a preferred storage method for menisci or cartilage allografts.  Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission.  The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation.  No deleterious effects are noted clinically because of the acellularity of the tissue.

 

REFERENCES: Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in
knee reconstruction: I. Basic science aspects and current status.  J Am Acad Orthop Surg 1998;6:165-168.

Caspari RB, Botherfield S, Horwitz RL, et al: HIV transmission via allograft organs and tissues.  Sports Med Arthroscopy Rev 1993;1:42-46.

9.         A 32-year-old man who works as a laborer has had left trapezius wasting and lateral scapular winging after injuring his shoulder when a cargo box fell onto his neck 8 months ago.  He now reports posterior shoulder pain and fatigue, and he has difficulty shrugging his shoulder.  Examination reveals marked scapular winging, impingement signs, and an asymmetrical appearance when the patient attempts a shoulder shrug.  Primary scapular-trapezius winging is the result of damage to the

 

1-         spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

2-         spinal accessory nerve, causing shoulder elevation with the scapula translated medially and the inferior angle rotated medially.

3-         long thoracic nerve, causing shoulder elevation with the scapula translated medially and the inferior angle rotated medially.

4-         long thoracic nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

5-         thoracodorsal nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has primary scapular-trapezius winging.  This condition can be caused by blunt trauma to the relatively superficial spinal accessory nerve that is located in the floor of the posterior cervical triangle in the subcutaneous tissue.  Other causes of injury include penetrating trauma, traction, or surgical injury.  With trapezius winging, the shoulder appears depressed and laterally translated because of an unopposed serratus anterior.  This contrasts with primary serratus anterior winging, which is caused by injury to the long thoracic nerve.  In this condition, the scapula assumes a position of superior elevation and medial translation, and the inferior angle is rotated medially.  The thoracodorsal nerve supplies the latissimus dorsi and is not involved in primary scapular winging.

 

REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging.  J Am Acad Orthop Surg 1995;3:319-325.

Wright TA: Accessory spinal nerve injury.  Clin Orthop 1975;108:15-18.

10.       A 32-year-old football coach has had a 4-month history of increasing right wrist pain, particularly during blocking exercises, and he reports significant pain with range of motion and gripping activities.  He denies any history of trauma.  Examination reveals dorsal wrist tenderness and boggy fullness over the dorsum of the wrist.  No erythema is noted.  Grip strength is 60% compared with the opposite side.  Radiographs are shown in Figures 5a and 5b.  What is the most likely diagnosis?

 

1-         Scapholunate dissociation

2-         Triangular fibrocartilage tear

3-         Scaphoid fracture

4-         Perilunate dislocation

5-         Kienbock’s disease

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has Kienbock’s disease (osteonecrosis of the lunate), which presents with boggy synovitis of the wrist, decreased range of motion, and often normal radiographs.  The patient’s radiographs reveal small fragments from the lunate, with increased density in the lunate body.  While a traumatic event may precede the patient’s pain, often an insidious increase in pain is found.  Repetitive trauma has been suggested as a possible cause.  This disease process is classically associated with an ulnar-negative variant.  An MRI scan, revealing a low-intensity signal in the lunate, is the best diagnostic tool for early Kienbock’s disease. 

 

REFERENCES: Green DP, Hotchkiss RN, Pederson WC: Green’s Operative Hand Surgery, ed 4.  Philadelphia, PA, Churchill Livingstone, 1999, pp 837-848.

Gerwin M, Weiland AJ: Avascular necrosis of the carpals.  Hand Clin 1993, p 761.

11.       Which of the following properties apply to the human meniscus when compared with articular cartilage?

 

1-         Less elastic and less permeable

2-         Less elastic and more permeable

3-         Of the same elasticity and permeability

4-         More elastic and more permeable

5-         More elastic and less permeable

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The meniscal cartilage, like articular cartilage, possesses viscoelastic properties.  The extracellular matrix is a biphasic structure composed of a solid phase (collagen, proteoglycan) that acts as a fiber-reinforced porous-permeable composite, and a fluid phase that may be forced through the solid matrix by a hydraulic pressure gradient.  Although these properties are shared with articular cartilage, the meniscus is more elastic and less permeable than articular cartilage.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 3-23.

Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2.  Rosemont, IL, AAOS, 1999, pp 349-354.

12.       An 18-year-old football player lands on a flexed knee and ankle after being tackled.  Examination reveals increased external rotation and posterior translation and varus at 30° of flexion, which decreases as the knee is flexed to 90°.  What is the most likely diagnosis?

 

1-         Torn posterolateral corner

2-         Torn posterior cruciate ligament (PCL) and posterolateral corner

3-         Torn PCL

4-         Rupture of the quadriceps tendon

5-         Rupture of the lateral collateral ligament

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury.  The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule).  This results in increased posterior translation and external rotation, as well as varus that is most notable at 30° of flexion and decreases as the knee is further flexed to 90°.  Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90° from 30°, while isolated PCL tears show the greatest degree of instability at 90° of flexion.  A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30° of knee flexion without posterior translation.

 

REFERENCES: Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries.  Am J Sports Med 1998;26:471-482.

Veltri DM, Warren RF: Isolated and combined posterior cruciate ligament injuries.  J Am Acad Orthop Surg 1993;1:67-75.

13.       Figure 6 shows the radiograph of a 14-year-old baseball player who felt a pop and had an immediate onset of pain in his elbow after a hard throw from the outfield.  The best course of action should be to

 

1-         obtain stress radiographs of the elbow.

2-         obtain an MRI scan of the elbow.

3-         apply a splint and initiate early range-of-motion exercises.

4-         apply a cast in 90° of flexion for 4 weeks.

5-         perform open reduction and internal fixation.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The valgus stress at the elbow caused by throwing strains the medial collateral ligament.  The medial epicondyle, on which the ligament inserts, is the last ossification center to fuse to the distal humerus, and acute avulsion of the medial epicondyle can occur in adolescents.  If the elbow is allowed to heal in a displaced position, valgus instability and loss of elbow extension may result.  Valgus instability is especially problematic for the throwing athlete.  Surgical treatment with rigid internal fixation is the treatment of choice for displaced medial epicondyle avulsion fractures.  Valgus instability is prevented, and the rigid fixation allows for early range of motion. 

 

REFERENCES: Case SL, Hennrikus WL: Surgical treatment of displaced medial epicondyle fractures in adolescent athletes.  Am J Sports Med 1997;25:682-686.

Woods GW, Tullos HS: Elbow instability and medial epicondyle fractures.  Am J Sports Med 1977;5:23-30.

14.       Osteophyte formation at the posteromedial olecranon and olecranon articulation in high-caliber throwing athletes is most often the result of underlying

 

1-         anterior capsular tears.

2-         forearm pronator and flexor muscle weakness.

3-         biceps or brachialis muscle weakness.

4-         ulnar collateral ligament insufficiency.

5-         radial collateral ligament insufficiency.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: During the late acceleration phase of throwing, the triceps forcibly contracts, extending the elbow as the ball is released.  Normally, this force is absorbed by the anterior capsule and the brachialis and biceps muscles.  However, if the ulnar collateral ligament is insufficient, the elbow will be in a subluxated position during extension and cause impaction of the olecranon and the olecranon fossa posteromedially.  Over time, osteophyte formation is likely to occur.

 

REFERENCES: Conway JE, Jobe FW, Glousman RE, Pink M: Medial instability of the elbow in throwing athletes: Treatment by repair or reconstruction of the ulnar collateral ligament.  J Bone Joint Surg Am 1992;74:67-83.

Wilson FD, Andrews, JR, Blackburn TA, McCluskey G: Valgus extension overload in the pitching elbow.  Am J Sports Med 1983;11:83-88.

15.       Sudden cardiac death in the young athlete is most frequently caused by

 

1-         hypertrophic cardiomyopathy.

2-         active myocarditis.

3-         mitral valve prolapse.

4-         aortic rupture.

5-         coronary artery disease.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in athletes, accounting for 40% of reported cases.  Most athletes have no previous symptoms, and sudden death may be the first clinical manifestation.  The prevalence of hypertrophic cardiomyopathy in the general population is 1 in 500, with a mortality rate of 2% to 4% in young adults.  Athletes with active myocarditis should not engage in sports for up to 6 months, and although they may be at risk for the development of chronic cardiomyopathy, it is rarely a cause of sudden cardiac death.  Mitral valve prolapse with an accompanying systolic murmur is common in the general population, but infrequently a cause of sudden cardiac death.  Weakening of the aortic wall associated with Marfan syndrome can result in abrupt rupture of the aorta.  This accounts for 3% of sudden cardiac deaths in young athletes.  Marfan syndrome usually can be detected on preparticipation screenings by its skeletal and ocular manifestations.  Atherosclerotic coronary artery disease is the most common cause of sudden cardiac death in older athletes, accounting for 75% of reported cases.  However, it is much less common in the young competitive athlete.

 

REFERENCES: Burke AP, Farb A, Virmani R, Goodin J, Smialek JE: Sports-related and non-sports-related sudden cardiac death in young adults.  Am Heart J 1991;121:568-575.

Maron BJ, Sharani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles.  JAMA
1996;276:199-204.

16.       A 14-year-old football player has had right knee pain for the past 2 months; however, he denies any history of trauma.  Examination shows an abductor lurch and increased external rotation of the right lower extremity.  The best course of action should be to

 

1-         apply a knee sleeve during sports.

2-         withdraw from football for 2 weeks.

3-         obtain AP and frog-lateral radiographs of the pelvis.

4-         obtain an MRI scan of the right knee.

5-         initiate physical therapy.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Slipped capital femoral epiphysis is the most common pathology involving the hip in adolescents.  While patients with acute slips may report severe pain and are unable to ambulate, those with chronic slips often have pain during ambulation, a limp, and increased external rotation of the hip.  While 60% of the patients specifically report hip pain, the remainder have pain in the thigh or knee.  The initial diagnostic study of choice is AP and frog-lateral radiographs of the pelvis; bilateral involvement is frequently seen. 

 

REFERENCES: Boyer DW, Mickelson MR, Ponseti IV: Slipped capital femoral epiphysis: Long-term follow-up study of one hundred and twenty-one patients.  J Bone Joint Surg Am 1981;63:85-95.

Stasikelis PJ, Sullivan CM, Philips WA, Polard JA: Slipped capital femoral epiphysis: Prediction of contralateral involvement.  J Bone Joint Surg Am 1996;78:1149-1155.

17.       Which of the following is considered the appropriate initial management protocol for an unconscious football player without spontaneous respirations?

 

1-         Log roll to a supine position, remove the helmet, and begin assisted breathing

2-         Stabilize the head and neck, log roll to a supine position, remove the helmet, and begin assisted breathing

3-         Log roll to a supine position, stabilize the head and neck, remove the face mask, and begin cardiopulmonary respiration (CPR)

4-         Log roll onto a spine board, stabilize the head and neck, remove the face mask, and begin CPR

5-         Stabilize the head and neck, log roll to a supine position, remove the face mask, and begin assisted breathing

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The on-field evaluation and management of the seriously injured athlete requires advance preparation and planning.  It is imperative that the health care team have a game plan in place and the proper equipment readily available.  The initial step consists of stabilizing the head and neck by manually holding the head and neck in a neutral position.  Then, in the following order, check for breathing, pulses, and level of consciousness.  If the athlete is breathing, simply remove the mouth guard and maintain the airway.  If the athlete is not breathing, the face mask must be removed and the chin strap left in place.  An open airway must be established, followed by assisted breathing.  CPR is only instituted when breathing and circulation are compromised.  If the athlete is unconcious or has a suspected cervical spine injury, the helmet must not be removed until the athlete has been transported to an appropriate facility and the cervical spine has been completely evaluated.

 

REFERENCES: McSwain NE, Garnelli RL: Helmet removal from injured patients.  Bull Am Coll Surg 1997;82:42-44.

Vegso JJ, Lehman RC: Field evaluation and management of head and neck injuries.  Clin Sports Med 1987;6:1-15.

Arndt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-101.

18.       Figure 7 shows the radiograph of an 18-year-old hockey player who sustained a shoulder injury during a fall into the side boards.  Examination reveals a significant prominence at the acromioclavicular joint.  Management should consist of

 

1-         a figure-of-8 clavicle strap.

2-         a sling for comfort, followed by early range-of-motion and strengthening exercises.

3-         open reduction and stabilization.

4-         immobilization in a spica cast.

5-         resection of the distal clavicle.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The radiograph shows a type V acromioclavicular separation with greater than 100% superior elevation of the clavicle.  This finding implies detachment of the deltoid and trapezius from the distal clavicle.  Because of severe compromise of function and potential compromise to the overlying skin, surgery is the treatment of choice for type V acromioclavicular separations.  During reduction and repair, meticulous repair of the deltotrapezial fascia will also aid in securing the repair.

 

REFERENCES: Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures.  J Am Acad Orthop Surg 1997;5:11-18.

Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocations.  Am J Sports Med 1995;23:324-331.

19.       A 22-year-old professional ballet dancer reports a 3-month history of posterior ankle pain that occurs when she changes from a flat foot to pointe (hyperplantar flexed position).  Examination does not elicit the pain with forced passive plantar flexion.  A radiograph is shown in Figure 8.  What is the most likely cause of the pain?

 

1-         Mild subtalar arthritis

2-         Posterior tibialis tendinitis

3-         Os trigonum entrapment syndrome

4-         Flexor hallucis longus tenosynovitis

5-         Retrocalcaneal bursitis

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The most common causes of posterior ankle pain in ballet dancers are flexor hallucis longus tenosynovitis and os trigonum syndrome.  Flexor hallucis longus tenosynovitis differs from a symptomatic os trigonum by the absence of pain with forced plantar flexion and the presence of pain with resisted plantar flexion of the great toe.  The pain is often felt in the posterior ankle and can be associated with a snapping or triggering sensation.  Os trigonum syndrome commonly occurs in ballet dancers who perform in a position of extreme plantar flexion.  The pain occurs from entrapment of the os trigonum between the posterior portion of the talus and calcaneus. 

 

REFERENCES: Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment.  J Bone Joint Surg Am 1996;78:1491-1500.

Khan K, Brown J, Way S, et al: Overuse injuries in classical ballet.  Sports Med
1995;19:341-357.

20.       An 18-year-old man recently underwent an uncomplicated arthroscopic partial medial meniscectomy that was complicated by reflex sympathetic dystrophy (RSD), also termed “sympathetically maintained pain” (SMP).  What is the most common finding of
this condition?

 

1-         Joint stiffness

2-         Cold intolerance

3-         Decreased sweating

4-         Osteopenia

5-         Disproportionate pain

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The hallmark for RSD or SMP is the presence of pain that is out of proportion to that expected for the degree of the injury.  SMP often extends well beyond the involved area and is present in a nonanatomic distribution.  The pain is frequently described as a burning sensation, with extreme sensitivity to light touch.  Joint stiffness can be present but is a nonspecific finding.  There may be cold intolerance, but this is not a cardinal symptom.  Sweating actually may be increased.  Osteopenia, if present, is a late finding. 

 

REFERENCES: Lindenfeld TN, Bach BR Jr, Wojtys EM: Reflex sympathetic dystrophy and pain dysfunction in the lower extremity.  Instr Course Lect 1997;46:261-268.

O’Brien SJ, Ngeow J, Gibney MA, Warren RF, Fealy S: Reflex sympathetic dystrophy of the knee: Causes, diagnosis, and treatment.  Am J Sports Med 1995;23:655-659.

21.       What is the main function of collagen found within articular cartilage?

 

1-         Compressive properties

2-         Tensile properties

3-         Proteoglycan synthesis

4-         Cartilage metabolism

5-         Joint lubrication

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The main function of collagen in articular cartilage is to provide the tissue’s tensile strength.  It also immobilizes proteoglycans within the extracellular matrix.  Compressive properties are maintained by proteoglycans.  Cartilage metabolism is maintained by the indwelling chondrocytes.  The flow of water through the tissue promotes transport of nutrients and provides a source of lubricant for the joint.

 

REFERENCES: Simon SR (ed): Orthopaedic Basic Science.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 3-44.

Mow VC, Ratcliffe A: Structure and function of articular cartilage and meniscus, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2.  Philadelphia, PA, Lippincott-Raven, 1997, pp 113-177.

22.       A 15-year-old girl who competes in gymnastics has immediate pain and giving way of the left elbow after falling from the uneven parallel bars and landing on her outstretched arms.  Examination reveals swelling and tenderness about the elbow, especially over the medial side.  Measurement of elbow motion shows 0° to 125° of flexion, and valgus stress at the elbow is painful.  AP, lateral, and stress radiographs are shown in Figures 9a through 9c.  Management should consist of

 

1-         arthroscopic repair of the ulnar collateral ligament.

2-         direct surgical repair of the ulnar collateral ligament.

3-         reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.

4-         a hinged elbow brace to allow early protected range of motion.

5-         immobilization of the elbow to allow healing of the ulnar collateral ligament.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: While many low-demand patients with injuries to the ulnar collateral ligament can be treated nonsurgically, Jobe and associates described two situations in which ulnar collateral ligament reconstruction is indicated: (1) an acute complete rupture in a competitive athlete who uses the upper extremities extensively and who wishes to remain active; and (2) chronic pain or instability that does not improve after at least 3 months of nonsurgical management.  Rarely is direct surgical repair of the ligament possible or able to withstand the valgus stresses applied to the elbow.  Most authors recommend surgical reconstruction of the ulnar collateral ligament using a palmaris longus, plantaris, or fourth toe extensor tendon from the fourth autograft.

 

REFERENCES: Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to the elbow in throwers.  Oper Tech Sports Med 1994;4:109-133.

Jobe FW, Kvitne RS: Elbow instability in the athlete.  Instr Course Lect 1991;40:17-23.

Smith GR, Altchek DW, Pagnani MJ, Keeley JR: A muscle-splitting approach to the ulnar collateral ligament of the elbow: Neuroanatomy and operative technique.  Am J Sports Med 1996;24:575-580.

23.       A 15-year-old boy who participates in track reports acute pain along the left iliac crest during a sprint.  Examination reveals that the anterior superior iliac spine is nontender.  The most likely diagnosis is an injury to the

 

1-         epiphysis.

2-         apophysis.

3-         enthesis.

4-         tendon.

5-         muscle.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has iliac apophysitis.  The radiographic findings are easily overlooked but usually reveal slight asymmetric widening of the iliac crest apophysis.  The apophysis is the most vulnerable structure, as it is three to five times weaker than the tendon.  This is not an epiphyseal site, and injury to the muscle or the tendinous insertion to bone (enthesis) is unlikely.

 

REFERENCES: Clancy WG Jr, Foltz AS: Iliac apophysitis and stress fractures in adolescent runners.  Am J Sports Med 1976;4:214-218.

Waters PM, Millis MB: Hip and pelvic injuries in the young athlete, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, pp 279-293.

Lombardo SJ, Retting AC, Kerlan RK: Radiographic abnormalities of the iliac apophysis in adolescent athletes.  J Bone Joint Surg Am 1983;65:444-446.

Paletta GA Jr, Andrish JT: Injuries about the hip and pelvis in the young athlete.  Clin Sports Med 1995;14:591-628.

24.       A 40-year-old woman who is an avid tennis player reports the insidious onset of progressive left shoulder pain for the past 2 months.  Examination reveals full range of motion with a positive impingement sign.  Strength in the supraspinatus and infraspinatus muscles is normal, although stress testing is painful.  An earlier subacromial cortisone injection provided good, but only temporary relief.  An AP radiograph of the left shoulder is shown in Figure 10.  Management should now consist of

 

1-         a rotator cuff exercise program and anti-inflammatory drugs.

2-         repeat subacromial cortisone injections as necessary.

3-         open subacromial decompression.

4-         arthroscopic evacuation of calcium deposits.

5-         open rotator cuff repair.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The radiograph shows calcific deposits within the substance of the supraspinatus tendon.  Patients with this condition are prone to recurrent bouts of acute inflammation in the shoulder.  While the response to cortisone injection is often dramatic, repeated injections are not recommended because of injury to the collagen fibers.  Good results have been obtained with arthroscopic evacuation of the calcium deposits.  In one study, the addition of a subacromial decompression did not improve the results.

 

REFERENCES: Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of calcific tendinitis of the shoulder.  J Shoulder Elbow Surg 1998;7:30-37.

Ark JW, Flock TJ, Flatow EL, Bigliani LU: Arthroscopic treatment of calcific tendinitis of the shoulder.  Arthroscopy 1992;8:183-188.

25.       Which of the following nerves is susceptible to entrapment near the calcaneal attachment site of the plantar fascia and can mimic or co-exist with plantar fasciitis?

 

1-         First branch of the lateral plantar nerve

2-         Dorsal cutaneous branch of the superficial peroneal nerve

3-         Medial calcaneal branch of the posterior tibial nerve

4-         Lateral branch of the medial plantar nerve

5-         Communicating branch of the fourth common digital nerve

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The first branch of the lateral plantar nerve is susceptible to entrapment beneath the deep fascia of the adductor hallucis muscle adjacent to the calcaneal attachment of the plantar fascia.  This can be a cause of chronic heel pain.  Additionally, the nerve is vulnerable to injury by a blind dissection in releasing the plantar fascia.  The dorsal cutaneous branch of the superficial peroneal nerve supplies sensation to the dorsum of the foot.  The medial calcaneal branch of the posterior tibial nerve lies in the subcutaneous tissues and innervates the skin of the heel.  It is vulnerable to injury from skin incisions on the medial side of the heel.  The lateral branch of the medial plantar nerve forms the second and third common digital nerves.  Entrapment of the proper medial plantar nerve can occur at the master knot of Henry.  This is well distal to the calcaneal attachment of the plantar fascia, and the pain usually radiates more distally in the arch, separate from heel pain.  The communicating branch of the fourth common digital nerve crosses to the third common digital nerve.  Therefore, the third common digital nerve receives supply from both the lateral and medial plantar nerves.  This dual supply has been implicated in the increased incidence of digital neuroma of the third common digital nerve.

 

REFERENCES: Bordelon RL:  Heel pain, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, CV Mosby, 1993, pp 837-857.

Mann RA, Baxter DE: Diseases of the nerves, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, CV Mosby, 1993, pp 543-574.

Baxter DE: The heel in sport.  Clin Sports Med 1994;13:683-693.

26.       Figure 11 shows the radiograph of an 18-year-old soccer player who reports recurrent lateral foot pain after sustaining an inversion injury.  History reveals that 6 months ago he had been treated in a non-weight-bearing cast for a fifth metatarsal fracture.  Management should consist of

 

1-         intermedullary fixation.

2-         a brace or taping to limit inversion stress.

3-         a short leg walking cast or a fracture walker.

4-         a non-weight-bearing short leg cast.

5-         a rigid orthotic insole, with early motion exercises.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Fractures in this area of the fifth metatarsal have a high incidence of delayed union, nonunion, and recurrence with nonsurgical management.  In an acute fracture, prolonged casting in a non-weight-bearing cast may allow for healing; however, in the presence of prolonged symptoms, recurrent fracture, and intermedullary sclerosis, surgical treatment is preferred.  Surgery most commonly consists of intermedullary fixation or medullary curettage and bone grafting, followed by application of a non-weight-bearing cast.

 

REFERENCES: Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management.  J Bone Joint Surg Am 1984;66:209-214.

DeLee JC: Fractures and dislocations of the foot, in Mann R, Coughlin M (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby, 1993, pp 1465-1503.

27.       Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?

 

1-         Ballistic stretching

2-         Static stretching

3-         Proprioceptive neuromuscular facilitation (PNF)

4-         Isokinetic

5-         Eccentric

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Evidence has shown that PNF is the treatment of choice to increase joint range of motion and flexibility.  PNF has the advantage of pushing the patient to stretch a little further when the muscle tendon unit is relaxed by a partner.  While isokinetic and eccentric exercises can improve flexibility, and therefore increase range of motion, their main purpose is to increase strength and endurance.  Ballistic stretching involves a large load applied rapidly; however, evidence has shown that static stretching, where a low load is applied for a long duration, offers a more significant benefit.

 

REFERENCES: Sady SP, Wortman M, Blanke D: Flexibility training: Ballistic, static or proprioceptive neuromuscular facilitation?  Arch Phys Med Rehabil 1982;63:261-263.

Tanigawa MC: Comparison of the hold-relax procedure and passive mobilization on increasing muscle length.  Phys Ther 1972;52:725-735.

Wallin D, Ekblom B, Grahn R, Nordenberg T: Improvement of muscle flexibility: A comparison between two techniques.  Am J Sports Med 1985;13:263-268.

28.       The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

 

1-         Rupture of the subscapularis tendon

2-         Tear of the rotator interval

3-         Humeral avulsion of the glenohumeral ligament (HAGL) lesion

4-         Anterior ligamentous periosteal sleeve avulsion (ALPSA) lesion

5-         Bankart lesion

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The arthroscopic view shows a HAGL lesion.  With the arthroscope directed anteroinferiorly, muscular striations of the subscapularis can be visualized through the avulsion site.  In vitro strain studies indicate that glenohumeral ligament failure on the humeral side occurs in approximately 25% of patients, while clinically this lesion has been reported in approximately 9% of patients with shoulder instability.  Failure to recognize and treat this lesion leads to persistent anterior instability.  An ALPSA lesion, a Bankart variant, occurs on the glenoid side and is characterized by a sleeve-like medial retraction and inferior rotation.  A Bankart lesion is the classic avulsion of the glenohumeral ligament from the glenoid rim.  The subscapularis tendon and the rotator interval are not shown in the figure. 

 

REFERENCES: Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability.  Arthroscopy 1995;11:600-607. 

Bigliani LU, Pollack RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament.  J Orthop Res 1992;10:187-197. 

Warner JJ, Beim GM: Combined Bankart and HAGL lesion associated with anterior shoulder instability.  Arthroscopy 1997;13:749-752. 

29.       An 18-year-old football player has intense pain and is unable to bear weight on the right knee after being tackled from the front.  A posterior knee dislocation is reduced on the field.  Because the game took place in a remote location, the patient is not examined in the emergency department until 5 hours after the injury.  Examination now shows a grossly swollen knee with moderate ischemia in the lower leg.  Posterior tibial and dorsalis pedis pulses are diminished.  The best course of action should be to

 

1-         obtain an emergent arteriogram.

2-         obtain an emergent MRI scan.

3-         perform a thorough examination of the knee ligaments.

4-         perform surgical repair or bypass of the injured popliteal vessels.

5-         perform surgical repair or bypass of the injured popliteal vessels and ligament reconstruction.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Vascular injuries occur in approximately 20% to 35% of knee dislocations, of which one third are posterior.  Recognition of the vascular injury is essential.  Normal pulses or normal capillary refill do not preclude an arterial injury, and arteriography should be considered in all knee dislocations.  If the leg is ischemic, the arteriogram should be circumvented and the patient taken directly to the operating room.  The risk of muscle fibrosis, contracture, or vascular insufficiency, and the need for amputation increase significantly when ischemia exceeds 6 hours.  This patient has ischemia and is considered a vascular emergency.  As such, delays for a thorough examination of the ligament, MRI scans, and even an arteriogram are unwarranted.  Concurrent ligamentous repair and reconstruction should be deferred until vascular stability has been achieved.

 

REFERENCES: Kremchek TE, Welling RE, Kremchek EJ: Traumatic dislocation of the knee.  Orthop Rev 1989;18:1051-1057.

Reckling FW, Peltier LF: Acute knee dislocations and their complications.  J Trauma 1969;9:181-191.

30.       A 17-year-old football player is unable to flex the distal interphalangeal (DIP) joint of his ring finger.  He states that he injured the finger 6 weeks ago while attempting to tackle another player who pulled free from his grip, but he did not inform his coach at the time of the injury.  Current radiographs show an observable fleck of bone volar to the base of the proximal phalanx.  Treatment should consist of

 

1-         fusion of the DIP joint with no reconstruction of the tendon.

2-         advancement and repair of the tendon to the base of the distal phalanx.

3-         two-stage reconstruction of the profundus tendon.

4-         Z-plasty advancement of the profundus tendon.

5-         tenodesis of the distal tendon remnant with the flexor digitorum sublimis.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon.  A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture.  Successful primary repair of the type II rupture has been reported as late as 2 months after the injury.  Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley.  Type III ruptures can be repaired up to several months after the injury. 

 

REFERENCES: Leddy JP: Avulsions of the flexor digitorum profundus.  Hand Clin
1985;1:77-83.

Kiefhaber TR: Closed tendon injuries in the hand.  Oper Tech Sports Med 1996;4:227-241.

31.       A 48-year-old ski instructor dislocates his nondominant shoulder in a fall.  Management consisting of application of a sling for 1 week results in improvement in his pain.  Follow-up examination 6 weeks after the injury reveals that the patient continues to have difficulty with shoulder elevation.  Management should now include

 

1-         use of the sling for an additional 3 weeks.

2-         physical therapy.

3-         a corticosteroid injection.

4-         an MRI scan of the rotator cuff.

5-         arthroscopic labral repair.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Patients who are older than age 45 years and have initial dislocations are at greater risk for tearing the rotator cuff.  Patients who are unable to lift the upper extremity or who have continued pain should undergo further evaluation for potential rotator cuff tears; early diagnosis is preferred.  Physical therapy or continued use of a sling will be of little benefit.  A corticosteroid injection might delay the diagnosis and compromise subsequent rotator cuff repair.  Repairing the labrum generally is not necessary in a patient of this age who has an initial dislocation.

 

REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient.  Clin Orthop 1986;206:192-195.

Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds):  The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 526-622.

32.       Figure 13 shows the MRI scan of a 29-year-old rock climber who reports increasing shoulder pain and weakness.  Based on these findings, atrophy will most likely occur in which of the following muscles?

 

1-         Infraspinatus and supraspinatus

2-         Infraspinatus

3-         Supraspinatus

4-         Teres minor

5-         Deltoid

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The MRI scan shows a cyst at the spinoglenoid notch.  These cysts are often associated with a labral injury, such as a superior labrum anterior and posterior (SLAP) lesion.  The suprascapular nerve passes through the suprascapular notch and sends motor branches to the supraspinatus and sensory branches to the capsule.  At the spinoglenoid notch, the infraspinatus branch of the suprascapular nerve is compressed by the cyst, leading to isolated infraspinatus atrophy.  The teres minor and the deltoid are innervated by the axillary nerve.

 

REFERENCES: Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature.  Arthroscopy 1995;11:727-734. 

Ianotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression.  Arthroscopy 1996;12:739-745.

Tirman PF, Feller JF, Janzen DL, Peterfy CG, Bergman AG: Association of glenoid labral cysts and labral tears in glenohumeral instability: Radiologic findings and clinical significance.  Radiology 1994;190:653-658.

33.       A 46-year-old man has acute tenderness along the ulnar aspect of the wrist after falling on his outstretched hand while playing basketball.  Examination reveals tenderness and mild swelling along the volar ulnar aspect of the wrist.  Radiogaphs are shown in Figures 14a through 14c.  Management should consist of

 

1-         immobilization.

2-         closed reduction.

3-         open reduction and internal fixation.

4-         early range of motion.

5-         excision.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The PA view of the wrist shows a pisiform fracture.  Pisiform fractures constitute 1% to 3% of all carpal bone fractures.  This fracture can be further evaluated with a carpal tunnel view or a supination oblique view of the wrist.  Initial management should consist of immobilization with a short arm cast.  If nonsurgical measures fail, bony excision is warranted.

 

REFERENCES: Failla JM, Amadio PC: Recognition and treatment of uncommon carpal fractures.  Hand Clin 1988;4:469-476.

Botte MJ, Gelberman RH: Fractures of the carpus, excluding the scaphoid.  Hand Clin 1987;3:149-161.

34.       A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight.  He now reports pain in the anterior aspect of the arm that worsens when he opens a door.  Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa.  The MRI scans are shown in Figures 15a and 15b.  If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of

 

1-         elbow extension motion.

2-         elbow flexion strength.

3-         forearm supination motion.

4-         forearm pronation strength.

5-         forearm supination strength.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load.  A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination.  The treatment of choice is a direct primary repair by a two-incision technique.  If left unrepaired, the most disabling consequence is the loss of forearm supination strength.  It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated.  Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic. 

 

REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes.  Am J Sports Med 1993;21:114-119.

Agins HJ, Chess JL, Hoekstra DV, Teitge RA: Rupture of the distal insertion of the biceps brachii tendon.  Clin Orthop 1988;234:34-38.

35.       Figure 16 shows the lateral radiograph of a patient who is scheduled to undergo an anterior cruciate ligament (ACL) reconstruction.  If the graft is tensioned at 20° of flexion and the femoral tunnel is created by passing a reamer over the guide wire marked “A,” the resulting ligament reconstruction will excessively

 

1-         tighten as the knee extends past 10° of flexion.

2-         tighten as the knee flexes past 90°.

3-         loosen as the knee extends past 10° of flexion.

4-         loosen as the knee flexes past 30°.

5-         loosen as the knee flexes past 90°.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: If the femoral tunnel is created using guide wire A, it will be too far anterior in the intercondylar notch.  The distance between a central tibial insertion for the ACL and an anterior femoral tunnel will progressively increase as the knee is flexed.  Therefore, if the graft is tensioned near extension, the ligament will excessively tighten as the knee flexes past 90°.  This will result in restricted knee flexion or failure of the graft as full flexion is gained.  There will be little effect on the ligament as it extends from 20° to 0° of flexion.  If the graft is tensioned in significant flexion (greater than 60°), it will be excessively loose as the knee fully extends.  

 

REFERENCES: Daniel DM, Fritschy D: Anterior cruciate ligament injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice.  Philadelphia, PA, WB Saunders, 1994, pp 1313-1360.

Larson RL, Tailon M: Anterior cruciate ligament insufficiency: Principles of treatment.  J Am Acad Orthop Surg 1994;2:26-35.

36.       Which of the following nerves is most commonly injured during revision surgery following a Bristow procedure?

 

1-         Dorsal scapular

2-         Suprascapular

3-         Axillary

4-         Musculocutaneous

5-         Ulnar

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Because of the previously transferred bone block of coracoid and short arm flexors, the musculocutaneous nerve often scars along the anteroinferior glenohumeral capsule.  Mobilization of this tissue places the nerve at greatest risk.  The axillary nerve is also potentially at risk, but this is nonspecific to prior surgery, particularly the Bristow procedure.

 

REFERENCES: Norris TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complications of Shoulder Surgery.  Baltimore, MD, Williams and Wilkins, 1993,
pp 98-116.

Flatow EL, Bigliani LU, April EW: An anatomic study of the musculocutaneous nerve and its relationship to the coracoid process.  Clin Orthop 1989;244:166-171.

37.       A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season.  An MRI scan confirms a complete ACL tear with no meniscal injuries.  The patient plans an early return to play and would like to avoid surgery.  Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in

 

1-         recurrent buckling with a probable meniscal tear.

2-         limitation of motion with a delay in recovery.

3-         a full return to activity with no limitations.

4-         an improvement in overall performance.

5-         an uneventful completion of the soccer season.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: While there are athletes who can function at a full level with an ACL tear, they are in the minority.  As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL.  Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports.  One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season.  Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability.

 

REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma.  Am J Sports Med 1997;25:656-658.

Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury.  Am J Sports Med 1997;25:191-195.

38.       A patient underwent anterior stabilization of the shoulder 6 months ago, and examination now reveals lack of external rotation beyond 0°.  The patient has a normal apprehension sign and normal strength, and the radiographs are normal.  Based on these findings, the patient is at greater risk for the development of

 

1-         recurring instability.

2-         osteoarthritis.

3-         osteonecrosis.

4-         a tear of the rotator cuff.

5-         internal impingement.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Because the patient’s shoulders are overtensioned anteriorly, premature osteoarthritis may develop.  This may create obligate translation posteriorly and increase the interarticular pressure of the humeral head against the glenoid.  Patients should achieve 20° to 30° of external rotation with the elbow at the side.  Late degenerative arthritis following a Putti-Platt procedure is associated with significant restriction of external rotation.  This patient’s shoulder has a reduced risk of anterior instability, rotator cuff tear, and internal impingement because of the limitation of motion.

 

REFERENCES: Hawkins RJ, Angelo RL: Glenohumeral osteoarthritis:  A late complication of the Putti-Platt repair.  J Bone Joint Surg Am 1990;72:1193-1197.

Norris TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complications of Shoulder Surgery.  Baltimore, MD, Williams and Wilkins, 1993, pp 98-116.

39.       A 13-year-old girl who competes in gymnastics reports the insidious onset of lateral left elbow pain over the past 6 months.  She also notes occasional catching episodes in the elbow; however, she denies any history of trauma.  Examination reveals tenderness over the lateral epicondyle and extensor muscle origin.  The elbow is stable and has full flexion, but lacks 10° of full extension.  An AP plain radiograph and an MRI scan are shown in Figures 17a and 17b.  Management of the elbow should consist of

 

1-         open excision of the radial head.

2-         a cortisone injection into the extensor muscle origin.

3-         a tennis elbow release.

4-         arthroscopic removal of loose bodies and microfracture of the crater.

5-         rest, physical therapy, pulsed electromagnetic therapy, and no further gymnastic activities.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient’s history suggests a loose body.  The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater.  Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum.  Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater.

 

REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum.  Am J Sports Med
1998;26:520-530.

Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast’s elbow.  Arthroscopy 1989;5:129-136.

Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow.  Arthroscopy 1998;14:797-803.

40.       A 25-year-old man injures his shoulder while skiing.  Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test.  What is the most likely diagnosis?

 

1-         Ruptured biceps tendon

2-         Subscapularis tear

3-         Anterior subluxation

4-         Internal impingement syndrome

5-         Locked posterior dislocation

 

PREFERRED RESPONSE: 2

 

DISCUSSION: A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment.  Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis.  A locked dislocation has limited passive movement.  A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma.  Internal impingement is not associated with subscapularis weakness.

 

REFERENCES: Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases.  J Bone Joint Surg Br 1991;73:389-394.

Hawkins RJ, Bokor DJ: Clinical evaluation of the shoulder, in Rockwood CA, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 149-177.

41.       A college basketball player is struck in the eye by a player’s hand while driving to the basket.  Fluorescein evaluation reveals the injury shown in Figure 18.  Management should consist of

 

1-         administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.

2-         evaluation of intact visual fields and pupillary responses prior to a return to play.

3-         consultation with an ophthalmologist prior to emergent repair of the damaged structure.

4-         measurement of ocular pressure and fundoscopic examination in a properly lit examination room.

5-         strict bed rest with the head elevated, minimizing head motion during the healing process.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The athlete has a corneal abrasion.  Fluorescein staining identifies the break in the epithelium when examined with ultraviolet light.  Topical antibiotics are used as prophylaxis against secondary bacterial infection, and the patch, applied with the lid closed, is used for comfort and to promote epithelial healing.  The accompanying symptoms, including pain, tearing, and photophobia, are usually too intense to allow a return to play.  Surgery is reserved for a corneal laceration with associated loss of the anterior chamber.  While a proper fundoscopic examination may be a consideration, increased intraocular pressure is not typically associated with this injury.  Traumatic hemorrhage in the anterior chamber (hyphema) necessitates strict bed rest during the early phases of healing; examination will most likely reveal the red fluid level of blood settling inferiorly in the anterior chamber.  It is often associated with increased intraocular pressure.

 

REFERENCES: Brucker AJ, Kozart DM, Nichols CW, et al: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face.  St Louis, MO, Mosby-Year Book, 1991, pp 650-670.

Zagelbaum BM: Treating corneal abrasions and lacerations.  Phys Sports Med 1997;25:38-44.

42.       In patient selection for meniscal allograft transplantation, which of the following variables has the greatest influence on outcome?

 

1-         Grade of chondromalacia

2-         Limb alignment

3-         Patient age  

4-         Patient weight    

5-         Postoperative level of activity

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Many clinical studies to date show that the extent of arthritis is the most common variable that has the greatest influence on outcome.  The success rate of allograft transplantation is significantly diminished in patients who have grade IV chondromalacia of the knee or notable flattening and general joint incongruity.

 

REFERENCES: Carter TR: Meniscal allograft transplantation.  Sports Med Arthroscopy Rev 1999;7:51-63.

Garrett JC: Meniscal transplantation: A review of 43 cases with two- to seven-year follow-up.  Sports Med Arthroscopy Rev 1993;2:164-167.

van Arkel ER, de Boer HH: Human meniscal transplantation: Preliminary results at 2- to 5-year follow-up.  J Bone Joint Surg Br 1995;77:589-595.

43.       A 10-year-old boy sustained an injury to the left knee.  The radiographic findings shown in Figure 19 are most commonly associated with injury to which of the following structures?

 

1-         Anterior cruciate ligament (ACL)

2-         Posterior cruciate ligament (PCL)

3-         Patellar tendon

4-         Lateral capsule

5-         Pes anserinus

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The radiograph shows a bony avulsion of the ACL attachment site on the tibial spine in this skeletally immature patient.  In this age group, injury often results in failure of the bony attachment site rather than the substance of the ligament.  Avulsion of the patellar tendon insertion site can occur, but this structure is located at the apophysis of the tibial tubercle.  The attachment site of the PCL is much more posterior.  In adults, bony avulsion is more commonly associated with PCL injuries than with ACL injuries.  When a small bony avulsion of the lateral capsule from the lateral tibial plateau is seen on the AP view, this finding is considered pathognomonic of an ACL injury (Segond sign) in adults.  The area of the pes anserinus is anterior and distal; avulsion would be unusual.

 

REFERENCES: Baxter MP, Wiley JJ: Fractures of the tibial spine in children: An evaluation of knee stability.  J Bone Joint Surg Br 1988;70:228-230.

Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia.  J Bone Joint Surg Am 1970;52:1677-1684.

DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, pp 406-432.

44.       What is the single most important nutritional factor affecting athletic performance?

 

1-         Maximum precompetition carbohydrate stores

2-         Adequate carbohydrate consumption during competition

3-         Maintenance of adequate serum sodium

4-         Maintenance of adequate serum potassium

5-         Maintenance of adequate hydration

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Maintenance of adequate hydration is the single most important factor affecting athletic performance.  While carbohydrate loading may be beneficial for some endurance athletes, the consumption of carbohydrates during exercise does not appear to be beneficial for athletes engaged in events that last less than 1 hour.  In general, athletes consuming a balanced diet do not need electrolyte supplementation.

 

REFERENCES: Maughan RJ, Noakes TD: Fluid replacement and exercise stress: A brief review of studies on fluid replacement and some guidelines for the athlete. Sports Med 1991;12:16-31.

Barr SI, Costill DL, Fink WJ: Fluid replacement during prolonged exercise: Effects of water, saline, or no fluid. Med Sci Sports Exerc 1991;23:811-817.

45.       A right-handed 20-year-old college baseball pitcher has had a 6-month history of vague right elbow pain while pitching.  Examination reveals full flexion of the elbow and a loss of only a few degrees of full extension.  The elbow is stable, but palpation reveals tenderness over the olecranon.  Plain radiographs are inconclusive.  MRI and CT scans are shown in Figures 20a and 20b.  Management should consist of

 

1-         repair of a triceps tendon avulsion.

2-         arthroscopy of the elbow for removal of loose bodies.

3-         arthroscopic removal of a posteromedial olecranon osteophyte.

4-         internal fixation of an olecranon stress fracture.

5-         rest, rehabilitation, and resumption of pitching when the fracture is healed.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions.  If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks.  A light throwing program generally can begin at 8 to 12 weeks.  Complete recovery may require 3 to 6 months.  If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture.

 

REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers.  Oper Tech Sports Med 1996;4:91-99.

Griffin LY (ed): Orthopaedic Knowledge Uupdate: Sports Medicine.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 191-203.

46.       What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

 

1-         Glenohumeral arthritis

2-         Fracture of the clavicle

3-         Tear of the rotator cuff

4-         Rupture of the long head of the biceps tendon

5-         Superior labrum anterior and posterior (SLAP) lesion

 

PREFERRED RESPONSE: 5

 

DISCUSSION: It is well known that suprascapular nerve entrapment can be secondary to many entities, and its association with ganglion cysts and SLAP lesions has been well documented.  Because of a superior labral tear, synovial fluid will leak out of the joint underneath the labrum, causing the cyst and secondary compression of the nerve.

 

REFERENCES: Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature.  Arthroscopy 1995;11:727-734.

Iannotti JP, Ramesey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression.  Arthroscopy 1996;12:739-745.

Moore TP, Fritts HM, Quick DC, Buss DD: Suprascapular nerve entrapment caused by supraglenoid cyst compression.  J Shoulder Elbow Surg 1997;6:455-462.

47.       A 27-year-old runner training for his first marathon reports lateral knee pain after an unusually long training run.  He states that the most significant pain occurs while running downhill.  Examination of the patient while he is laying on the unaffected side reveals increased pain when manual pressure is applied to the lateral femoral epicondylar area during knee range of motion of 30° to 45°.  What is the most likely diagnosis?

 

1-         Popliteal tendinitis

2-         Iliotibial band friction syndrome

3-         Excessive lateral pressure syndrome

4-         Lateral meniscal tear

5-         Stress fracture

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Iliotibial band friction syndrome is one of the most common causes of lateral knee pain in runners.  It is caused by increased friction between the iliotibial band and the lateral femoral condyle because of increased tension on the lateral structures.  It may be caused by a prominence of the lateral epicondyle or a malalignment of the lower extremity in the runner, including genu varum, tibia vara, heel varus and forefoot supination, or compensating pronation.  These structural characteristics can couple with relative muscle imbalance and lead to an altered running gait, enhancing friction between the lateral femoral condyle and the iliotibial band.  Management is usually nonsurgical, including stretching of the iliotibial band and strengthening of the hip abductor muscles, with occasional use of cortisone injections or iontophoresis. 

 

REFERENCES: Noble CA: The treatment of iliotibial band friction syndrome. Br J Sports Med 1979;13:51-54.

James SL: Running injuries to the knee. J Am Acad Orthop Surg 1995;3:309-318.

James SL, Jones DV: Biomechanical aspects of distance running, in Cavanagh PR (ed): Biomechanics of Distance Running. Champaign, IL, Human Kinetic Books, 1990, pp 249-269.

48.       A 30-year-old woman who runs approximately 30 miles a week has had right hip and groin pain for the past 3 weeks.  Examination reveals an antalgic gait, limited motion of the right hip, and pain, especially with internal and external rotation.  Plain radiographs are normal, and an MRI scan is shown in Figure 21.  Management should consist of

 

1-         immediate internal fixation of the right femoral neck stress fracture.

2-         non-weight-bearing crutch ambulation until symptoms resolve, followed by a gradual resumption of activities.

3-         ultrasound therapy to promote fracture healing.

4-         a metabolic work-up.

5-         a bone scan to look for other stress fractures.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: A stress fracture of the hip is a relatively common problem in endurance sports.  These fractures are classified as compression-side, tension-side, and displaced femoral neck fractures.  The MRI scan shows a compression-side stress fracture.  Compression-side fractures usually occur in the inferior or calcar area of the proximal femur, and non-weight-bearing crutch ambulation for 6 to 7 weeks will most likely result in healing.  Once the patient is walking without pain or a limp, activities can be slowly increased.  Because tension-side fractures have a high risk of displacement, treatment should consist of immediate internal fixation. 

 

REFERENCES: Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 239-253.

Fullerton LR Jr, Snowdy HA: Femoral neck stress fractures.  Am J Sports Med
1988;16:365-377.

49.       Which of the following primary prognostic factors best predicts the outcome of the knee lesion shown in Figure 22?

 

1-         Location

2-         Size

3-         Knee stability

4-         Patient age

5-         Degree of pain

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient has osteochondritis dissecans.  While location, size, and knee stability are all relevant to the overall prognosis, studies have shown that younger patients with open growth plates have a better prognosis of healing when compared with patients who have closed growth plates.  The degree of pain is also relevant to treatment, but it is subjective rather than objective and is not as reliable of a prognostic indicator as age.

 

REFERENCES: Stanitski CL: Osteochondritis dissecans of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, vol 3, pp 387-405.

Cahill B: Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee.  Clin Sports Med 1985;4:367-384.

Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study.  J Bone Joint Surg Am 1977;59:769-776.

50.       Figures 23a and 23b show the AP and lateral radiographs of the elbow of a 30-year-old professional pitcher.  The pathology shown in these studies is most consistent with which of the following conditions?

 

1-         Insertional triceps tendinitis

2-         Valgus extension overload

3-         Medial epicondylitis

4-         Stress fracture of the olecranon

5-         Chronic olecranon bursitis

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The radiographs show the osteophytic build-up of the posteromedial corner of the elbow that occurs with valgus extension overload in the pitching elbow.  This is the result of excessive valgus forces during the acceleration and deceleration phases of throwing.  These forces, coupled with medial elbow stresses, cause a wedging of the olecranon into the medial wall of the olecranon fossa.  Valgus instability of the elbow may further stimulate osteophyte formation.  Repetitive impact of a spur within the olecranon fossa may cause fragmentation and eventual formation of loose bodies.

 

REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers.  Oper Tech Sports Med 1996;4:91-99.

Field LD, Savoie FJ: Common elbow injuries in sport.  Sports Med 1988;26:193-205.

Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitching elbow.  Am J Sports Med 1983;11:83-88.

51.       Figure 24 shows the radiograph of a 10-year-old boy who sustained a valgus injury to the knee.  Examination reveals grade III medial laxity.  Initial management should consist of

 

1-         an MRI scan. 

2-         stress radiographs of the knee. 

3-         activities as tolerated. 

4-         a hinged range-of-motion brace. 

5-         a knee immobilizer.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Based on the mechanism of injury and findings of medial laxity, the most likely diagnosis is injury to either the growth plate or the medial collateral ligament.  With the open physeal plate, this area of injury is presumed present until proven otherwise; therefore, stress radiographs should be obtained before implementing any treatment or ordering more extensive and expensive tests.

 

REFERENCES: DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994,
vol 3, pp 406-432.

Clanton TO, DeLee JC, Sanders B, Neidre A: Knee ligament injuries in children.  J Bone Joint Surg Am 1979;61:1195-1201.

Torg JS, Pavlov H, Morris VB: Salter-Harris type III fracture of the medial femoral condyle occurring in the adolescent athlete.  J Bone Joint Surg Am 1981;63:586-591.

52.       A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching.  Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability.  Plain AP radiographs of both shoulders are shown in Figures 25a and 25b.  Management should consist of

 

1-         referral to a pitching coach to improve throwing mechanics.

2-         a weight-training program that concentrates on rotator cuff strengthening.

3-         rest until symptoms have resolved, followed by a gradual return to pitching.

4-         a metabolic work-up.

5-         cessation of pitching until the physis is closed.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has the classic signs of Little Leaguer’s shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis.  Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely.  The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic.

 

REFERENCES: Carson WG Jr, Gasser SI: Little Leaguer’s shoulder: A report of 23 cases.  Am J Sports Med 1998;26:575-580.

Barnett LS:  Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers.  A case report.  J Bone Joint Surg Am 1985;67:495-496.

53.       A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing.  He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition.  Management should
consist of

 

1-         ultrasound, iontophoresis, and stretching, with an early return to sports.

2-         a local corticosteroid injection and strengthening, with a delayed return to sports.

3-         immobilization and rehabilitation, with a delayed return to sports.

4-         early surgical repair, prolonged rehabilitation, and a return to sports.

5-         rehabilitation, with delayed surgical repair if the patient is unable to return to sports.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management.  Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management. 

 

REFERENCES: Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles.  Am J Sports Med 1995;23:702-705.

Clanton TO, Coupe KJ: Hamstring strains in the athlete: Diagnosis and treatment.  J Am Acad Orthop Surg 1998;6:237-248.

54.       What mechanism contributes to strength gains during conditioning of the preadolescent athlete?

 

1-         Enhanced neurogenic adaptations

2-         Advanced myogenic adaptations

3-         Increased contractile proteins

4-         Increased short-term energy sources

5-         Thickening of the connective tissue

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Prepubescent athletes gain strength through neurogenic adaptations, including recruitment of motor units, reduced inhibition, and learned motor skills.  Myogenic adaptations (muscle hypertrophy) occur after puberty and include increased contractile proteins, thickening of the connective tissue, and increased short-term energy sources such as creatine phosphate. 

 

REFERENCES: Grana WA: Strength training, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine.  Philadelphia, PA, WB Saunders, 1994, pp 520-526.

Micheli LJ: Strength training, in Sullivan JA, Grana WA (eds): The Pediatric Athlete.  Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 17-20.

55.       Following an episode of transient quadriplegia in contact sports, an athlete’s return to play is absolutely contraindicated when

 

1-         the spinal canal to vertebral body ratio (Torg ratio) is less than or equal to 0.8.

2-         electromyelographic studies are abnormal.

3-         MRI scans or contrast-enhanced CT scans show severe spinal stenosis.

4-         unilateral burning pain persists.

5-         the episode of quadriplegia lasts 5 minutes.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Return to play decisions after traumatic spinal or spinal cord injury are not always clear-cut and often must be made on a patient-by-patient basis.  The Torg ratio has been found to have low sensitivity in patients with large vertebral bodies.  Abnormal electromyographic studies can persist in the face of normal function and do not define spinal injury.  Duration of quadriplegia is not related to anatomic pathology.  Findings on MRI scans or contrast-enhanced CT scans consistent with stenosis include lack of a significant cerebrospinal fluid signal around the cord, bony or ligament hypertrophy, or disk encroachment.  Based on these findings, return to play should be avoided.

 

REFERENCES: Cantu RC, Bailes JE, Wilberger JE Jr: Guidelines for return to contact or collision sport after a cervical spine injury.  Clin Sports Med 1998;17:137-146.

Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ: Normal cervical spine morphometry and cervical stenosis in asymptomatic professional football players: Plain film radiography, multiplanar computer tomography, and magnetic resonance imaging.  Spine 1991;16:178-186.

Bailes JE, Hadley MN, Quigley MR, Sonntag VK, Cerullo LJ: Management of athletic injuries of the cervical spine and spinal cord.  Neurosurgery 1991;29:491-497.

56.       A 16-year-old snowboarder has significant pain and is still unable to bear weight after sustaining a lateral ankle injury in a fall 1 week ago.  Examination reveals swelling and tenderness in the sinus tarsi.  AP, lateral, and mortise radiographs of the ankle are unremarkable.  Management should consist of

 

1-         an elastic bandage, cold packs, and weight bearing as tolerated.

2-         non-weight-bearing and a CT scan of the talus.

3-         cast immobilization for 10 days, followed by progressive rehabilitation.

4-         cast immobilization for 6 weeks, followed by progressive rehabilitation.

5-         stirrup splinting, cold packs, and aggressive rehabilitation.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Because there is a significant possibility that the patient may have a fracture of the lateral process of the talus, there is some disagreement as to the best radiographic study to identify this injury.  A CT scan is an appropriate diagnostic tool to visualize the fracture and identify any displacement.  Displaced lateral process fractures are best treated surgically. 

 

REFERENCES: Kirkpatrick DP, Hunter RE, Janes PC, Mastrangelo J, Nicholas RA: The snowboarder’s foot and ankle.  Am J Sports Med 1998;26:271-277.

Ebraheim NA, Skie MC, Podeszwa DA, Jackson WT: Evaluation of process fractures of the talus using computed tomography.  J Orthop Trauma 1994;8:332-337.

57.       A 24-year-old man who plays golf noted the immediate onset of pain on the ulnar side of his hand and has been unable to swing a club for the past 6 weeks after striking a tree root with his club during his golf swing.  Examination reveals full motion of the wrist, diminished grip strength, and tenderness over the hypothenar region.  A CT scan of the hand and wrist is shown in Figure 26.  Management should consist of

 

1-         immobilization of the wrist until the fracture heals.

2-         excision of the hook of the hamate.

3-         internal fixation of the fractured hook of the hamate.

4-         ultrasound therapy to promote fracture healing.

5-         limited intercarpal arthrodesis.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Fractures of the hook of the hamate frequently are not identified in the acute phase.  Because the fracture can be difficult to see on plain radiographs, the lack of findings can lead to a painful nonunion.  A carpal tunnel view may show the fracture, but a CT scan will best detect the injury.  Immobilization is the treatment of choice and will result in union in most patients unless the diagnosis is delayed.  However, excision of the fragment may be necessary for patients who have nonunion, persistent pain, or ulnar nerve palsy.

 

REFERENCES: Carroll RE, Lakin JF: Fracture of the hook of the hamate: Acute treatment.  J Trauma 1993;34:803-805.

Whalen JL, Bishop AT, Linscheid RL: Nonoperative treatment of acute hamate hook fractures.  J Hand Surg Am 1992;17:507-511.

58.       An 18-year-old football player sustains a contact injury to his right lower leg, and radiographs show a closed transverse fracture of the middle third of the tibia.  Based on the clinical examination, a compartment syndrome is suspected.  When measuring compartment pressures, the highest tissue pressure is recorded how many centimeters proximal or distal to the fracture site?

 

1-         0 cm to 5 cm

2-         5 cm to 10 cm

3-         10 cm to 15 cm

4-         15 cm to 20 cm

5-         Greater than 20 cm

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Measurements of compartment pressures in patients with tibial fractures and compartment syndrome reveal that the highest tissue pressures are recorded at the level of the fracture or within 5 cm of the fracture.  Tissue pressures show a statistically significant decrease when they are recorded at increasing distances proximal and distal to the site of the highest pressure recorded.  To reliably determine the location of the highest tissue pressure in patients with tibial fractures, measurements should be obtained, at a minimum, in both the anterior and deep posterior compartments at the level of the fracture, as well as at locations proximal and distal.  The highest tissue pressure recorded should serve as a basis for determining the need for fasciotomy.

 

REFERENCES: Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD: Compartment pressure in association with closed tibial fractures: The relationship between tissue pressure, compartment, and the distance from the site of the fracture.  J Bone Joint Surg Am 1994;76:1285-1292.

Whitesides TE Jr, Heckman MM: Acute compartment syndrome: Update on diagnosis and treatment.  J Am Acad Orthop Surg 1996;4:209-218.

59.       A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley.  Further diagnostic work-up should include

 

1-         an electromyogram (EMG) of the upper extremity.

2-         an ultrasound of the short head of the biceps.

3-         an MRI scan of the rotator cuff.

4-         a CT scan with contrast of the anterior labrum.

5-         a subclavian venogram.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has a rupture of the long head of the biceps; however, patients older than age 45 years are at greater risk of having an associated rotator cuff tear.  An MRI scan should be ordered to avoid missing concomitant rotator cuff pathology.  While patients may report pain radiating down the arm at the time of the tendon rupture, an EMG is not indicated.  The short head of the biceps is intact and needs no further work-up, even though the muscle descends in most cases.  The anterior labrum can be injured but is not associated with this deformity.  

 

REFERENCES: Neer CS II, Bigliani LU, Hawkins RJ: Rupture of the long head of the biceps related to the subacromial impingement.  Orthop Trans 1977;1:114.

Hawkins RJ, Murnaghan JP: The shoulder, in Gruess RL, Ronnie WRJ (eds): Adult Orthopaedics.  New York, NY, Churchill Livingstone, 1984, pp 945-1054.

60.       A 16-year-old ice hockey player is struck on the chest by the puck.  He skates a few strides and then collapses.  What is the most likely diagnosis?

 

1-         Acute aortic dissection

2-         Pulmonary contusion

3-         Commotio cordis

4-         Acute cardiac tamponade

5-         Splenic rupture

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Sudden cardiac arrest following a blow to the chest in young athletes has been termed “commotio cordis.”  It is most common in Little League and other youth projectile sports (eg, ice hockey, lacrosse).  The cause, although not completely determined, is most likely an arrhythmia related to the impact in a vulnerable time in the cardiac cycle.  Resuscitation has proven to be exceedingly difficult, resulting in a high mortality rate.

 

REFERENCES: Maron BJ, Strasburger JF, Kugler JD, Bell BM, Brodkey FD, Poliac LC: Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes.  Am J Cardiol 1997;79:840-841.

Link MS, Maron BJ, Estes NAM III: Commotio cordis, in Estes NAM III, Salem DN, Wang PJ (eds): Sudden Cardiac Death in the Athlete.  Armonk, NY, Futura, 1998, pp 515-528.

61.       A 24-year-old dancer sustains the injury shown in Figure 28.  Management should
consist of

 

1-         closed reduction and application of a well-molded cast.

2-         open reduction and percutaneous pin fixation.

3-         open reduction and internal fixation with a mini fragment plate and screws.

4-         intramedullary screw fixation.

5-         brief immobilization and symptomatic treatment.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has a moderately displaced distal diaphyseal fracture of the fifth metatarsal, and the most appropriate treatment is brief immobilization and symptomatic management.  Attempts at closed reduction are unlikely to appreciably alter the position of the fracture.  Surgical techniques for either reduction of the fracture or fixation have not been shown to result in improved functional outcomes.

 

REFERENCES: O’Malley MJ, Hamilton WG, Munyak J: Fractures of the distal shaft of the fifth metatarsal: “Dancer’s Fracture.”  Am J Sports Med 1996;24:240-243.

DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, CV Mosby, 1993, pp 1465-1703.

Hamilton WG: Foot and ankle injuries in dancers, in Yokum L (ed): Sports Clinics of North America.  Philadelphia, PA, Williams and Wilkins, 1988.

62.       A 22-year-old volleyball player has atrophy of the infraspinatus muscle.  This deficit is the result of entrapment of what nerve?

 

1-         Axillary nerve in the posterolateral space

2-         Dorsal scapular nerve at the medial border of the scapula

3-         Suprascapular nerve in the scapular notch

4-         Suprascapular nerve in the spinoglenoid notch

5-         Subscapular nerve at the rotator interval

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Suprascapular deficits, as the result of repetitive forceful internal rotation with overhead ball striking, occur in the spinoglenoid notch.  Compression interferes with distal suprascapular nerve innervation to the infraspinatus, while allowing the supraspinatus to function normally.  A scapular notch entrapment of this nerve would involve both the supraspinatus and the infraspinatus.  The axillary, dorsal scapular, and subscapular nerves do not affect the infraspinatus.

 

REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players.  J Bone Joint Surg Am 1987;69:260-263.

Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve.  Arthroscopy 1990;6:301-305.

63.       Figure 29 shows the radiograph of a 25-year-old woman who has had a 3-month history of ankle pain after sustaining an inversion injury to the ankle.  She reports occasional catching, but no sense of instability.  Examination reveals ligament stability.  Management should consist of

 

1-         a non-weight-bearing short leg cast.

2-         open reduction and internal fixation.

3-         no weight bearing with motor exercises for 8 weeks.

4-         debridement, curettage, and drilling.

5-         an ankle brace or taping when participating in athletic activity.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Osteochondral lesions of the talar dome can have a traumatic or nontraumatic etiology.  Most authors site a probable traumatic etiology for lateral lesions.  Stage I and II lesions, which are composed of compressed subchondral bone or a partial detached osteochondral fragment, can be treated initially in a non-weight-bearing short leg cast for 6 weeks.  Stage III medial lesions can also be treated in the same manner.  If symptoms persist, the treament of choice is debridement of the fracture, curettage of the lesion, and drilling of the subchondral bone.  This treatment also applies to lateral stage III and all stage IV lesions.  If the fragment is at least one third of the size of the talar dome, management should consist of open reduction and internal fixation.  In patients with more chronic lesions (4 to 6 months of persistent pain), the threshold to proceed with surgery is lower, even in a stage II lesion.

 

REFERENCES: Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226. 

Pettine KA, Morrey BF: Osteochondral fractures of the talus: A long-term follow-up.  J Bone Joint Surg Br 1987;69:89-92. 

64.       A 19-year-old college cross-country runner is amenorrheic and has recurrent stress fractures.  Long-term management should consist of

 

1-         cross training with swimming and cycling.

2-         a complete cessation of running.

3-         vitamin D and calcium supplements.

4-         increased caloric intake.

5-         oral contraceptives, vitamin D, and calcium supplements.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The triad of menstrual dysfunction, disordered eating, and stress fracture is well recognized in women who participate in endurance sports.  The best treatment remains to be determined, but at present, the combination of oral contraceptives to regulate menses, an increased intake of calcium and vitamin D, as well as nutritional counseling, is the recommended treatment for decreased bone mass related to exercise-induced amenorrhea.

 

REFERENCES: Nattiv A, Armsey TD Jr: Stress injury to bone in the female athlete.  Clin Sports Med 1997;16:197-224.

Drinkwater BL: Exercise and bones: Lessons learned from female athletes.  Am J Sports Med 1996;24:S33-S35.

65.       A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management.  Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion.  He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness.  The MRI scans are shown in Figures 30a and 30b.  To completely resolve his symptoms, treatment should consist of

 

1-         rigid open reduction and internal fixation of the os acromiale with autologous bone graft.

2-         arthroscopic repair of the rotator cuff and acromioplasty.

3-         arthroscopic excision of the os acromiale.

4-         arthroscopic decompression of the supraglenoid cyst.

5-         open distal clavicle excision (Mumford procedure).

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The MRI scans show a mesoacromion with tendonopathy of the supraspinatus.  The history and physical findings indicate that the patient has a symptomatic os acromiale.  Simple excision of the unstable os acromiale has not yielded consistently good results.  Meticulous internal fixation using tension banding with cannulated screws and autologous bone grafting has shown good results for this problem.

 

REFERENCES: Hutchinson MR, Veenstra MA: Arthroscopic decompression of shoulder impingement secondary to os acromiale.  Arthroscopy 1993;9:28-32.

Warner JJ, Beim GM, Higgins L: The treatment of symptomatic os acromiale.  J Bone Joint Surg Am 1998;80:1320-1326.

66.       A 39-year-old competitive cyclist sustains an injury to her left hip in a fall.  Gadolinium arthrography, with an accompanying MRI scan, is shown in Figure 31.  A cleft, or defect, identified by the arrow, indicates a detachment of the

 

1-         acetabular labrum.

2-         zona orbicularis.

3-         iliofemoral ligament.

4-         acetabular pulvinar.

5-         retinacular vessels.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The area indicated by the arrow represents gadolinium contrast extending into a separation between the lateral labrum and its acetabular attachment.  This can be a traumatic detachment, but occasionally a cleft may be present as a normal variant of the labral morphology.  The capsular attachment of the iliofemoral ligament is peripheral to the labrum.  The pulvinar is the common name applied to the fat and overlying synovium contained within the acetabular fossa above the ligamentum teres.  The zona orbicularis is a circumferential thickening of the capsule around the femoral neck, and the retinacular vessels travel within the capsular synovium up the femoral neck to supply the femoral head.

 

REFERENCES: Petersilge CA, Haque MA, Petersilge WJ, Lewin JS, Lieberman JM, Buly R: Acetabular labral tears: Evaluation with MR arthrography.  Radiology 1996;200:231-235.

Czerny C, Hofmann S, Neuhold A, et al: Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging.  Radiology 1996;200:225-230.

Byrd JWT: Indications and contraindications, in Byrd JWT (ed): Operative Hip Arthroscopy.  New York, NY, Thieme, 1998, pp 7-24.

67.       A cortisone injection in the subacromial space will most likely result in

 

1-         elevated blood glucose levels in patients with diabetes.

2-         increased instability in multidirectional patients.

3-         accelerated rupture of the long head of the biceps.

4-         accelerated osteoporosis of the tuberosity.

5-         altered proprioception of the glenohumeral joint.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: A cortisone injection in the subacromial space will most likely result in elevated blood glucose levels in patients with type I diabetes mellitus.  Patients should be warned of this potential complication.  Cortisone does not have an effect on instability or proprioception, and a single injection would not affect osteoporosis.  Repetitive injections or injection into the tendon itself could accelerate rupture of the biceps tendon.

 

REFERENCES: Matsen FA III, Arntz CT: Subacromial impingement, in Rockwood CA, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, pp 623-646.

Koehler BE, Urowitz MB, Killinger DW: The systemic effects of intra-articular corticosteroid.  J Rheumatol 1974;1:117-125.

68.       A high school athlete reports the sudden onset of low back pain while performing a dead lift.  Examination reveals a lumbar paraspinal spasm and a positive straight leg raising test.  The deep tendon reflexes, motor strength, and sensation in the lower extremeties are normal.  The radiographs are normal.  If symptoms persist for more than a few weeks, management should consist of

 

1-         an electromyogram and nerve conduction velocity studies.

2-         an MRI scan.

3-         a bone scan.

4-         physical therapy.

5-         bed rest.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: In adolescents, a lumbar herniated disk is characterized by a paucity of clinical findings; a positive straight leg raising test may be the only consistent positive finding.  This may result in a long period of nonsurgical management that fails to provide relief.  Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation.  When an adolescent who lifts weights has a history of low back pain that fails to respond to a short period of active rest, an MRI scan is the study of choice to evaluate for a lumbar herniated disk.

 

REFERENCES: Epstein JA, Epstein NE, Marc J, Rosenthal AD, Lavine LS:  Lumbar intervertebral disk herniation in teenage children:  Recognition and management of associated anomalies.  Spine 1984;9:427-432.

Hashimoto K, Fujita K, Kojimoto H, Shimomura Y: Lumbar disc herniation in children.  J Pediatr Orthop 1990;10:394-396.

69.       A 22-year-old skier reports painful range of motion in the left thumb after falling forward on his outstretched hand while holding his ski pole.  Examination of the left thumb reveals increased AP laxity and 45° of valgus laxity at the metacarpophalangeal (MCP) joint.  Examination of the right thumb shows 25° of valgus laxity at the MCP joint.  Radiographs are normal.  Management should consist of 

 

1-         primary repair of the ulnar collateral ligament.

2-         volar plate arthroplasty.

3-         pinning of the MCP joint for 6 weeks.

4-         a thumb spica cast.

5-         a hand-based thumb spica splint.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has a complete tear of the ulnar collateral ligament as defined by MCP joint laxity of greater than 30° (or 15° greater laxity compared with the opposite side).  Primary repair is the treatment of choice because displacement of the ligament superficial to the adductor aponeurosis (Stener lesion) must be corrected.  Any volar plate injury can be addressed during repair of the ulnar collateral ligament. 

 

REFERENCE: Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint.  J Am Acad Orthop Surg 1997;5:224-229.

70.       Which of the following structures is most commonly involved in lateral epicondylitis?

 

1-         Anconeus

2-         Extensor digitorum communis

3-         Extensor carpi radialis longus

4-         Extensor carpi radialis brevis

5-         Extensor carpi ulnaris

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The most common specific site of involvement is the origin of the extensor carpi radialis brevis.  It is usually caused by overuse activities, such as the eccentric overload exhibited during a backhand in tennis.  In most patients, the characteristic friable, grayish tissue described as angiofibroblastic hyperplasia or hyaline degeneration is seen at the extensor carpi radialis brevis origin.

 

REFERENCES: Nirschl RP: Elbow tendinosis/tennis elbow.  Clin Sports Med 1992;11:851-870.

Regan W, Wold LE, Coonrad R, Morrey BF: Microscopic histopathology of chronic refractory lateral epicondylitis.  Am J Sports Med 1992;20:746-749.

71.       When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surgery would most
likely reveal

 

1-         significant quadricep weakness in the pateller tendon compared with the hamstring.

2-         significant quadricep weakness in the hamstring compared with the pateller tendon.

3-         significant weakness in the hamstring compared with the patellar tendon.

4-         significant hamstring weakness in the pateller tendon compared with the hamstring.

5-         no significant difference between the hamstring and the pateller tendon.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically.  Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength.

 

REFERENCES: Carter TR, Edinger S: Isokinetic evaluation of anterior cruciate ligament reconstruction: Hamstring versus patellar tendon.  Arthroscopy 1999;15:169-172

Howell SM, Taylor MA: Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft.  J Bone Joint Surg Am 1996;78:814-825.

Shelbourne KD, Nitz P: Accelerated rehabilitation after anterior cruciate ligament reconstruction.  Am J Sports Med 1990;18:292-299.

72.       A quarterback sustains a rough tackle after which he appears confused, has a dazed look on his face and an unsteady gait on standing.  He denies loss of consciousness.  Reexamination within 10 minutes is normal, the patient is lucid, and he wants to return to play.  The coach and the player should be advised that he may

 

1-         return to play immediately.

2-         return to play in 1 week, if asymptomatic.

3-         return to play in 1 month, if asymptomatic.

4-         return only after a screening CT scan.

5-         not return to play for the season.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has a grade I (mild) concussion that can result in confusion and disorientation, without loss of consciousness.  This concussion syndrome is completely reversible, with no long-term sequelae.  Athletes who sustain a grade I concussion may return to play after 15 minutes if there are no lingering symptoms, such as headache or vertigo.  A grade II concussion is characterized by loss of consciousness of less than 5 minutes.  With this type of injury, the athlete can return to play in 1 week, if asymptomatic.  If a grade III (severe) concussion is sustained, the athlete should avoid contact for a minimum of 1 month before considering a return to competition.  A grade III concussion is characterized by a loss of consciousness of greater than 5 minutes or posttraumatic amnesia of greater than 24 hours.  A CT scan is not indicated in a grade I injury.  An athlete who sustains three grade I or grade II concussions, or two grade III concussions may not return to play for the season. 

 

REFERENCES: Torg JS, Gennarelli TA: Head and cervical spine injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine Principles & Practice.  Philadelphia, PA, WB Saunders, 1994, vol 1, pp 417-462.

Cantu RC: Criteria for return to competition after closed head injury, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face.  St Louis, MO, Mosby, 1991.

73.       The bone avulsion shown in Figure 32 has a high correlation with tearing of the

 

1-         iliotibial band.  

2-         anterior cruciate ligament.

3-         posterior cruciate ligament.

4-         lateral collateral ligament.

5-         biceps femoris tendon.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: As described by Segond in 1987, an avulsion fracture of the lateral tibial plateau is commonly referred to as a Segond fracture.  Subsequent to 1987, several authors have also found that the lateral capsular sign represents, but is not limited to, a disruption of the middle third of the lateral capsule and a tear of the anterior cruciate ligament. 

 

REFERENCES: Bach BR, Warren RF: Radiographic indicators of anterior cruciate ligament injury, in Feagin JA (ed): The Crucial Ligaments.  New York, NY, Churchill Livingston, 1988, pp 301-327.

Segond P: Recherches cliniques et experimentales sur les epanchements sanguins du genou par entorse.  Prog Med (Paris) 1987;7:297.

Johnson LL: Lateral capsular ligament complex: Anatomical and surgical considerations.  Am J Sports Med 1979;7:156-160.

74.       A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season.  Management should consist of

 

1-         cast immobilization and a return to play as symptoms allow.

2-         cast immobilization and a return to play when union is achieved.

3-         open reduction and internal fixation, followed by early range of motion with a return to play when union is achieved.

4-         open reduction and internal fixation, followed by a return to play with protective casting.

5-         symptomatic treatment, with definitive treatment at the end of the season.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The union rate for minimally displaced midthird scaphoid fractures is quite high with cast immobilization while allowing a return to sports.  Inadequate immobilization results in a much higher nonunion rate.  Early fixation and rehabilitation have been proposed for sports or positions that are not amenable to cast immobilization.  While immobilization of a nondisplaced fracture results in an acceptably high union rate, there is no advantage to fixation in conjunction with immobilization in the course of healing.  With adequate immobilization and protection, play restrictions until healing has occurred are unnecessary.

 

REFERENCES: Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in the athlete.  Am J Sports Med 1996;24:182-186.

Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management in midthird scaphoid fractures in the athlete.  Am J Sports Med 1994;22:711-714.

Riester JN, Baker BE, Mosher JF, Lowe D: A review of scaphoid fracture healing in competitive athletes.  Am J Sports Med 1985;13:159-161.

75.       A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee.  Examination reveals a contusion over the anterior tibial tubercle and a
small effusion.  MRI scans are shown in Figures 33a through 33c.  What is the most likely diagnosis?

 

1-         Partial tear of the patellar tendon

2-         Osteochondral fracture of the femur

3-         Anterior cruciate ligament (ACL) tear

4-         Posterior cruciate ligament (PCL) tear

5-         Patella fracture 

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The MRI scans show disruption of the fibers of the PCL.  Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion.  When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered.  In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%.

 

REFERENCES: Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging.  Philadelphia, PA, WB Saunders, 1997, pp 699-700.

Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries.  Am J Sports Med 1998;26:471-482.

Fischer SP, Fox JM, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD: Accuracy of diagnoses from magnetic imaging of the knee: A multi-center analysis of one thousand and fourteen patients.  J Bone Joint Surg Am 1991;73:2-10.

76.       A 15-year-old diver has had persistent, activity-related low back pain for the past 2 months.  He denies any history of trauma.  Examination reveals that the pain is localized to the lumbosacral junction, and there are no radicular symptoms.  The pain is worse with back extension.  Neurologic examination is normal, as are AP, lateral, and oblique radiographs of the lumbosacral spine.  Further evaluation should include

 

1-         flexion and extension radiographs of the lumbosacral spine.

2-         diskography.

3-         an MRI scan of the lumbosacral spine.

4-         a bone scan with single proton emission computed tomography (SPECT).

5-         a renal ultrasound.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Spondylolysis may develop as a stress fracture resulting from repetitive hyperextension during athletic activities.  In young people, the pars interarticularis is thin, the neural arch has not yet reached maximum strength, and the intravertebral disk is less resistant to shear.  While clinical symptoms may lead to the suspicion of spondylolysis, radiographic confirmation may be difficult in early cases.  Plain radiographs may be negative initially, and the plain MRI scan may not offer good visualization of the pars.  A bone scan with SPECT is very sensitive initially.  CT scans with regular axial and reverse-gantry angled cuts may help determine the type of fracture and the course of treatment.

 

REFERENCES: Congeni J, McCulloch J, Swanson K: Lumbar spondylolysis: A study of natural progression in athletes.  Am J Sports Med 1997;25:248-253.

Harvey CJ, Richenberg JL, Saifuddin A, Wolman RL: The radiological investigation of lumbar spondylolysis.  Clin Radiol 1998;53:723-728.

77.       A 23-year-old college basketball player reports persistent lateral ankle pain after sustaining an inversion injury 6 months ago.  Examination reveals pain over the anterolateral ankle, absence of swelling, and no clinical instability.  Management consisting of vigorous physical therapy fails to provide relief, and a intra-articular corticosteroid injection provides only temporary relief.  Radiographs obtained at the time of injury and subsequent AP and varus stress views are normal.  A recent MRI scan fails to show any abnormalities.  Management should now include

 

1-         cast immobilization.

2-         arthroscopy.

3-         continued physical therapy.

4-         a repeat corticosteroid injection.

5-         a short course of oral steroids.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Because the patient has failed to respond to appropriate nonsurgical management and imaging studies are normal, the use of arthroscopy not only aids in the diagnosis of chronic ankle pain, but is also helpful in its treatment.  In patients with this condition, typical findings include synovitis in the lateral gutter and fibrosis along the talofibular articulation; syndesmosis chondromalacia of the talus and ankle also may be found.  In patients with anterior soft-tissue impingement, approximately 84% who have a poor response to nonsurgical management will have a good to excellent response after arthroscopic synovectomy and debridement.

 

REFERENCES: Ferkel RD, Fasulo GJ: Arthroscopic treatment of ankle injuries.  Orthop Clin North Am 1994;25:17-32.

Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP: Arthroscopic treatment of anterolateral impingement of the ankle.  Am J Sports Med 1991;19:440-446.

78.       Which of the following tissues used for anterior cruciate ligament (ACL) reconstruction has the highest maximum load to failure?

 

1-         Allograft ACL

2-         Bone-patellar tendon-bone with a width of 10 mm

3-         Fascia lata with a width of 15 mm

4-         Central quadriceps tendon with a width of 15 mm

5-         Quadruple semitendinosus and gracilis tendons

 

PREFERRED RESPONSE: 5

 

DISCUSSION: While the patellar tendon ligament is considered by many to be the tissue of choice for ACL reconstruction, more recent studies have shown that the quadruple semitendinosus and gracilis tendon graft has the greatest stiffness and offers the highest maximum load to failure.

 

REFERENCES: Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques.  J Bone Joint Surg Am 1999;81:549-557.

Cooper DE, Deng XH, Burstein AL, Warren RF: The strength of the central third patellar tendon graft: A biomechanical study.  Am J Sports Med 1993;21:8l8-823.

Brown CH Jr, Steiner ME, Carson EW: The use of hamstring tendons for anterior cruciate ligament reconstruction: Technique and results.  Clin Sports Med 1993;12:723-756.

Engebretsen L, Lewis JL: Graft selection and biomechanical considerations in ACL reconstruction.  Sports Med Arthroscopy Rev 1996;4:336-341.

79.       Creatine is currently being used by athletes as a dietary supplement in an attempt to enhance performance.  What is the physiologic basis for its use?

 

1-         Assists in carbohydrate metabolism and glycogen synthesis by producing adenosine diphosphate (ADP) to enhance aerobic activities

2-         Converts to phosphocreatine (PCr), which acts as an energy reservoir for adenosine triphosphate (ATP) in muscle tissue

3-         Converts to PCr, which enhances the production of ADP and promotes the metabolism of triglycerides as an energy source

4-         Converts to PCr, which enhances the production of ADP and promotes the metabolism of proteins as an energy source

5-         Converts to ADP by creatine kinase (CK) providing an energy reservoir for the production of ATP

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Creatine is currently used as a nutritional supplement in an attempt to enhance athletic performance.  The physiologic basis for its use is based on its conversion by CK to PCr, which acts as an energy reservoir in muscle cells for the production of ATP.  A number of studies that examined the effect of creatine supplementation on performance concluded that while creatine does not increase peak force production, it can increase the amount of work done in the first few anaerobic short duration, maximal effort trials.  The mechanism for this enhancement of work is unknown, but it is most likely secondary to the increase in the available PCr pool.

 

REFERENCES: Greenhaff PL: Creatine and its application as an ergogenic aid.  Int J Sport Nutr 1995;5:S100-S110.

Greenhaff PL, Casey A, Short AH, Harris R, Soderlund K, Hultman E: Influence of oral creatine supplementation on muscle torque during repeated bouts of maximal voluntary exercise in man.  Clin Sci 1993;84:565-571. 

Trump ME, Heigenhauser GJ, Putman CT, Spriet LL: Importance of muscle phosphocreatine during intermittent maximal cycling.  J Appl Physiol 1996;80:1574-1580.

Hultman E, Soderlund K, Timmons JA, Cederblad G, Greenhaff PL: Muscle creatine loading in men.  J Appl Physiol 1996;81:232-237.

80.       A 16-year-old high school football player sustains an injury to the left hip.  The avulsed fragment identified by the arrow in Figure 34 represents the origin of which of the following structures?

 

1-         Ischiofemoral ligament

2-         Pubofemoral ligament

3-         Rectus femoris

4-         Sartorius

5-         Gluteus minimus

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The avulsed fragment represents the origin of the rectus femoris from the anterior inferior iliac spine and the brim of the acetabulum.  Avulsion of the anterior inferior iliac spine is much less common than avulsion of the anterior superior iliac spine with its origin of the sartorius.  The origin of the gluteus minimus is from the outer cortex of the iliac wing and has not been reported as a source of bony avulsion.  The hip capsule is composed of the ischiofemoral and pubofemoral ligaments, in addition to the iliofemoral ligament.  The pelvic attachment of the ischiofemoral ligament is from the ischial part of the acetabulum posteriorly, while the pubofemoral ligament attaches to the pubic portion inferiorly.  Technically, ligaments do not have origins and insertions as muscle tendon groups do, but have attachment sites.

 

REFERENCES: Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis.  Am J Sports Med 1985;13:349-358.

Mader TJ: Avulsion of the rectus femoris tendon: An unusual type of pelvic fracture.  Pediatr Emerg Care 1990;6:198-199.

81.       Which of the following methods of meniscal repair has the highest load to
failure strength?

 

1-         Horizontal suture

2-         Vertical suture

3-         Mulberry knot

4-         T-fix suture

5-         Meniscal arrow

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Numerous experimental studies have shown that vertical suture techniques are superior to all of the other noted methods.  In fact, vertical sutures have been shown to be twice as strong as several of these techniques.

 

REFERENCES: DeHaven KE: Meniscus repair.  Am J Sports Med 1999;27:242-250.  

Dervin GF, Downing KJ, Keene GC, McBride DG: Failure strengths of suture versus biodegradable arrow for meniscal repair: An in vitro study.  Arthroscopy 1997;13:296-300.

Barber FA: Endoscopic meniscal repair: The T-fix technique.  Sports Med Arthroscopy Rev 1999;7:28-33.

82.       Figure 35 shows the lateral radiograph of a 15-year-old basketball player who felt a dramatic pop in his knee when landing after a lay-up.  The patient reports that he cannot bear weight on the injured extremity.  Management should consist of

 

1-         closed reduction and casting in extension.

2-         open reduction with suture fixation of the proximal fragment.

3-         closed reduction, followed by functional bracing.

4-         open reduction and internal fixation with screws and complete proximal tibial epiphysiodesis.

5-         open reduction and internal fixation with screws.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Tibial tubercle avulsion is an injury of the adolescent knee that most often occurs just before the end of growth.  The fracture usually occurs with jumping, either at push-off or landing.  This patient has a type III injury.  In type III injuries, the articular surface is disrupted, and meniscal injury and compartment syndrome can occur.  Open reduction is the treatment of choice, and anterior fasciotomy should be considered prophylactically at the time of surgery.  Although the fracture heals with an anterior epiphysiodesis of the proximal tibia, little growth remains in this patient and no special handling of the physis is warranted.

 

REFERENCES: Ogden JA, Tross RB, Murphy MJ: Fractures of the tibial tuberosity in adolescents.  J Bone Joint Surg Am 1980;62:205-215.

Pape JM, Goulet JA, Hensinger RN: Compartment syndrome complicating tibial tubercle avulsion.  Clin Orthop 1993;295:201-204.

83.       A 52-year-old man has pain in the sternal area after landing on his right shoulder in a fall from his bicycle.  In addition, he reports that he had difficulty swallowing and breathing immediately after the fall, but the symptoms resolved.  A CT scan reveals a posterior sternoclavicular dislocation.  Initial management should include

 

1-         a snug figure-of-8 splint and observation for spontaneous reduction.

2-         closed reduction under general anesthesia.

3-         closed reduction under general anesthesia and percutaneous pinning.

4-         open reduction and capsuloligamentous repair.

5-         open reduction and wire stabilization of the joint.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Posterior sternoclavicular dislocations require rapid treatment because of the proximity of major neurovascular structures and the airway.  Initial management should consist of closed reduction under general anesthesia in the operating room with a chest surgeon available.  A successful closed reduction is usually stable.  Internal fixation of sternoclavicular injuries should be avoided because of the likelihood of hardware migration and possible injury to the mediastinal structures.  If closed reduction is unsuccessful, open reduction is indicated.  Treatment following reduction of the sternoclavicular joint includes the application of a figure-of-8 splint and a sling for 6 weeks, followed by stretching and strengthening exercises.

 

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont IL, American Academy of Orthopaedic Surgeons, 1999, pp 287-297.

Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1990, vol 2, pp 1010-1017.

84.       What nerve is at greatest risk of harm from the portal shown in Figure 36?

 

1-         Radial

2-         Ulnar

3-         Median

4-         Lateral antebrachial cutaneous

5-         Posterior antebrachial cutaneous

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The figure shows the anterolateral portal for elbow arthroscopy, and injury to the radial nerve has been reported in conjunction with this portal site.  Studies have shown that closer proximity to the radial nerve is associated with more distal portal sites.  The lateral and posterior antebrachial cutaneous nerves are both at less risk of injury.  The ulnar and median nerves are both fairly remote to this location.

 

REFERENCES: Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL: Arthroscopic anatomy of the lateral elbow: A comparison of three portals.  Arthroscopy 1994;10:602-607.

Papilion JD, Neff RS, Shall LM: Compression neuropathy of the radial nerve as a complication of elbow arthroscopy: A case report and review of the literature.  Arthroscopy 1988;4:284-286.

Poehling GG, Whipple TL, Sisco L, Goldman B: Elbow arthroscopy: A new technique.  Arthroscopy 1989;5:222-224.

85.       In the majority of patients with chronic anterior cruciate ligament (ACL)-deficient knees, analysis of the gait pattern during level walking will most likely reveal which of the following changes?

 

1-         No significant differences in gait from the contralateral knee

2-         No change in knee flexion-extension moment with balancing of quadriceps and hamstring activity

3-         A change in knee flexion-extension moment with decreased hamstring activity

4-         A change in knee flexion-extension moment with decreased demand on the quadriceps and a net increase in hamstring activity

5-         A change in knee flexion-extension moment with increased demand on the quadriceps

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Patients with chronic ACL-deficient knees typically have lower than normal net quadriceps activity during the middle portion of the stance phase; the net moment about the knee reverses from one that demands quadriceps activity to one that demands increased hamstring activity.  This type of gait is termed “quadriceps avoidance.”  This avoidance is believed to be a functional adaptation to reduce anterior tibial translation, and it is most prevalent as the knee moves from 45° of flexion toward full extension, the arc of motion through which the ACL is most responsible for stability.

 

REFERENCES: Hurwitz DE, Andriacchi TP, Bush-Joseph CA, Bach BR Jr: Functional adaptations in patients with ACL-deficient knees.  Exerc Sport Sci Rev 1997;25:1-20.

Andriacchi TP, Birac D: Functional testing in the anterior cruciate ligament-deficient knee.  Clin Orthop 1993;288:40-47.

Solomonow M, Baratta R, Zhou BH, et al:  The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability.  Am J Sports Med 1987;15:207-213.

86.       Glenohumeral inferior stability in the adducted shoulder position is primarily a function of the 

 

1-         rotator cuff.

2-         posterior glenohumeral ligament.

3-         long head of the biceps tendon.

4-         inferior glenohumeral ligament complex.

5-         superior glenohumeral ligament.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: When the arm is adducted, the superior structures, including the superior glenohumeral ligament, are responsible in limiting the inferior translation.  With the arm abducted, the inferior glenohumeral ligament complex is responsible for limiting inferior subluxation.  Rotator cuff activity can actually depress the humeral head and does not play a role in preventing inferior subluxation.  The long head of the biceps and the posterior glenohumeral ligament do not play a role in protecting the shoulder from inferior instability.

 

REFERENCES: Warner JJ, Deng XH, Warren RF, Torzilli PA: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint.  Am J Sports Med 1992;20:675-685.

Harryman DT II, Sidles JA, Harris SL, Matsen FA III: The role of the rotator interval capsule in passive motion and stability of the shoulder.  J Bone Joint Surg Am 1992;74:53-66.

87.       A 20-year-old football player has repeated episodes of heat cramps during summer training sessions.  A deficiency of what electrolyte is most responsible for heat cramps?

 

1-         Potassium

2-         Magnesium

3-         Chloride

4-         Sodium

5-         Iron

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Sodium deficiency is the cause of heat cramps. It is the principle electrolyte of sweat and is readily lost during training, especially in warmer temperatures.  The condition can be avoided by adding extra table salt to food and maintaining good hydration before and after sports activities.  Salt tablets are to be avoided when a patient has heat cramps because the high soluble load will cause gastric irritation.

 

REFERENCES: Bergeron MF, Armstrong LE, Maresh CM: Fluid and electrolyte losses during tennis in the heat.  Clin Sports Med 1995;14:23-32.

Halpern B: Fluid and electrolyte replacement in athletes.  Sports Med Digest 1994;16:1-5.

88.       Figure 37 shows the radiograph of a 23-year-old football player who sustained a blow to the anterior aspect of his shoulder.  Examination reveals pain and limited rotation.  He is unable to flex the arm above the shoulder. Management should include which of the following studies?

 

1-         Axillary radiograph

2-         Arthrogram

3-         Electromyogram

4-         Bone scan

5-         Arteriogram

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has a posterior dislocation.  The radiograph reveals marked internal rotation, but fails to show whether the humeral head is posteriorly displaced.  Therefore, an axillary radiograph should be obtained to help confirm the diagnosis.  Transverse view CT or MRI scans also may be useful.  The other studies will not help confirm the diagnosis.  In addition to a direct posterior blow, a shoulder dislocation may be caused by a seizure disorder or electrocution.

 

REFERENCES: Bloom MH, Obata WG: Diagnosis of posterior dislocation of the shoulder with the use of Velpeau axillary and angle-up roentgenographic views.  J Bone Joint Surg Am 1967;49:943-949.

Rockwood CA: Subluxations and dislocations about the shoulder, in Rockwood CA, Green DP (eds): Fractures in Adults, ed 2.  Philadelphia, PA, JB Lippincott, 1984, vol 1, pp 806-856.

89.       A 21-year-old football player had severe pain and immediate swelling in the left anteromedial chest wall while bench pressing near maximal weights several days ago.  Examination at the time of injury revealed a mass on the anteromedial chest wall.  Follow-up examination now reveals decreased swelling, and axillary webbing is observed.  The patient has weakness to adduction and forward flexion.  The injured muscle originates from the

 

1-         proximal clavicle and sternocostal margin.

2-         proximal humerus.

3-         coracoid process.

4-         distal clavicle and acromion.

5-         anterior scapula.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has a pectoralis major rupture, an injury that occurs most commonly during weight lifting.  Grade III injuries represent complete tears of either the musculotendinous junction or an avulsion of the tendon from the humerus, the most common injury site.  Examination will most likely reveal ecchymoses and swelling in the proximal arm and axilla, and strength testing will show weakness with internal rotation and in adduction and forward flexion.  Axillary webbing, caused by a more defined inferior margin of the anterior deltoid as the result of rupture of the pectoralis, can be seen as the swelling diminishes.  Surgical repair is the treatment of choice for complete ruptures.  Nonsurgical treatment is associated with significant losses in adduction, flexion, internal rotation, strength, and peak torque.  The pectoralis major originates from the proximal clavicle and the border of the sternum, including ribs two through six.  The pectoralis major inserts (rather than originates) on the humerus.  The coracoid process is the insertion site for the pectoralis minor, as well as the origin for the conjoined tendon.  The pectoralis major has no attachment or origin from the scapula.  The anterior deltoid originates from the lateral one third of the clavicle and the anterior acromion.

 

REFERENCES: Miller MD, Johnson DL, Fu FH, Thaete FL, Blanc RO: Rupture of the pectoralis major muscle in a collegiate football player: Use of magnetic resonance imaging in early diagnosis.  Am J Sports Med 1993;21:475-477.

Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis.  Am J Sports Med 1992;20:587-593.

90.       A 24-year-old baseball pitcher reports pain over the posterior aspect of his shoulder that occurs only during throwing.  He notes that the discomfort is greatest during the late cocking and early acceleration phases.  Examination reveals localized tenderness with palpation over the external rotators and posterior glenoid.  Radiographs are shown in Figures 38a through 38c.  What is the most likely diagnosis?

 

1-         Fracture of the posterior glenoid

2-         Triceps insertion avulsion

3-         Calcific tendinitis

4-         Posterior glenoid exostosis

5-         Loose body

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The radiographs show a posterior glenoid osteophyte, often termed a “thrower’s exostosis.”  These exostoses are best visualized on the Stryker notch view and may be missed on other more standard radiographic views of the shoulder.  CT and MRI scans may be used, but usually add little information to the radiographic findings.  Arthroscopic examination of patients with this condition commonly reveals undersurface tearing of the rotator cuff and posterior labrum.  Treatment of this condition remains somewhat controversial, with avocation of both nonsurgical and surgical techniques.  

 

REFERENCES: Meister K, Andrews JR, Batts J, Wilk K, Baumgarten T, Baumgartner T: Symptomatic thrower’s exostosis: Arthroscopic evaluation and treatment.  Am J Sports Med 1999;27:133-136.

Ferrari JD, Ferrari DA, Coumas J, Pappas AM: Posterior ossification of the shoulder: The Bennett lesion. Etiology, diagnosis, and treatment.  Am J Sports Med 1994;22:171-176.

Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posteriorsuperior glenoid rim: An arthroscopic study.  J Shoulder Elbow Surg 1992;1:238-245.

91.       What percent of the adult human meniscus is vascularized?

 

1-         0%

2-         5%

3-         25%

4-         50%

5-         100%

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The adult menisci are considered to be relatively avascular structures, with the peripheral blood supply originating predominately from the lateral and medial genicular arteries.  Branches of these vessels form the perimeniscal capillary plexus, which supplies the peripheral border throughout its attachment to the joint capsule.  Vascular penetration studies have shown that 10% to 30% of the peripheral portion of the medial meniscus and 10% to 25% of the lateral meniscus are vascularized.

 

REFERENCES: Arnoczky SP, Warren RF: Microvasculature of the human meniscus.  Am J Sports Med 1982;10:90-95.

Arnoczky SP, Warren RF: The microvasculature of the meniscus and its response to injury: An experimental study in the dog.  Am J Sports Med 1983;11:131-141.

92.       A 30-year-old man who participates in recreational sports reports the spontaneous onset of intermittent pain and swelling about the right knee.  Examination reveals a 3+ effusion, with a range of motion of 10° to 60°.  He has mild diffuse tenderness but no instability. MRI scans and an arthroscopic view are shown in Figures 39a through 39c.  Management should consist of

 

1-         arthroscopic debridement of the articular lesion and resurfacing.

2-         knee aspiration and an intra-articular cortisone injection.

3-         rheumatologic evaluation.

4-         infectious disease evaluation for possible Lyme disease.

5-         arthroscopic synovectomy.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has synovial chondromatosis.  The MRI scans show multiple small proscribed areas of signal intensity in the gutters and suprapatellar pouch, suggesting very small loose bodies.  The arthroscopic view shows the classic appearance of multiple small chondral loose bodies.  Synovial chondromatosis is a condition in which the synovium undergoes metaplasia, producing multiple chondral loose bodies that can subsequently ossify.  The treatment of choice, removal of the loose bodies and arthroscopic synovectomy, results in a lower incidence of recurrence than other treatment methods.

 

REFERENCES: Coolican MR, Dandy DJ: Arthroscopic management of synovial chondromatosis of the knee: findings and results in 18 cases.  J Bone Joint Surg Br
1989;71:498-500.

Ogilvie-Harris DJ, Saleh K: Generalized synovial chondromatosis of the knee: A comparison
of removal of the loose bodies alone with arthroscopic synovectomy.  Arthroscopy
1994;10:166-170.

93.       Figure 40 shows the plain radiograph of a 30-year-old woman who has had a long history of standing bilateral anterior knee pain and a sense of patellar instability without frank dislocation.  Nonsurgical management consisting of anti-inflammatory drugs and physical therapy has failed to provide relief.  Examination reveals full range of motion of both knees, with moderate patellofemoral crepitance.  Patellar apprehension and patellar grind tests are positive.  The Q-angle measures 20°.  Management should now consist of

 

1-         bilateral arthroscopic lateral releases.

2-         bilateral arthroscopic lateral releases and medial retinacular thermal shrinkage.

3-         bilateral lateral releases and anteromedialization of the tibial tubercles.

4-         physical therapy and the use of patella-stabilizing braces.

5-         physical therapy with taping.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The history, physical examination, and radiographs indicate that the patellofemoral pain is most likely caused by excessive lateral patellar pressure and patellar maltracking.  Because the radiographs reveal the lateral tilt of the patella and lateral subluxation, the treatment of choice is bilateral lateral releases with anteromedialization of the tibial tubercles.  This procedure corrects not only the excessive lateral patellar pressure, but also the lateral subluxation.  The use of patella-stabilizing braces or taping may provide temporary relief, but these implements are not well-tolerated and they will not change the underlying biomechanics of the knee.  Simple lateral release is indicated for isolated lateral tilt, but it does not correct the lateral subluxation.  The use of thermal capsular shrinkage for the medial retinaculum has not been proven to provide long-term correction of the deformity.

 

REFERENCES: Boden BP, Pearsall AW, Garrett We Jr, et al: Patellofemoral instability: Evaluation and management.  J Am Acad Orthop Surg 1997;5:47-57.

Fulkerson JP:  Patellofemoral pain disorders: Evaluation and management.  J Am Acad Orthop Surg 1994;2:124-132.

94.       A 24-year-old runner who underwent an allograft reconstruction of the anterior cruciate ligament (ACL) 3 years ago now reports anterior knee pain.  Examination reveals no swelling or effusion, and the patient has full motion.  A Lachman test and a pivot-shift test are negative.  Palpation reveals tenderness on the patellar tendon and at the inferior pole of the patella.  AP and lateral radiographs are shown in Figures 41a and 41b.  Management should consist of

 

1-         immediate biopsy of the proximal tibia.

2-         aspiration and culture of the knee.

3-         observation with activity modification.

4-         a white blood cell scan.

5-         revision of the ACL reconstruction.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The radiographs show tunnel enlargement, which is seen after ACL reconstruction, particularly with allografts.  Occasionally, there will be formation of an associated subcutaneous pretibial cyst.  It has been proposed that the tunnel enlargement and cyst are the result of incomplete incorporation of allograft tissues within the bone tunnels.  There may be residual graft necrosis, allowing synovial fluid to be transmitted through the tunnel to collect in the pretibial area, manifesting as a synovial cyst.  In the absence of cyst formation, the presence of tunnel enlargement does not appear to adversely affect the clinical outcome.  Based on studies by Fahey and associates, continued tunnel expansion does not occur.  Victoroff and associates report good results with curettage and bone grafting of the tibial tunnel if a pretibial cyst is present.  Because this patient does not have a pretibial cyst, observation with activity modification is the preferred treatment.

 

REFERENCES: Fahey M, Indelicato PA: Bone tunnel enlargement after anterior cruciate ligament replacement.  Am J Sports Med 1994;22:410-414.

Victoroff BN, Paulos L, Beck C, Goodfellow DB: Subcutaneous pretibial cyst formation associated with anterior cruciate ligament allografts: A report of four cases and literature review.  Arthroscopy 1995;11:486-494.

95.       What is the most common mechanism of injury that produces turf toe?

 

1-         Valgus stress at the first metatarsophalangeal (MTP) joint

2-         Hyperflexion stress

3-         Hyperextension stress

4-         Varus stress

5-         Axial load

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The most common mechanism of injury for turf toe is a hyperextension injury to the MTP joint.  The foot is typically in a dorsiflexed position with the heel raised when an external force drives the MTP joint into further dorsiflexion.  The joint capsule usually tears at the metatarsal neck because its attachment is weaker there than at the proximal phalanx.  Some compression injuries to the dorsal articular surface of the metatarsal head can result from extension or hyperextension.

 

REFERENCES: Clanton TO, Ford JJ: Turf toe injury.  Clin Sports Med 1994;13:731-741.

Rodeo SA, O’Brien S, Warren RF, et al: Turf toe: An analysis of metatarsophalangeal joint sprains in professional football players.  Am J Sports Med 1990;18:280-285.

96.       A 68-year-old man embarks on a 24-week strength training program.  He trains at 80% of his single repetition maximum for both the upper and lower extremities.  Which of the following changes can be anticipated?

 

1-         An absolute decrease in aerobic capacity

2-         A decrease in capillary density in the trained muscles

3-         A significant increase in strength

4-         A significant improvement in Vo_2max

5-         No change in the cross-sectional area of the trained muscles

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Consistent, long-term exercise training in older athletes has proven very beneficial in reversing both endurance and strength losses that traditionally have been seen with aging.  This patient’s program will lead to a significant increase in the strength, cross-sectional area, and capillary density of the trained muscles.  No major changes in aerobic capacity are anticipated.  Strength improvements of up to 5% per day, similar to those for younger athletes, have been identified in this population in one study.

 

REFERENCES: Kirkendall DT, Garrett WE Jr: The effects of aging and training on skeletal muscle.  Am J Sports Med 1998;26:598-602.

Frontera WR, Meredith CN, O’Reilly KP, Knuttgen HG, Evans WJ: Strength conditioning in older men: Skeletal muscle hypertrophy and improved function.  J Appl Physiol 1988;64:1038-1044.

97.       A 26-year-old ballet dancer reports posterolateral ankle pain, especially with maximal plantar flexion.  Examination reveals maximal tenderness just posterior to the lateral malleolus, and symptoms are heightened with forced passive plantar flexion.  Radiographs are shown in Figures 42a and 42b.  What is the most likely cause of the patient’s symptoms?

 

1-         Posterior impingement of the os trigonum

2-         Subluxation of the peroneal tendon

3-         Posterior tibial stress fracture

4-         Osteochondritis dissecans of the lateral dome of the talus

5-         Stenosis of the peroneal tendon sheath

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has a symptomatic os trigonum caused by impingement that occurs with maximal plantar flexion of the ankle in the demi-pointe or full-pointe position.  Patients frequently report posterolateral pain localized behind the lateral malleolus that may be misinterpreted as a disorder of the peroneal tendon.  Pain with passive plantar flexion (the plantar flexion sign) indicates posterior impingement, not a problem with the peroneal tendon.  The symptoms are not characteristic of a stress fracture, nor do the radiographs show a stress fracture or an osteochondritis dissecans lesion.  The os trigonum is modest in its dimensions.  The incidence or magnitude of symptoms does not correlate with the size of the fragment.  Large fragments may be asymptomatic, while small lesions may create significant symptoms.  

 

REFERENCES: Marotta JJ, Micheli LJ: Os trigonum impingement in dancers.  Am J Sports Med 1992;20:533-536.

Hamilton WG: Foot and ankle injuries in dancers, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, CV Mosby, 1993, pp 1241-1276.

98.       A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player.  In reconstructing the PCL, it is optimal to reconstruct the

 

1-         anterolateral bundle and tension the graft at 10° of flexion.

2-         anterolateral bundle and tension the graft at 90° of flexion.

3-         posteromedial bundle and tension the graft at 10° of flexion.

4-         posteromedial bundle and tension the graft at 45° of flexion.

5-         posteromedial bundle and tension the graft at 90° of flexion.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The PCL is a nonisometric structure with nonuniform tension during knee motion, with maximum tension at 90° of flexion.  While the posteromedial PCL fibers have been found to be the most isometric, the anterolateral fibers represent the bulk of the ligament.  Studies have suggested that anterior placement of the femoral tunnel is superior to placement in an isometric position.  The anterolateral bundle tightens as the knee flexes; therefore, it is optimal to tension the graft at 90° of flexion.

 

REFERENCES: Harner CD, Xerogeanes JW, Livesay GA, et al: The human posterior cruciate ligament complex: An interdisciplinary study.  Ligament morphology and biomechanical evaluation.  Am J Sports Med 1995;23:736-745.

Burns WC II, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee.  Am J Sports Med 1995;23:424-430.

99.       Figure 43 shows the lateral radiograph of a patient who underwent anterior cruciate ligament reconstruction.  Based on the tunnel placement shown in the radiograph, evaluation of postoperative knee range of motion will most likely show

 

1-         normal flexion and extension.

2-         loss of extension.

3-         loss of flexion.

4-         loss of flexion and extension.

5-         hyperextension.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The radiograph shows the correct tibial tunnel and anterior femoral tunnel; therefore, range of motion will most likely show loss of flexion.

 

REFERENCES: Brown CH Jr, Carson EW: Revision anterior cruciate ligament surgery.  Clin

Bernhardt DT, Landry GL: Sports injuries in young athletes.  Adv Pediatr 1995;42:465- Sports Med 1999;18:109-171.

Brown HR, Indelicato PA: Complications of anterior cruciate ligament reconstruction.  Op Tech Orthop 1992;2:125-135. 

100.     A 10-year-old soccer player has bilateral heel pain and reports that the pain is worse during and immediately after sports.  Examination reveals that the calcaneal tuberosities are painful to palpation bilaterally.  What is the most likely diagnosis?

 

1-         Plantar fasciitis

2-         Calcaneal apophysitis

3-         Achilles tendinitis

4-         Calcaneal bursitis

5-         Stress fractures of the calcanei

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Calcaneal apophysitis (Sever’s disease) is a common cause of heel pain in children who are active in sports.  The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program.  In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed.  There is no effect on the long-term growth of the calcaneus.

 

REFERENCES: Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome.  J Pediatr Orthop 1987;7:34-38. 500.

 

 

FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK