ORTHOPEDIC MCQS ONLINE QUESTION BANK H2D

ORTHOPEDIC MCQS ONLINE QUESTION BANK H2D

2685. (3157) Q6-3976:

Which of the following serves as the best landmark for proper screw entry into the lumbar pedicle:

 

1) The junction of the transverse process and inferior facet

3) The articulating interface of the superior and inferior facets

2) The junction of the transverse process and superior facet

5) There is no relationship between the nerve root and the superior facet.

4) The medial border of the superior facet

 

The junction of the transverse process and the inferior facet represents the most appropriate entry point of the pedicle screw. This junction directly overlies the pedicle and ensures safe placement through the pedicle and into the vertebral body.Correct Answer: The junction of the transverse process and inferior facet

 

 

2686. (3158) Q6-3977:

A potential major complication of lumbar pedicle screws is:

 

1) Lateral screw breakout injuring the vertebral artery

3) Medial screw breakout injuring the vertebral artery

2) Lateral screw breakout injuring the exiting nerve root

5) Medial screw breakout causing vertebral fracture

4) Medial screw breakout injuring the exiting nerve root

 

The exiting nerve root traverses immediately medial then caudal to the lumbar pedicle. Therefore, a screw that breaks out medially or inferiorly from the pedicle is a potential risk to the nerve root.Correct Answer: Medial screw breakout injuring the exiting nerve root

 

 

2687. (3159) Q6-3978:

Common indications for lumbar pedicle screw fixation include:

 

1) Rigid stabilization for patients undergoing arthrodesis or interbody fusion

3) Stabilization after trauma to the lumbar spine

2) Correction of lumbar spinal deformity

5) Rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of lumbar spinal deformity and stabilization after trauma to the lumbar spine

4) Rigid stabilization for patients undergoing arthrodesis or interbody fusion, and correction of lumbar spinal deformity

 

Common indications for pedicle screw fixation include rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of deformity, and stabilization after trauma.Correct Answer: Rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of lumbar spinal deformity and stabilization after trauma to the lumbar spine

 

 

2688. (3160) Q6-3979:

Advantages of minimally invasive lumbar interbody fusion over traditional open interbody fusion include:

 

1) Minimal muscle dissection and trauma

3) Better fusion rates

2) Wider surgical exposure

5) Better decompression

4) Lowered risk of nerve root injury

 

Minimally invasive lumbar interbody fusion involves less muscle dissection and trauma than traditional open approaches. The surgical exposure is more limited, though, and there is no evidence to date of minimally invasive techniques providing better fusion rates or lowered risk of nerve root injury.Correct Answer: Minimal muscle dissection and trauma

 

 

 

1) Surgical loupes and headlight

3) Intraoperative fluoroscopy

2) Operating microscope

5) Surgical loupes and headlight, operating microscope, and intraoperative fluoroscopy

4) Surgical loupes and headlight and operating microscope

 

All of the above instruments are of value to a surgeon when performing minimally invasive lumbar fusion.Correct Answer: Surgical loupes and headlight, operating microscope, and intraoperative fluoroscopy

 

 

2690. (3162) Q6-3981:

Which of the following statements is true regarding minimally invasive posterior lumbar interbody fusion:

 

1) Minimally invasive fusion may be safely performed only with the assistance of endoscopy.

3) Internal fixation with pedicle screws is not possible via the minimally invasive approach.

2) Minimally invasive fusion increases the risk of nerve root injury.

5) Minimally invasive surgery has improved fusion rates.

4) Intraoperative fluoroscopy is of great value in minimally invasive fusion.

 

Intraoperative fluoroscopy or radiography is vital for the proper identification of lumbar level and vertebral structures in minimally invasive posterior lumbar interbody fusions. While endoscopic assistance has been well described as a method of minimally invasive fusion, it is not vital to this technique. There is no evidence to date of increased risk of nerve root injury with minimally invasive techniques, and it is possible to internally fixate the lumbar segment with pedicle screws through minimally invasive techniques.Correct Answer: Intraoperative fluoroscopy is of great value in minimally invasive fusion.

 

 

2691. (3163) Q6-3982:

Which of the following is not a described technique of minimally invasive anterior lumbar interbody fusion:

 

1) Laparoscopic transperitoneal

3) Mini-open retroperitoneal

2) Endoscopic retroperitoneal

5) None of the above are described techniques

4) All of the above are described techniques

 

All of the above are well-described techniques of minimally invasive anterior lumbar interbody fusion.Correct Answer: All of the above are described techniques

 

 

2692. (3164) Q6-3983:

Which of the following statements is false regarding minimally invasive transperitoneal anterior lumbar interbody fusion:

 

1) This technique may be safely performed at all lumbar levels.

3) Laparoscopy is of great value in the transperitoneal approach to the anterior lumbar spine.

2) This technique allows direct access to pathology in the vertebral body.

5) None of the above

4) There is a potential risk of injuring the aorta and its bifurcation with this technique.

 

Due to the potential risk of injury to the aorta and its bifurcation, which occurs at the L4 level, this procedure is difficult and may be impossible to perform above the L4 level. Retroperitoneal approaches allow access to more superior lumbar levels due to the more lateral trajectory taken to avoid the aorta and its bifurcation.Correct Answer: This technique may be safely performed at all lumbar levels.

 

 

 

1) Inferior articulating process

3) Spinous process

2) Superior articulating process

5) Transverse foramen

4) Transverse process

 

The lateral mass of the cervical spinal segments includes the inferior and superior articulating processes, the transverse foramen, and the transverse process. The spinous process is not an element of the lateral mass.Correct Answer: Spinous process

 

 

2694. (3166) Q6-3985:

To avoid vertebral artery injury during cervical lateral mass screw placement, it is best to:

 

1) Start at the midpoint and aim the screw laterally

3) Start medially and aim the screw perpendicular

2) Start at the midpoint and aim the screw medially

5) Start laterally and aim the screw medially.

4) Start medially and aim the screw medially

 

To avoid injury to the vertebral artery when placing lateral mass screws, it is best to avoid placing the screw in the medial portion of the lateral mass, where the vertebral body is most likely to be found.Correct Answer: Start at the midpoint and aim the screw laterally

 

 

2695. (3167) Q6-3986:

Which of the following is/are potential complications associated with posterior cervical decompression and placement of lateral mass screws:

 

1) Injury to the vertebral artery

3) Traction injury to the cervical nerve roots

2) Compression injury to the spinal cord

5) Injury to the vertebral artery, traction injury to the cervical nerve, and traction injury to the cervical nerve roots

4) Injury to the vertebral artery and traction injury to the cervical nerve roots only

 

All of the above are potential complications associated with posterior cervical decompression and placement of lateral mass screws.Correct Answer: Injury to the vertebral artery, traction injury to the cervical nerve, and traction injury to the cervical nerve roots

 

 

2696. (3168) Q6-3987:

Which of the following statements is true regarding the C 2 lateral mass:

 

1) The vertebral artery assumes a more lateral position at this level.

3) The vertebral artery is found outside of the transverse foramen at this level.

2) The vertebral artery assumes a more medial position at this level.

5) None of the above

4) The vertebral artery precludes placement of lateral mass screws at this level.

 

The vertebral artery assumes a more lateral position at the C 2 level; therefore, screw placement at this level should follow a medial trajectory to avoid injury to the vertebral artery.Correct Answer: The vertebral artery assumes a more lateral position at this level.

 

 

 

1) Removal of the posterior arch of C 1

3) Following a medial trajectory with the C 1 screws

2) Placing the C 2 screws through the pedicle

5) Removal of the posterior arch of C 1, placing the C 2 screws through the pedicle, and following a medial trajectory with the C 1 screws

4) Removal of the posterior arch of C 1, and placing the C 2 screws through the pedicle only

 

The C 1 and C 2 levels have unique anatomies that require variation in lateral mass screw fixation technique. Removing the C 1 arch assists in proper placement of the C 1 screws via a lateral trajectory. The C 2 pedicle is large, and pedicle screws are commonly placed at this level to avoid vertebral artery injury in the small lateral masses. C 1 lateral mass screws follow the long axis of the C 1 lateral mass as visualized on pre-operative CT scanning.Correct Answer: Removal of the posterior arch of C 1, and placing the C 2 screws through the pedicle only

 

 

2698. (3170) Q6-3989:

Which of the following conditions is not associated with cervical fractures:

 

1) Rheumatoid arthritis

3) Ankylosing spondylitis

2) Ossiculum terminale

5) None of the above

4) Os odontoideum

 

Rheumatoid arthritis, ankylosing spondylitis, and os odontoideum have been associated with fractures as part of their presentation or etiology. Os odontoideum is most likely an old nonunion fracture or injury to vascular supply of the developing odontoid process. However, one has to differentiate true os odontoideum from the more common ossiculum terminale, which describes the nonunion of the apex at the secondary ossification center and is not a fracture.Correct Answer: Ossiculum terminale

 

 

2699. (3171) Q6-3990:

Which of the following pathogens is not typically implicated in diskitis:

 

1) Staphylococcus aureus

3) Pseudomonas aeruginosa

2) Staphylococcus albus

5) Gram-positive cocci

4) Staphylococcus epidermidis

 

The gram-positive cocci are typical opportunistic pathogens that are capable of causing infection in the vertebral disk space. Most commonly they seed via the hematogenous route but local translocation has also been implicated. Unless a patient has been hospitalized for a while and iatrogenesis is ruled out, Pseudomonas species usually do not cause diskitis.Correct Answer: Pseudomonas aeruginosa

 

 

2700. (3172) Q6-3991:

Which imaging modality is usually the least sensitive in diagnosing discitis:

 

1) Plain radiograph

3) Magnetic resonance image (MRI)

2) Computed tomography (CT) scan

5) Tomograms

4) Technetium bone scan

 

The least helpful modality in diagnosing early discitis is the plain radiograph. Fluoroscopy does not give insight into the state of the intervertebral disk. It can suggest loss of disk height or involvement of the vertebral bone but will not reveal infection limited to the disk. The CT scan is useful because of its excellent resolution of bony structures and associated changes secondary to disk infection. MRI is the best modality to characterize the soft tissues in the cervical spine.Correct Answer: Plain radiograph

 

Pottâs disease is most commonly treated by:

 

1) Decompression

3) Antibiotic therapy only

2) Antibiotic therapy and immobilization

5) Decompression and fusion

4) Spinal orthosis

 

The treatment of tuberculous involvement of the spine is rarely surgical. Most commonly, the spine remains stable and fusion is not necessary. However, orthosis in combination with long-term antibiotic therapy is the key for successful treatment. A collar is sufficient to provide enough stability and comfort for the lesion to heal.Correct Answer: Antibiotic therapy and immobilization

 

 

2702. (3174) Q6-3993:

Which of the following is characteristic of patients with Klippel-Feil syndrome:

 

1) Absence of the vertebral pedicles

3) Shortened pedicles

2) Absence of intervertebral joints

5) Increased interpediculate distance

4) A narrow spinal canal

 

Klippel-Feil syndrome is a rare disorder characterized by the congenital fusion of any two of the seven cervical vertebrae. The cause is a failure in the early segmentation during fetal development. The fused segments show absence of intervertebral joints. Associated abnormalities may include scoliosis; spina bifida; anomalies of the kidneys and ribs; and other midline anomalies.Correct Answer: Absence of intervertebral joints

 

 

2703. (3186) Q6-4005:

A burst fracture results in failure of the:

 

1) Anterior column

3) Posterior column

2) Middle column

5) Middle and posterior columns

4) Anterior and middle columns

 

A burst fracture by definition is failure of the anterior and middle columns due to axial loading, which often leads to instability and neurologic impairment.Correct Answer: Anterior and middle columns

 

 

2704. (3187) Q6-4006:

 

 

 

Slide 1

What type of fracture is presented in the radiograph (Slide):

 

1) Teardrop fracture

3) Compression fracture

2) Burst fracture

5) Clay-shovelerâs fracture

4) Hangmanâs fracture

 

Clearly seen in this radiograph is a fracture along the anterior/inferior vertebral body, which is a characteristic of a teardrop fracture.Correct Answer: Teardrop fracture

 

2705. (3188) Q6-4007:

 

 

 

Slide 1

What type of fracture is presented in the radiograph (Slide):

 

1) Teardrop fracture

3) Compression fracture

2) Burst fracture

5) Clay-shovelerâs fracture

4) Hangmanâs fracture

 

Clearly seen in this radiograph is a fracture along the anterior/inferior vertebral body, which is a characteristic of a teardrop fracture.Correct Answer: Teardrop fracture

 

 

2706. (3189) Q6-4008:

Which of the following may be used as treatment options for bilateral facet dislocations:

 

1) Traction reduction of dislocations

3) Open reduction

2) Halo fixation

5) All of the above

4) Open fixation

 

All of the choices are used in the treatment of bilateral jumped facets, often in combination or sequence.Correct Answer: All of the above

 

 

2707. (3190) Q6-4009:

Which of the following fracture types is the most stable fracture:

 

1) Teardrop fracture

3) Unilateral facet dislocation

2) Burst fracture

5) Clay-shovelerâs fracture

4) Hangmanâs fracture

 

The avulsion of part or all of the spinous process that occurs after a violent flexion motion is a one-column injury. The injury is a stable fracture treated by external orthosis, which rarely results in neurologic impairment. The other answer choices may be considered stable in some instances, but none of them are stable all of the time.Correct Answer: Clay-shovelerâs fracture

 

Unilateral facet dislocation may be distinguished radiographically from bilateral facet dislocation by which of the following features:

 

1) Misalignment of the spinous processes

3) Subluxation <25%

2) Subluxation >50%

5) Spinal canal compromise

4) Marked angular deformity

 

Unilateral jumped facets typically involve anterolisthesis of the upper vertebral body, which is less than 25%. Misalignment of the spinous processes and spinal canal compromise may be seen with either unilateral or bilateral facet dislocation. Subluxation greater than 50% and marked angular deformity are characteristics of bilateral facet dislocations.Correct Answer: Subluxation

<25%

 

 

2709. (3271) Q6-4114:

The annual incidence of cervical radiculopathy in men is 107.3 per 100,000 and 63.5 per 100,000 in women. The incidence for both groups occurs within which of the following peak age ranges:

 

1) 45-49 years

3) 55-59 years

2) 50-54 years

5) 65-69 years

4) 60-64 years

 

Although the incidence rate of cervical radiculopathy in men is nearly double the rate found in women, the peak age range is the same (50-54 years).Correct Answer: 50-54 years

 

 

2710. (3272) Q6-4115:

Which of the following structures are found within an intervertebral foramen:

 

1) Dorsal root ganglion

3) Radicular artery and vein

2) Connective tissue

5) All of the above

4) Recurrent meningeal nerves

 

In addition to the dorsal root ganglion, connective tissue, radicular artery and vein, and recurrent meningeal nerves, spinal nerve roots and adipose also comprise an intervertebral foramen.Correct Answer: All of the above

 

 

2711. (3273) Q6-4116:

Most cervical radiculopathy occurs as a result of inflammatory mediators released after mechanical injury, without direct compression of the nerve root(s).

 

1. True

2. False

    

   Approximately 75% of cervical radiculopathies occur as a result of direct compression of nerve roots, with at least one study noting âa pressure of only 10 mm Hg produced significant conduction block, the potential [of nerve impulses] falling under 60 percent of its initial value in 15 minutes. With higher levels of pressure, we have observed incomplete recovery after many hours of recording.â Disk protrusion, with the associative release of inflammatory mediators, is responsible for up to 25% of cervical radiculopathies. One study even suggests âchemical release from the nucleus pulposus into the nerve root epidural space, without herniation of the nucleus pulposus and without direct nerve root compression, caused radiculopathic pain in an animal model.âCorrect Answer: False

    

    

   C 1 reflexes include which of the following:

    

   1. Sternocleidomastoid reflex

3. Deltoid reflex

   1. Clavicle reflex

   5) Biceps reflex

   4) Jaw jerk

    

   The C 1 reflex, while rarely tested, involves the jaw jerk.Correct Answer: Jaw jerk

    

    

   2713. (3275) Q6-4118:

   Typical C 3 reflexes include which of the following:

    

   1) Sternocleidomastoid reflex

   3) Pectoralis reflex

   2) Head retraction reflex

   5) None of the above

   4) Biceps reflex

    

   No reflexes are associated with the C 3 spinal nerve.Correct Answer: None of the above

    

    

   2714. (3276) Q6-4120:

   Which of the following is a distinguishing feature of a C 7 radiculopathy rarely found in C 6 radiculopathies:

    

   1) Paresthesia of the middle finger

   3) Little to no pain in associated muscles

   2) Anterior chest pain

   5) None of the above

   4) âEpauletâ pain in the associated shoulder and lateral arm

    

   C 7 radiculopathies classically entail pain and/or sensory changes involving the middle finger. C 6 radicular symptoms generally involve the thumb and first finger. C 8 radiculopathies involve the pinkie and ring fingers.Correct Answer: Paresthesia of the middle finger

    

    

   2715. (3277) Q6-4121:

   Studies suggest that cervical radiculopathy (or related pathology) of which nerve root may partially explain the phenomenon of cervicogenic headaches:

    

   1) C 3

   3) C 5

   2) C 4

   5) C 7

   4) C 6

    

   Headaches observed with upper cervical pathology may be due, in part, to the convergence of C 1-, C 2-, and C 3-level pain fibers with second-order neurons of the descending sensory tract of cranial nerve V.Correct Answer: C 3

    

    

   2716. (3278) Q6-4122:

   Which of the following diagnostic tests is preferred for suspected cervical radiculopathy:

    

   1) Chest radiograph

   3) C-reactive protein assay

   2) Magnetic resonance imaging

   5) All of the above

   4) Myelogram

    

   Although myelogram and nerve conduction studies are useful tests, they are invasive. Magnetic resonance imaging studies are the most appropriate choice for diagnosis. Most important in the diagnosis of cervical radiculopathy is a thorough history and physical examination.Correct Answer: Magnetic resonance imaging

    

   2717. (3279) Q6-4123:

   What is the preferred treatment method for patients with cervical radiculopathy:

    

   1) Physical therapy

   3) Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)

   2) Surgical repair

   5) None of the above

   4) Bed rest

    

   Most patients with cervical radiculopathy are best treated medically after the age of 50. In other age groups, based on the history, physical examination, and number of involved nerve roots, a combination of the above methods may be appropriate. Surgical therapy may be necessary in patients refractory to medical management.Correct Answer: Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)

    

    

   2718. (3351) Q6-4231:

   A 17-year-old high school football player presents to the emergency department after being removed from play following a harsh tackle. The patient reports a sharp burning and stinging pain through his left arm that has not resolved since the tackle. A careful history revealed that this is the fourth episode of burning and stinging pain. In each episode of pain, the symptoms have lasted longer than the previous episode. The patient also reports that he has suffered from two prior episodes of transient weakness and numbness in all extremities following harsh tackles. Which of the following statements concerning this patient is correct:

    

   1) There is no contraindication to return to play in this patient.

   3) There is an absolute contraindication to return to play in this patient.

   2) There is a relative contraindication to return to play in this patient.

   5) The patient should not participate in football games, but should feel free to continue lifting weights and practicing.

   4) Because this patient has suffered repeated episodes of transient pain after tackles, he is obviously experienced enough to not need education and counseling to help prevent recurrence.

    

   It is important to understand the current return to play criteria for cervical spine injuries in athletes. There is an absolute contraindication to return to play in patients who have: a) more than two previous episodes of transient quadriparesis/quadriplegia, b) clinical history, physical examination findings, or imaging confirmation of cervical myelopathy/myelomalacia, and c) continued cervical neck discomfort, decreased range of motion, or any evidence of a neurologic deficit from baseline after any cervical spine injury. Patient education and follow-up are always indicated in patients with burners and stingers. This patient should not participate in football games, exercise, or practice until full mobility and strength has returned, and all neurologic symptoms have resolved.Correct Answer: There is an absolute contraindication to return to play in this patient.

    

    

    

   2719. (3352) Q6-4232:

   Which of the following statements regarding radiographic evaluation of patients with burners and stingers is correct:

    

   1) A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present.

   3) An extension lateral cervical conventional radiograph is used to determine the Torg ratio.

   2) A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present.

   5) A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

   4) A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

    

   The Torg ratio is calculated using an extension lateral cervical radiograph. To calculate the Torg ratio, divide the distance between the midpoint of the posterior aspect of the vertebral body to the nearest point on the corresponding spinolaminar line by the anteroposterior width of the vertebral body. A Torg ratio , 0.8 is associated with cervical spinal stenosis and sustained burners and stingers in athletes with cervical spine-extension-compression type injuries.Correct Answer: A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

    

   2720. (3353) Q6-4233:

   Which of the following statements concerning burners and stingers is incorrect:

    

   1) Burners and stingers typically result from depression of the ipsilateral shoulder and deviation of the neck to the contralateral side.

   3) In treating burners and stingers, it is important to restore pain-free mobility in the upper extremities by strengthening and stretching.

   2) Burners and stingers are commonly seen in elderly patients.

   5) None of the above

   4) Follow-up and patient education are important in all cases of burners and stingers, regardless of the duration of symptoms.

    

   Burners and stingers are usually seen in children, adolescents, and athletes. Choice A is correct, and explains why burners and stingers are typically seen in tackle injuries sustained by football players and in motorcycle accidents. Choices C and D are correct because management of patients with burners and stingers should always include strengthening, stretching, patient education, and follow-up.Correct Answer: Burners and stingers are commonly seen in elderly patients.

    

    

   2721. (3354) Q6-4235:

   A 26-year-old man with HIV presents to your office with symptoms of lower back pain, difficulty with ambulation, loss of appetite, mild fever, and malaise for 2 weeks. The patient states that he has had difficulty with compliance to his medical management. You suspect that he has a low CD4 count, which is confirmed by laboratory tests. Physical examination reveals tenderness at the L4-L5 level. The patient has abnormal gait. Ankle dorsiflexion and plantarflexion are 1 out of 5 bilaterally. The Achilles tendon reflex is absent bilaterally; all other reflexes are normal. A T2-weighted magnetic resonance imaging (MRI) study shows slightly increased intensity of the disk at the L4-L5 level and an obvious epidural abscess. Conventional radiographs of the lumbar region are normal. Management of this patient should consist of:

    

   1) Admission to the intensive care unit (ICU) and intravenous administration of broad-spectrum antibiotics

   3) Counseling the patient on the importance of compliance with medical management

   2) Consideration of urgent surgical intervention and evacuation of the epidural abscess

   5) All of the above

   4) Surveillance for signs of further neurologic deterioration

    

   All of the above answer choices are correct. The patient described above has HIV and is severely immunocompromised. Because of the severity of the patientâs condition, immediate admission to the ICU and intravenous administration of a broad-spectrum antibiotic regimen is indicated. Biopsy and drainage of the infected regions should be performed. It is important in this case to monitor the patient for any signs of neurologic deterioration. Finally, to prevent recurrent cases of diskitis, or other infections, it is important to counsel the patient on compliance with medical management.Correct Answer: All of the above

    

    

   2722. (3355) Q6-4236:

   Which of the following statements regarding diskitis is correct:

    

   1) Signs and symptoms of diskitis generally progress rapidly.

   3) Diskitis commonly occurs in the thoracic region of the spine.

   2) Intravenous drug use and immunocompromise are not generally considered risk factors for diskitis.

   5) All of the above

   4) Blood cultures are generally positive in up to 70% of patients with diskitis.

    

   Diskitis is usually indolent, and patients live with symptoms for several months before seeking treatment. Intravenous drug use and immunocompromise are two important risk factors for diskitis, along with surgical procedures involving the spine. Diskitis rarely occurs in the thoracic spine; instead, diskitis usually occurs in the lumbar spine. Blood cultures should be taken in any patient with suspected diskitis.Correct Answer: Blood cultures are generally positive in up to 70% of patients with diskitis.

    

    

   2723. (3356) Q6-4237:

   Which of the following statements regarding lesions of the spinal cord caused by bullet wounds is true:

    

   1) Twenty-five percent of patients with complete lesions recover one motor level after 1 year.

   3) Complete lesions occur in more than 50% of all gunshot wounds to the spine.

   2) Thirty-three percent of patients with incomplete lesions usually have a partial or complete recovery after 1 year.

   5) All of the above

   4) Seventy-five percent of patients in whom the bullet has passed through the spinal canal will experience a complete lesion.

    

   All of the statements are true. Knowledge of these facts is important in decision-making and management of patients who are victims of gunshot wounds to the spine.Correct Answer: All of the above

    

   2724. (3357) Q6-4238:

   An 18-year-old man presents to the emergency department after sustaining a high-velocity gunshot wound to the umbilical region of the abdomen. An exit wound is found at the L3-L5 region of the lower back. Neurological examination shows grade 0/5 strength in his tibialis anterior muscles, gastrocnemius/soleus muscles, and extensor hallucis longus muscles bilaterally. His quadriceps and hamstrings strength is grade 2/5 bilaterally. A bullet fragment was seen at L4 within the spinal canal on computed tomography (CT) imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. Management should consist of:

    

   1) Administration of a broad-spectrum antibiotic for 14 days

   3) Continued serial neurologic examinations

   2) Removal of the bullet fragment at L4

   5) A, B, and C

   4) Intravenous administration of dexamethasone for 24 hours

    

   Because the bullet entered the patientâs umbilical region of the abdomen, significant gastrointestinal damage is suspected. When this occurs, administration of a broad-spectrum antibiotic for 7 to 14 days is indicated to prevent infection and sepsis from gastrointestinal flora. The bullet fragment at L4 should be removed because studies have shown that removal of a bullet from a patient with complete or incomplete neural deficits at T12 to L4 is associated with statistically significant increases in motor recovery as compared to nonoperative management. Intravenous administration of dexamethasone is not indicated for gunshot wounds to the spine because the benefits of steroids do not outweigh the risks.Correct Answer: A, B, and C

    

    

   2725. (3358) Q6-4241:

   Magnetic resonance imaging (MRI) is appropriate in which of the following circumstances:

    

   1) Malignancy is suspected as a cause of kyphosis

   3) Patient with congenital kyphosis

   2) Neurologic deficit is suspected as a result of kyphosis

   5) All of the above

   1. Patient with back pain and a history of osteoporosis

       

      It is appropriate to obtain an MRI in all of the above circumstances. Magnetic resonance imaging allows a physician to evaluate the cerebrospinal fluid and spinal cord to localize the cause of a neurologic deficit. The presence of back pain in a patient with kyphosis and osteoporosis suggests the possibility of a vertebral compression fracture; these fractures may not always be seen with conventional radiographs. The use of MRI is recommended for the evaluation of a patient with congenital kyphosis to evaluate the morphology of the malformed segment and to rule out associated pathology.Correct Answer: All of the above

       

       

      2726. (3359) Q6-4242:

      What percentage of women with osteoporotic fractures develop kyphosis:

       

      1) 10%

      3) 25%

      2) 15%

   2. 60%

4. 30%

 

Approximately 15% of women with osteoporotic fractures develop kyphosis. This is often due to the presence of multiple vertebral compression fractures with segmental kyphosis at each level.Correct Answer: 15%

 

A 7-year-old boy presents to the emergency department (ED) with fever, headache, neck pain, nausea, vomiting, and mental status changes. The patient was involved in a motor vehicle accident in his parentâs car and experienced whiplash 4 weeks prior to his presentation at the ED. Laboratory studies show an elevated white blood cell (WBC) count and erythrocyte sedimentation rate (ESR). Which of the following statements concerning this patient is correct:

 

1. A lumbar puncture may reveal cerebral spinal fluid (CSF) with an increased number of neutrophils, decreased glucose content, and increased protein levels.

3) Radiographic findings for whiplash-related trauma may be negative in this patient.

2) A CSF culture may reveal Haemophilus influenzae.

5) All of the above

4) The patient should be admitted to the pediatric intensive care unit (PICU) and started on an intravenous antibiotic regimen.

 

The patient presented with the classic signs and symptoms of pediatric bacterial meningitis. Meningitis should be suspected in patients with neck pain, fever, and altered mental status. A lumbar puncture may show CSF with a high neutrophil count, high protein level, and decreased glucose; a CSF culture may reveal bacteria such as H influenzae. In children with a history of trauma, it is important to note that no radiographic findings may be present in 19% to 34% of patients. Because of the severity of the patientâs symptoms and diagnosis of bacterial meningitis, it is important to admit him to the PICU and begin intravenous antibiotics.Correct Answer: All of the above

 

 

2728. (3361) Q6-4244:

Which of the following statements concerning neck pain is incorrect:

 

1) Patients with traumatic neck injury and pain must be stabilized and assessed with a full neurologic examination while immobilized.

3) Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managing patients with neck pain.

2) Elderly patients may have symptoms of traumatic neck injury without a history of trauma.

5) Rest and physical therapy

4) Surgery for neck pain may be indicated for patients with a cervical spine fracture with evidence of instability, neoplastic disorders, spinal stenosis, and nerve root compression.

 

Choices A, B, D, and E are correct and are important considerations with managing a patient with neck pain. Rest and physical therapy are important and effective in treating neck pain. Prolonged immobilization of the neck with a collar, however, can result in deconditioning of the cervical paraspinal musculature, which can increase the patientâs risk for further neck injury.Correct Answer: Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managing patients with neck pain.

 

 

2729. (3362) Q6-4245:

Schmorlâs nodes may be seen on radiographic studies in all of the following disorders except:

 

1) Spina bifida

3) Degenerative disk disease

2) Scheuermannâs kyphosis

5) Osteoporosis

4) Trauma

 

Schmorlâs nodes are seen in association with several disorders including Scheuermannâs kyphosis, degenerative disk disease, trauma, and osteoporosis. Schmorlâs nodes are not commonly seen in patients with spina bifida.Correct Answer: Spina bifida

 

All of the following are possible treatments for congenital or acquired torticollis except:

 

1) No treatment because spontaneous resolution is possible in cases of congenital torticollis

3) Holding infants so that chin is rotated toward the affected side

2) Active and passive stretching therapies in patients with congenital torticollis until puberty

5) Use botulinum toxin, hard collars, or braces in severe cases

4) Physical therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and use of a soft collar

 

Several treatment options exist for congenital and acquired torticollis. In very mild cases of congenital torticollis, the deformity may be self-limited and no therapy needs to be administered. Sometimes active and passive stretching of the neck can work well if performed before 1 year of life. Parents may hold the babyâs head so that the chin is rotated toward the affected side. Acquired torticollis can also be managed by physical therapy using NSAIDs and a soft collar. The use of botulinum toxin or braces can be a form of therapy in recalcitrant cases.Correct Answer: Active and passive stretching therapies in patients with congenital torticollis until puberty

 

 

 

2731. (3364) Q6-4249:

What is the incidence of congenital torticollis in the general population:

 

1) 0.1% to 0.3%

3) 0.3 to 1.0%

2) 0.5% to 0.8%

5) 2% to 5%

4) 0.3% to 1.9%

 

Epidemiological studies have shown that the incidence of congenital torticollis is approximately 0.3% to 1.9% in the general population.Correct Answer: 0.3% to 1.9%

 

 

2732. (3381) Q6-4296:

Which of the following is a contraindication to kyphoplasty:

 

1) Local osteomyelitis

3) Sepsis

2) Osteoblastic lesions

5) All of the above

1. Bleeding diathesis

    

   It is important to properly evaluate a patient prior to any surgical procedure. If a patient presents with osteomyelitis, osteoblastic lesions, sepsis, or bleeding diathesis, then surgery should be postponed until the underlying condition is corrected.Correct Answer: All of the above

    

    

   2733. (3382) Q6-4297:

   Approximately how many vertebral compression fractures occur in the United States annually:

    

   1) 70,000

   3) 700,000

   2) 500,000

2. 1.5 million

4) 1 million

 

There are approximately 700,000 reported vertebral compression fractures annually in the United States.Correct Answer: 700,000

 

It is important to distinguish between acute or subacute vertebral compression fractures and old healed fractures radiographically. Which of the following can help distinguish an acute fracture from a chronic fracture:

 

1) T1-weighted magnetic resonance image (MRI)

3) Fat-suppressed T2-weighted MRI

2) T2-weighted MRI

5) Computed tomography (CT)

1. Dual energy X-ray absorptiometry (DEXA) scan

    

   One can distinguish an acute or subacute vertebral compression fracture from an old, healed fracture by evaluating the fat-suppressed T2-weighted MRI or short tau inversion recovery (STIR) images. These images will show increased signal intensity suggesting an acute fracture. All of the other forms of imaging mentioned may also be used to evaluate the patient but are not the best techniques for differentiating an acute from a subacute fracture. DEXA scans are used to evaluate for osteoporosis. Although CT imaging provides excellent osseous detail, it may not allow for differentiation of an acute from a chronic fracture unless evidence of fracture healing is seen. Another method for evaluating the acuity of a vertebral compression fracture is a three-phase bone scan, which will demonstrate increased radiotracer activity at the site of an acute or subacute fracture.Correct Answer: Fat-suppressed T2-weighted MRI

    

    

    

   2735. (3484) Q6-4424:

   What is the prevalence of Schmorlâs nodes in the general population:

    

   1) 3%

   3) 10%

   2) 7%

2. 19%

4) 15%

 

Approximately 10% of the population has Schmorlâs nodes, which are often completely benign.Correct Answer: 10%

 

 

2736. (3500) Q6-4450:

A 34-year-old man presents to the emergency department after sustaining a low-velocity gunshot wound to the upper back. Radiologic studies reveal bullet fragments scattered throughout the T6 to T8 levels. No evidence of instability is present on conventional radiographs and computed tomography. The patient was stabilized and a full neurologic examination was performed, revealing no major neurologic deficits. Management of this patient should consist of:

 

1. Removal of the bullet fragments from the T6 to T8 vertebral bodies

3) High-dose intravenous methylprednisolone administration for 24 hours

2) Removal of the bullet fragments from the T6 to T8 vertebral bodies and instrumented fusion from T4 to T10

5) Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any neurologic deficits

4) Broad-spectrum antibiotic administration for 7 days

 

Removal of the bullet fragments from the T6 to T8 levels is not indicated because the patient does not have neurologic deficits and therefore does not require spinal cord decompression via bullet removal. Decompression via bullet removal for neural deficits in the thoracic spine has been shown to result in higher rates of complications compared with nonoperative management. High-dose steroid administration is not indicated in patients with gunshot wounds to the spine because the benefits of steroids are outweighed by the risks. The administration of broad-spectrum antibiotics is not indicated in this patient because the bullet did not pass through the gastrointestinal tract. Nonoperative management and regular observation for progression of neurologic deficits is important in this patient because of the localization of the bullet fragments to the thoracic spine, the lack of neurologic deficits, and the lack of instability.Correct Answer: Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any neurologic deficits

 

 

A patient with slipped capital femoral epiphysis (SCFE) should have an endocrine workup if presenting with which of the following features:

 

1) Bilateral involvement

3) Age <10 or >15 years

2) Body mass index greater than the 95th percentile for age

5) Female gender

4) Negative family history

 

Endocrine workup is only indicated for age ,10 or .15 years, or stature less than the 10th percentile. Bilaterality, obesity, and negative family history are common findings in idiopathic SCFE. Although SCFE is more common in males, it is not uncommon in females.Correct Answer: Age <10 or >15 years

 

 

2738. (3509) Q6-4461:

All of the following disorders can result in thoracic kyphosis measuring >40º except:

 

1) Ankylosing spondylitis

3) Klippel-Feil syndrome

2) Osteoporosis

5) Juvenile osteochondrosis

4) Tuberculosis

 

Klippel-Feil syndrome is a congenital disorder characterized by cervical fusion and malformation. It does not involve the thoracic spine. Conversely, ankylosing spondylitis, a sero-negative spondyloarthropathy, results in excessive kyphosis of the thoracic spine. Osteoporosis can result in kyphosis due to the presence of multiple vertebral compression fractures. Tuberculosis is also known to cause kyphosis due to involvement of the thoracic spine. Lastly, juvenile osteochondrosis, also known as Scheuermannâs kyphosis, is often associated with thoracic kyphosis.Correct Answer: Klippel-Feil syndrome

 

 

2739. (3598) Q6-6462:

Occipitocervical fusion is often technically difficult in patients with rheumatoid arthritis due to all of the following reasons except:

 

1) Reduced bone quality

3) Persistent steroid use

2) Subaxial cervical instability

5) Frequent combination of both occipitocervical deformity and subaxial subluxation necessitating more extensive constructs

4) Occipital condyle fracture

 

Reduced bone quality is common in patients with rheumatoid arthritis. Steroid use may contribute to poor bone quality, impair bony fusion, and impede wound healing. The combination of occipitocervical deformity and subaxial subluxation may make individual patient constructs more extensive.Correct Answer: Occipital condyle fracture

 

 

2740. (3599) Q6-6463:

The majority of studies confirm the presence of atlanto-axial subluxation (AAS) when:

 

1) Anterior atlantodental intervals (AADI) > 0 mm or posterior atlantodental intervals (PADI) < 18 mm

3) AADI > 2 mm or PADI ≤ 16 mm

2) AADI > 1 mm or PADI ≤ 14 mm

5) AADI > 4 mm or PADI ≤ 18 mm

4) AADI > 3 mm or PADI ≤ 14 mm

 

As described by Puttlitz and colleagues, AAS is defined as an AADI greater than 3 mm or a PADI less than 14 mm.Correct Answer: AADI > 3 mm or PADI ≤ 14 mm

 

The most common traumatic indications for occipitocervical fusion include type III occipital condyle fractures and:

 

1) Basilar invagination

3) Odontoid fracture

2) Atlanto-axial subluxation

5) C 1-C 2 instability

4) Atlanto-axial dissociation

 

Basilar invagination and atlanto-axial subluxation are more commonly present in degenerative disorders and less in trauma. Odontoid fractures are usually treated via C 1-C 2 fusion or odontoid screw fixation, although less commonly occipitocervical fusion is required. C 1-C 2 instability, similarly, is usually treated via C 1-C 2 stabilization. A more common traumatic indication for occipitocervical fusion is atlanto-axial dissociation.Correct Answer: Atlanto-axial dissociation

 

 

2742. (3601) Q6-6465:

Occipitocervical fusion is indicated in all of the following situations except:

 

1) Diseased C 1-C 2 facet joints

3) C 1-C 2 instability with intact posterior arch of the atlas

2) C 1-C 2 instability with decompressive laminectomy

5) Atlanto-occipital instability

1. C 1-C 2 instability with fractured posterior arch of the atlas

    

   An unstable C 1-C 2 segment, with intact posterior elements, may be treated via a C 1-C 2 fusion. If decompression is necessary or the posterior elements at C 1-C 2 are involved, then extension to the occiput may be necessary.Correct Answer: C 1-C 2 instability with intact posterior arch of the atlas

    

    

   2743. (3602) Q6-6466:

   Approximately what percentage of individuals with rheumatoid arthritis will develop basilar invagination:

    

   1) 1%

   3) 5%

   2) 3%

2. 20%

4) 10%

 

As per Sandhu and researchers, approximately 11% of patients with rheumatoid arthritis will eventually develop basilar invagination.Correct Answer: 10%

 

 

2744. (3986) Q6-8238:

Which approach(es) will provide access to the middle and anterior columns of the thoracic spine:

 

1. Posterior

3) Anterior and posterolateral (costotransversectomy)

2) Anterior (thoracotomy)

5) None of the above

4) Interlaminar

 

The anterior and posterolateral approaches provide access to the vertebral body (the anterior and middle columns of the spine) for performance of a corpectomy procedure, for example.

Correct Answer: Anterior and posterolateral (costotransversectomy)

 

A 30-year-old man underwent an anterior lumbar discectomy and fusion at L4-L5 and L5-S1 through an anterior retroperitoneal approach 1 month ago. He now reports that he is unable to obtain and maintain an erection. The most likely cause of this condition is:

 

1) Disruption of the sympathetic nerves during anterior lumbar exposure

3) Not related to the surgical dissection

2) Traction on the parasympathetic nerve at the L4-L5 level

5) Sexual dysfunction secondary to retrograde ejaculation

1. Injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level

    

   Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction is often nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-S3 and S3-S4 and are not usually involved in the surgical field for anterior L4-L5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-L5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.

    

   Correct Answer: Not related to the surgical dissection

    

    

   2746. (4014) Q6-8266:

   What percentage of patients with cervical myelopathy living in North America exhibit ossification of the posterior longitudinal ligament:

    

   1) 1%

   3) 10%

   2) 5%

2. 50%

4) 25%

 

Although ossification of the posterior longitudinal ligament is considered most common in the Japanese population, 25% of North Americans with cervical myelopathy exhibit signs of this condition.

Correct Answer: 25%

 

 

2747. (4015) Q6-8267:

A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical laminectomy from C 3 to C 7. The risk of post laminectomy kyphosis is greatest with removal of which of the following structures:

 

1. More than 80% of the lamina

3) Interspinous ligament

2) More than 50% of each facet joint

5) Ligamentum flavum

4) Facet joint capsules

 

Post laminectomy kyphosis is often seen in patients who have removal of more than 50% of each facet joint or 100% of one facet joint. It is not commonly seen with removal of the ligamentum flavum or interspinous ligament. Less frequently, post laminectomy kyphosis is seen with removal of more than 80% of the lamina or excision of the facet joint capsules.

 

Correct Answer: More than 50% of each facet joint

 

Which of the following variables is the most reliable predictor of poor outcome following arthroscopic debridement of an arthritic knee:

 

1) Presence of mechanical symptoms

3) Varus malalignment

2) Outerbridge grade IV chondromalacia

5) Duration of symptoms

4) Patient age

 

The presence of mechanical symptoms is a reliable predictor of successful outcome. Age has not been shown to reliably predict outcome following knee debridement. Although a prolonged duration of symptoms correlates with poor outcome, the presence of varus malalignment has a far more dismal prognosis.Correct Answer: Varus malalignment

 

 

 

2749. (154) Q7-205:

Studies have shown that anterior cruciate ligament (ACL) deficiency may result in abnormal meniscal strain found particularly in what region:

 

1) Anterior horn of the lateral meniscus

3) Patellofemoral joint

2) Anterior horn of the medial meniscus

5) Posterior horn of the medial meniscus

4) Posterior horn of the lateral meniscus

 

While acute anterior cruciate ligament (ACL) injury alters the strain patterns in the lateral meniscus, chronic ACL insufficiency increases the strain in the medial meniscus and often results in tears of the posterior horn. In a study of 176 consecutive patients undergoing ACL reconstruction, there was an increasing incidence of meniscal tears as the ACL injury became more chronic with a significant increase in all medial meniscal tears and a relatively constant incidence of lateral meniscal tears.Correct Answer: Posterior horn of the medial meniscus

 

 

 

2750. (155) Q7-207:

When comparing women to men, the NCAA Injury Surveillance System has demonstrated a higher rate of injury to what structure:

 

1) Patellar tendon

3) Posterior cruciate ligament (PCL)

2) Anterior cruciate ligament (ACL)

5) Medial collateral ligament

4) Posterolateral ligament complex

 

Anterior cruciate ligament injury has been observed to be 2 to 3 times more common in female basketball players than in their male counterparts. The higher risk of ACL injury in women may be related to laxity, larger Q angles, excessive pronation, increased hamstring flexibility, decreased notch width index, posture (less knee and hip flexion), and possible hormone influences.Correct Answer: Anterior cruciate ligament (ACL)

 

 

After landing awkwardly on his flexed knee, a 22-year-old basketball player has immediate onset of pain and difficulty bearing weight. With the knee flexed 30°, examination reveals increased varus, external rotation, and posterior translation which decreases when the knee is flexed to 90°. The patient most likely has injured what structure(s):

 

1) Posterolateral complex

3) Posterior cruciate ligament

2) Posterolateral complex and posterior cruciate ligament

5) Posterior cruciate ligament and medial collateral ligament

4) Lateral collateral ligament

 

With an isolated injury to the posterior cruciate ligament (PCL), posterior translation increases at greater degrees of flexion demonstrating the greatest posterior translation at 90°. Injury to the lateral collateral ligament leads to varus laxity in 30° flexion without posterior translation. With an injury to the PCL and posterolateral complex, varus, external rotation, and posterior translation are detectable at 30° and increase as the knee is flexed to 90°. Isolated tears of the posterolateral complex lead to increased varus, external rotation, and posterior translation at 30° that decreases as the knee is flexed to 90° and the PCL tightens.Correct Answer: Posterolateral complex

 

 

 

2752. (157) Q7-209:

When interference screws are used for femoral fixation during an endoscopic anterior cruciate ligament (ACL) reconstruction using autograft patellar tendon, how much divergence between the screw and bone plug is acceptable before pull-out strength is compromised to a clinically significant level:

 

1) 0º

3) 20º

2) 10º

5) 70º

4) 30º

 

Recent studies have indicated that nearly 40% of endoscopic anterior cruciate ligament reconstructions demonstrate screw-bone plug divergence. Divergence angles of less than 30° do not significantly alter pull-out strength clinically.Correct Answer: 30º

 

 

 

2753. (158) Q7-210:

The use of functional braces as part of a nonsurgical program for anterior cruciate ligament (ACL) insufficiency has been criticized primarily for what reason:

 

1) Most patients do not feel more stable in the brace.

3) The use of functional braces slows voluntary reaction time of the hamstring muscles.

2) Functional bracing does not limit anterior translation of the tibia in the ACL-deficient knee.

5) Functional bracing may prevent injury to the menisci.

4) Functional bracing increases stresses across the patellofemoral joint.

 

Using functional bracing in ACL-deficient knees has been shown to limit anterior translation of the tibia. Approximately two-thirds of patients feel more stable in a brace. Unfortunately, most braces slow voluntary reaction times of the hamstring muscles, which are important dynamic stabilizers of the joint. Patellofemoral stresses have not been shown to increase with the use of functional bracing.Correct Answer: The use of functional braces slows voluntary reaction time of the hamstring muscles.

 

 

All of the following can lead to loss of motion following anterior cruciate ligament (ACL) reconstruction except:

 

1) Non-anatomic graft placement

3) Intercondylar notch scarring

2) Concomitant ligament surgery

5) Immobilization

4) Use of allograft patellar tendon

 

Etiologic factors for loss of motion following anterior cruciate ligament reconstruction include: intercondylar notch scarring, non-anatomic graft placement, capsulitis with ligament scarring or calcification, concomitant ligament surgery, immobilization, anterior nodule or Cyclops lesion, infection, and/or reflex sympathetic dystrophy. The use of allograft tissue has not been shown to increase the risk of arthrofibrosis.Correct Answer: Use of allograft patellar tendon

 

 

 

2755. (4037) Q7-213:

Endurance training in athletes increases all of the following muscle properties except:

 

1) Hypertrophy (size) of type 1 fibers

3) Mass of connective tissue

2) Strength

5) Number of glycogen-producing enzymes

4) Number of mitochondria

 

Although fast-twitch muscle fibers (type II) undergo hypertrophy with high-resistance training, they do not increase in size with endurance training. Endurance training results in more efficient use of glycogen and an increased capacity for aerobic metabolism which, in turn, increases the number of mitochondria and glycogen-producing enzymes.Correct Answer: Hypertrophy (size) of type 1 fibers

 

 

 

2756. (160) Q7-215:

The cell responsible for healing a meniscal tear is the:

 

1) Primitive mesenchymal cell

3) Monocyte

2) Fibrochondrocyte

5) Synovial type B cell

4) Synovial type A cell

 

The fibrochondrocyte is the cell responsible for meniscal healing. Synovial type A cells are important in phagocytosis. Synovial type B cells produce synovial fluid. The target cell for bone morphogenic protein is the undifferentiated perivascular mesenchymal cell.Correct Answer: Fibrochondrocyte

 

 

 

2757. (161) Q7-216:

All of the following structures have attachment to the medial femoral condyle except the:

 

1) Adductor magnus

3) Superficial medial collateral ligament

2) Medial head of the gastrocnemius

5) Popliteus

4) Patellofemoral ligament

 

The popliteus attaches to the posterior aspect of the lateral femoral condyle. All of the other mentioned structures attach to the medial femoral condyle: the adductor magnus superiorly, the superficial medial collateral ligament and the gastrocnemius inferiorly, and the medial patellofemoral ligament anteriorly deep to the vastus medialis.Correct Answer: Popliteus

 

 

 

 

1) Allow for co-contraction of the musculature around the knee

3) Allow hip muscular activity for stability

2) Stabilize the foot

5) Improve aerobic power and endurance in the leg

4) Apply physiologic compressive loads to the knee

 

Closed-chain exercises for the lower extremity have been shown to be effective following anterior cruciate ligament reconstruction for several reasons. They allow co-contraction of the muscles crossing the knee, stabilize the foot against resistance, apply compressive loads to the knee, and allow for hip motion for stability. Such exercises have not been shown to have any effect on the aerobic capacity of the leg.Correct Answer: Improve aerobic power and endurance in the leg

 

 

 

2759. (163) Q7-218:

A 24-year-old cross-country runner complains of anterior knee pain after running. Palpation reveals point tenderness at the inferior pole of the patella. Range of motion is full and exam demonstrates no patellofemoral crepitus. Management should include:

 

1) Cortisone injection into the site of tenderness

3) Nonsteroidal anti-inflammatory medication and quadriceps stretching exercises

2) Use of a knee immobilizer for 6 weeks

5) Open patellar tendon debridement

4) Arthroscopic lateral release

 

This scenario is consistent with infrapatellar tendinitis (jumperâs knee), which is common in runners and jumpers. The mechanism often involves chronic overloads of the tendon. Anti-inflammatory medication may alleviate symptoms while quadriceps stretching decreases the load on the tendon by increasing the resting length of the muscle-tendon unit. Open patellar tendon debridement should be reserved for cases of chronic tendonitis that are refractory to conservative management.Correct Answer: Nonsteroidal anti-inflammatory medication and quadriceps stretching exercises

 

 

 

2760. (164) Q7-219:

To be considered for repair, a meniscal tear must fulfill all of the following criteria except:

 

1) The tear should be longer than 10 mm.

3) The torn segment must be minimally damaged.

2) The tear must be contained entirely within the vascular zone.

5) The tear should not be degenerative.

4) A peripheral rim of meniscal tissue must exist.

 

Meniscal repair is now recognized as an effective treatment method for certain types of meniscal tears. To be considered for repair, a meniscal tear must be long enough to cause instability of the torn portion (usually longer than 10 mm). The tear should also be within the vascular zone of the mensicus where healing is most likely to occur. There must also be minimal damage to the torn segment. In general, meniscal tears in older patients tend to be degenerative in nature, precluding a successful repair.

Although the peripheral tissue must be minimally damaged for a successful repair, the presence of meniscal tissue peripherally is not necessary prior to considering repair.Correct Answer: The tear should not be degenerative.

 

 

an acute anterior cruciate ligament (ACL) injury:

 

1) Posterolateral aspect of the tibia and the middle aspect of the lateral femoral condyle

3) Lateral patellar facet and lateral trochlear groove

2) Posterolateral aspect of the tibia and the posteriar aspect of the lateral femoral condyle

5) Posteromedial aspect of the tibia and the anteromedial aspect of the lateral femoral condyle

4) Anterolateral aspect of the tibia and the posterolateral aspect of the lateral femoral condyle

 

During anterior cruciate ligament (ACL) injury, anterior translation of the tibia and the associated valgus force create a compressive load on the articular cartilage in the posterolateral aspect of the tibia and the anterolateral aspect of the lateral femoral condyle. It has been estimated that approximately 80% of acute ACL injuries demonstrate this pattern on magnetic resonance imaging.Correct Answer: Posterolateral aspect of the tibia and the middle aspect of the lateral femoral condyle

 

 

 

2762. (166) Q7-221:

Six days following anterior cruciate ligament (ACL) reconstruction, a patient returns for follow-up with a fever of 102° F, local incisional drainage, painful decreased knee motion, effusion, erythema, and warmth in the knee. Aspiration of the knee reveals cloudy, blood-tinged synovial fluid. A white blood cell count of the aspirate was 60,000 with 85% polymorphonuclear cells.

Appropriate management at this time should include:

 

1) Admission to the hospital and administration of IV antibiotics.

3) Immediate arthroscopic lavage with incision and drainage of all associated wounds.

2) Starting the patient on oral antibiotics followed by careful outpatient observation over the next several days.

5) Immediate arthroscopic lavage with incision and drainage of all associated wounds, partial synovectomy, and debridement with graft retention.

4) Immediate arthroscopic lavage with incision and drainage of all associated wounds, partial synovectomy, and graft debridement.

 

Although reported infection rates following anterior cruciate ligament (ACL) reconstruction are as low as 0.3%, the treatment of septic arthritis in the early postoperative period can be challenging. In a patient with a suspected infection, immediate arthroscopic lavage with debridement of necrotic tissue and partial synovectomy is paramount. In a recent review of 831 arthroscopically guided ACL reconstructions, McAllister and associates reported complete resolution of all four infected cases with early lavage, debridement, and graft retention followed by IV, then oral antibiotics. However, the clinical outcome of these patients was inferior to that of patients who had undergone uncomplicated ACL reconstruction due to the damage of the articular cartilage as a result of the infection.Correct Answer: Immediate arthroscopic lavage with incision and drainage of all associated wounds, partial synovectomy, and debridement with graft retention.

 

 

 

2763. (167) Q7-222:

In a congruent patellofemoral joint, the patella centers within the trochlear groove by what degree of flexion:

 

1) 5° to 10°

3) 15° to 20°

2) 10° to 15°

5) 25° to 30°

4) 20° to 25°

 

Laurin and colleagues recognized that the normally tracking patella centered within the trochlea by 20° of knee flexion. Fulkerson and Hungerford demonstrated patellar engagement between 15° to 20° using computerized tomography scans.Correct Answer: 15° to 20°

 

 

ligament (ACL) fixation using hamstring tendon graft fixation with soft tissue interference screws:

 

1) Use of a longer screw provides stronger fixation strength.

3) Fixation strength has not been shown to be affected by screw length.

2) A small diameter screw provides stronger fixation strength.

5) Better fixation is achieved with larger bone tunnel diameter.

4) The best fixation is achieved with a long screw and aperture fixation.

 

A recent study compared the cyclic and time-zero pull-out forces of 7 Ã 25 mm and 7 Ã 40 mm blunt-threaded metal interference screws for hamstring graft tibial fixation in 8 paired human cadaveric specimens. There were no measurable differences in the mean cyclic failure strength, pull-out strength, or stiffness between the 2 sizes of screws. One potential advantage of using a longer screw is the relative ease with which it can be removed compared with a shorter screw should revision surgery become necessary.Correct Answer: Fixation strength has not been shown to be affected by screw length.

 

 

 

2765. (169) Q7-227:

Which of the following statements concerning allograft use in anterior cruciate ligament (ACL) reconstruction is incorrect:

 

1) Allograft sterilization using gamma irradiation has not been shown to adversely affect its tensile properties.

3) Allograft use diminishes postoperative pain.

2) Allograft use avoids donor site morbidity.

5) Allograft incorporation is slower than autograft.

4) Allograft use decreases surgical time.

 

Secondary sterilization is achieved with the use of ethylene oxide or gamma irradiation, both of which have detrimental effects on the allograft. Ethylene oxide residues remain on the tissue and stimulate an intra-articular reaction. Gamma radiation has been shown to decrease structural and mechanical properties of the tissue. Irradiation also alters the collagen morphology of sterilized tissues. Currently, the most accepted method of allograft sterilization involves sterile harvesting and deep freezing.Correct Answer: Allograft sterilization using gamma irradiation has not been shown to adversely affect its tensile properties.

 

 

 

2766. (170) Q7-228:

Which of the following choices represents the correct order of layers in the direct insertion of a human ligament:

 

1) Bone, uncalcified fibrocartilage, calcified fibrocartilage, and ligament

3) Bone, hypertrophic layer, fibrous layer, and ligament

2) Bone, fibrous layer, hypertrophic layer, and ligament

5) Bone, calcified fibrous layer, uncalcified fibrous layer, and ligament

4) Bone, calcified fibrocartilage, uncalcified fibrocartilage, and ligament

 

Histologic sectioning of a direct ligament insertion of rotator cuffs in cadavers demonstrates 4 discrete layers: ligament, uncalcified fibrocartilage layer, calcified fibrocartilage layer, and bone. Some authors have suggested that the uncalcified fibrocartilage ensures that the tendon fibers do not compress at a hard tissue interface.Correct Answer: Bone, calcified fibrocartilage, uncalcified fibrocartilage, and ligament

 

 

 

 

1) Maltracking describes the bony anatomy, while malalignment describes the soft tissue anatomy.

3) Malalignment refers to the patellar articulation only.

2) Maltracking refers to the patellar articulation only.

5) Malalignment describes a static relationship, while maltracking describes a dynamic relationship.

4) Malalignment refers to passive instability, while maltracking refers to active instability.

 

Terminology describing the setting for patellar instablility can be confusing when the terms âmalalignment,â âmaltracking,â and âinstabilityâ are used interchangeably. Malalignment is an abnormal static relationship between the patella, its associated soft tissues, and the femoral and tibial axes. Maltracking is an expression of the dynamic relationships of these components and is noted during both active and passive motion.Correct Answer: Malalignment describes a static relationship, while maltracking describes a dynamic relationship.

 

 

 

2768. (172) Q7-230:

Which of the following findings has not been reported following abrasion arthroplasty as treatment for the painful, arthritic knee:

 

1) An increase of the medial joint space on radiograph

3) Formation of a fibrocartilage articular surface

2) Intermediate or long-term symptomatic improvement in the majority of patients

5) Worsening of symptoms in 10% to 20% of patients

4) Formation of primarily type I collagen

 

Although popular in the 1980s, abrasion arthroplasty for the treatment of osteoarthritis of the knee has not been shown to reliably improve patientsâ symptoms. Although some authors have found radiographic evidence of an increased joint space in approximately 50% of patients, these findings have not corresponded to an improvement in symptomatology. Abrasion arthroplasty results in the formation of a fibrocartilaginous articular surface that varies in composition with immature type I collagen predominant.Correct Answer: Intermediate or long-term symptomatic improvement in the majority of patients

 

 

 

2769. (173) Q7-231:

Which of the following anatomic landmarks of the knee represents the contact area between the lateral femoral condyle and the anterior horn of the lateral meniscus when the knee is in full extension:

 

1) Outerbridgeâs ridge

3) Notch of Grant

2) Blumensattâs line

5) Sulcus terminalis

4) Davidâs point

 

The indentation on the lateral femoral condyle often seen on the lateral radiograph of the knee represents the contact area between the femoral condyle and the anterior portion of the lateral meniscus and is often referred to as the sulcus terminalis. After an acute anterior cruciate ligament (ACL) injury or recurrent giving way episode in a chronically ACL deficient knee, the sulcus terminalis is the region in which a bone contusion is typically seen on an magnetic resonance image.Correct Answer: Sulcus terminalis

 

 

 

2770. (174) Q7-232:

Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:

 

1) Residual anterior cruciate ligament laxity

3) Loss of knee flexion

2) Osteophytes near the tibial spine

5) Loss of terminal knee extension

4) Hypertrophy of the tibial spine

 

The overall results following adequate reduction of the tibial spine are good to excellent. Loss of terminal knee extension is thought to occur due to hyperemia, subsequent hypertrophy or displacement of the tibial spine and resultant bony blockage.Correct Answer: Loss of knee flexion

 

 

2771. (175) Q7-233:

Which of the following initial treatment regimens is most appropriate for a 12-year-old boy with osteochondritis dissecans and no effusion or mechanical symptoms:

 

1) Arthroscopic fixation of the lesion

3) Moderation of activities

2) Arthroscopic drilling of the lesion

5) Arthroscopic synovectomy and debridement

4) Arthroscopic removal of loose bodies

 

Arthroscopic treatment of osteochondritis dissecans is limited to those patients with mechanical symptoms, effusion, and/or radiographic evidence of loose bodies in the joint. Osteochondritis of the femoral condyle may well heal with moderation of activities.Correct Answer: Moderation of activities

 

 

 

2772. (176) Q7-234:

Which of the following radiographic views allows the best visualization of the acromioclavicular (AC) joint:

 

1) Stryker notch view

3) Garth view

2) Zanca view

5) Anteroposterior shoulder view

4) Serendipity view

 

In addition to standard views, a 10° cephalic tilt (Zanca) view is helpful to evaluate anteroposterior arthritis or distal clavicle osteolysis. This view is taken with approximately half the voltage of a standard anteroposterior shoulder radiograph and allows an unobstructed look at the acromioclavicular joint without soft tissue or bony overlay.

 

 

The Stryker notch radiograph allows visualization of a Hill-Sachs impression fracture of the posterior humeral head.

 

The glenoid fossa, or Garth view, is a true anteroposterior of the glenohumeral joint with the radiograph beam directed 45Â

° from the plane of the thorax.

 

The Serendipity view is used to evaluate the sternoclavicular joint and is a 40° cephalic tilt view with the patient supine.

Correct Answer: Zanca view

 

 

2773. (177) Q7-235:

Following two previous shoulder stabilization procedures for recurrent dislocations, a 45-year-old man complains of pain and limited motion. Examination reveals increased passive external rotation and an inability to lift the back of the hand away from his back. Which of the following muscles is injured:

 

1) Subscapularis

3) Infraspinatus

2) Supraspinatus

5) Teres minor

4) Deltoid

 

The patient has an incompetent subscapularis muscle. An inability to lift the back of the hand away from the back (a positive Lift-off test) has been described by Gerber and colleagues and is a reliable method of evaluating subscapularis integrity. Patients with subscapularis tears often demonstrate an increase in passive external rotation and weakness in internal rotation.Correct Answer: Subscapularis

 

 

2774. (178) Q7-236:

Which of the following structures provides static restraint to anterior humeral head translation in relation to the glenoid at 90° of abduction and external rotation:

 

1) Subscapularis muscle

3) Superior glenohumeral ligament

2) Supraspinatus muscle

5) Inferior glenohumeral ligament

4) Middle glenohumeral ligament

 

Biomechanics studies have demonstrated that the anterior band of the inferior glenohumeral ligament (IGHL) provides the primary static restraint to anterior shoulder translation. Neither the subscapularis nor the supraspinatus provides static restraint to the glenohumeral joint.Correct Answer: Inferior glenohumeral ligament

 

 

 

2775. (179) Q7-237:

Which of the following is not a cause of failure following arthroscopic subacromial decompression:

 

1) Error in diagnosis

3) Reconstitution of bursal tissue

2) Detachment of the deltoid

5) Retained coracoacromial (CA) ligament

4) Inadequate bone resection

 

Causes of failure following arthroscopic decompression are similar to the causes of failure following open acromioplasty. Numerous studies have documented errors in diagnosis as the most common cause of failure. Inadequate bone resection can also cause continued pain and dysfunction. A retained coracoacromial ligament attachment can decrease the volume in the subacromial space and lead to recurrent impingement. Although bursal tissue can reconstitute following partial excision, this has not been shown as a common cause of failure following decompression. Deltoid detachment may cause weakness and pain.Correct Answer: Reconstitution of bursal tissue

 

 

 

2776. (180) Q7-238:

Which of the following structures is involved in the âessential lesionâ of a stiff shoulder:

 

1) Biceps tendon

3) Posterior capsule

2) Coracohumeral ligament

5) Axillary pouch

4) Labrum

 

The long head of the biceps tendon defines the region of the rotator interval, which is the area between the anterior edge of the supraspinatus tendon and the superior edge of the subscapularis tendon. This region usually is contracted in individuals who lack external rotation of the adducted shoulder. Coracohumeral ligament contracture is an important component of adhesive capsulitis.Correct Answer: Coracohumeral ligament

 

 

 

2777. (181) Q7-240:

A 35-year-old businessman sustains a type III acromioclavicular (AC) separation of his dominant shoulder. Preferred treatment should be:

 

1) Open subacromial decompression with distal clavicle resection

3) Repair of coracoacromial ligament and fixation with a Bosworth screw

2) Arthroscopic subacromial decompression

5) Reduction of the AC joint and stabilization with pins

4) Symptomatic treatment followed by return to activities as tolerated

 

Long-term outcome studies have demonstrated good and excellent results following symptomatic, nonsurgical treatment of grade I-III acromioclavicular separations. Surgical treatment may lead to complications (especially with the use of transfixing smooth pins), loss of reduction, and chronic pain due to joint instability.Correct Answer: Symptomatic treatment followed by return to activities as tolerated

 

 

2778. (182) Q7-241:

Which of the following muscles is most responsible for deceleration of the arm during pitching:

 

1) Deltoid

3) Teres minor

2) Coracobrachilis

5) Short head of the biceps

4) Long head of the biceps

 

During the deceleration phase, the excess kinetic energy that was not transferred to the ball is dissipated by controlled deceleration of the upper extremity. The rotator cuff (primarily teres minor) is the principle decelerator and is susceptible to tensile failure from eccentric loading.Correct Answer: Teres minor

 

 

 

2779. (183) Q7-242:

Which of the following is the definition of internal impingement of the shoulder:

 

1) Impingement of the under surface of the rotator cuff against the posterosuperior glenoid labrum

3) Impingement of the bursal-surface of the rotator cuff against a prominent acromion

2) Impingement of the under surface of the rotator cuff against the anterior glenoid labrum

5) Impingement of the rotator cuff against an intra-articular loose body

4) Impingement of the bursal-surface of the rotator cuff against a hypertrophied coracoacromial ligament

 

When a shoulder is placed in a position of abduction and external rotation, the rotator cuff can impinge against the posterosuperior glenoid labrum. This phenomenon has recently been the explanation for pain when the apprehension test is performed. A positive relocation test occurs when this discomfort is relieved by posterior translation of the humeral head.Correct Answer: Impingement of the under surface of the rotator cuff against the posterosuperior glenoid labrum

 

 

 

2780. (184) Q7-243:

Which of the following conditions most often accompanies a dislocation of the longhead of the biceps tendon?

 

1) Anterior instability

3) Subscapilars tendon pathology or tear

2) Presence of a Buford complex

5) Excessive glenoid anteversion

4) Hill-Sachs lesions

 

Although âisolatedâ ruptures of the biceps tendon have been described, most cases involving biceps tendon pathology are accompanied by rotator cuff injury. When computerized tomography arthrograms are performed on patients who have clinical criteria for isolated ruptures of the long head of the biceps, the incidence of isolated lesions decreases to 6%. Although primary bicipital tendinitis was recognized as a frequent cause of anterior shoulder pain in the 1950s, it is currently a diagnosis of exculsion that is made far less frequently.Correct Answer: Subscapilars tendon pathology or tear

 

 

Which of the following combinations correctly describes the contributions of the acromioclavicular ligaments and coracoclavicular ligaments in stabilizing the acromioclavicular joint:

 

1) Horizontal stability is controlled by the coracoacromial ligament.

3) Horizontal stability is controlled by the coracoclavicular ligament and vertical stability is controlled by the acromioclavicular ligament.

2) Vertical stability is controlled by the acromioclavicular ligament.

5) Horizontal stability is controlled by the acromioclavicular ligament and vertical stability is controlled by the coracoclavicular ligament.

4) Horizontal stability is controlled by the coracoacromial ligament and vertical stability is controlled by the acromioclavicular ligament.

 

Fuduka and colleagues have studied the individual ligamentous contributions to acromioclavicular stability by performing load displacement tests on sectioned cadaveric models. These experiments led to the conclusion that the horizontal stability of the acromioclavicular joint is controlled by the acromioclavicular ligament and vertical stability is controlled by the coracoclavicular ligament.Correct Answer: Horizontal stability is controlled by the acromioclavicular ligament and vertical stability is controlled by the coracoclavicular ligament.

 

 

 

2782. (230) Q7-340:

Which of the following statements is true concerning the bands of the anterior cruciate ligament:

 

1) The anterolateral band is tightest in flexion.

3) The posteromedial band is tightest in extension.

2) The posterolateral band is tightest in flexion.

5) The anteromedial band is tightest in extension.

4) The anteromedial band is tightest in flexion.

 

The anterior cruciate ligament is composed of at least two functional bands. The larger anteromedial band is tightest in flexion and loosest in extension. The smaller posterolateral band is tightest in extension and loosest in flexion. Conventional anterior cruciate ligament reconstruction replaces only the anteromedial band.Correct Answer: The anteromedial band is tightest in flexion.

 

 

 

2783. (234) Q7-345:

Which of the following statements is true concerning the bands of the posterior cruciate ligament:

 

1) The anterolateral band is tightest in flexion.

3) The posteromedial band is tightest in flexion.

2) The posterolateral band is tightest in flexion.

5) The anteromedial band is tightest in extension.

4) The anteromedial band is tightest in flexion.

 

The posterior cruciate ligament is composed of two functional bands. The larger anterolateral band is tightest in flexion and loosest in extension. The smaller posteromedial band is tightest in extension and loosest in flexion. Conventional posterior cruciate ligament reconstruction replaces only the anterolateral band.Correct Answer: The anterolateral band is tightest in flexion.

 

 

 

2784. (235) Q7-346:

The most sensitive test for posterior cruciate ligament injury is the:

 

1) Posterior drawer test

3) Posterior sag sign

2) Quadriceps active drawer test

5) Dynamic posterior shift test

4) Posterior Lachman test

 

All of the above tests have been described for evaluating posterior cruciate ligament injury. Of these tests, the posterior drawer test is the most sensitive(95%).Correct Answer: Posterior drawer test

 

 

In a pitcher with an ulnar collateral ligament injury of his dominant elbow, pain is generally most severe during:

 

1) Wind-up

3) Late cocking

2) Early cocking

5) Rest following activity

4) Follow-through

 

With ulnar collateral ligament injury, pain is usually exacerbated during the late cocking and the acceleration phases of throwing when the stresses on the ulnar collateral ligament are greatest.Correct Answer: Late cocking

 

 

 

2786. (237) Q7-348:

A 30-year-old male avid runner presents with a 2-week history of right lateral knee pain. He denies any history of trauma, swelling, or mechanical symptoms. The pain only occurs with running and is relieved by cessation of activity. Physical examination does not demonstrate any effusion, and there is no pathologic laxity of the collateral or cruciate ligaments. There is tenderness to palpation along the lateral aspect of the knee that is most severe over the lateral epicondyle, particularly with the knee flexed to 30°. The next most appropriate course of action is:

 

1) Obtain an magnetic resonance image

3) Arthroscopic debridement of the right lateral meniscus

2) Steroid injection to the right knee

5) Stretching of the right iliotibial band, temporary decrease in mileage, and anti-inflammatory medication

4) Arthroscopic repair of the right lateral meniscus

 

The patient has iliotibial band friction syndrome, which is common in runners. Physical therapy is successful in the majority of patients. Rarely, debridement of an ellipse of the iliotibial band will be required to provide relief.Correct Answer: Stretching of the right iliotibial band, temporary decrease in mileage, and anti-inflammatory medication

 

 

 

2787. (238) Q7-349:

 

 

 

Figure 1

This radiograph shows a diaphysis of a 21-year-old female collegiate soccer player. She reports pain in the midshaft of her tibia for 7 months. She has been previously treated with cessation of soccer, 8 weeks in a short leg cast, and 3 months of treatment with an ultrasonic bone stimulator. Recommended treatment at this time should include:

 

1) Observation

3) Application of a short leg case

2) Application of a long leg cast

5) Insertion of a reamed intramedullary nail

4) Continued treatment with an ultrasonic bone stimulator

 

The tibia is the bone most prone to stress fractures in athletes. The appearance of the "dreaded black line" is a poor prognostic indicator for healing. Since this patient has failed nonoperative treatment, insertion of a reamed intramedullary nail would offer her the best chance of healing and earlier return to activity.Correct Answer: Insertion of a reamed intramedullary nail

 

 

A "stinger" (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in football) most commonly affects the:

 

1) Spinal cord

3) C-7/C-8 nerve roots

2) C-5/C-6 nerve roots

5) Musculocutaneous nerve

4) Axillary nerve

 

"Stingers" are common in football. They generally result from a transient stretch to the C-5/C-6 nerve roots resulting in temporary loss of strength of the biceps, deltoid, and spinatus muscles. It is generally safe to allow the athlete to return to participation, provided the cervical spine examination is normal and any neurological deficits have completely resolved.Correct Answer: C-5/C-6 nerve roots

 

 

 

2789. (240) Q7-351:

A 16-year-old male high school football player was making a tackle when he felt sudden pain in his right long finger. He has swelling and tenderness along the volar aspect of the injured digit. He is unable to actively flex the distal interphalangeal joint of the injured digit. Radiographs are negative for fracture. Recommended treatment should include:

 

1) Observation

3) Splinting of the distal interphalangeal joint in flexion

2) Splinting of the distal interphalangeal joint in extension

5) Surgical repair

4) Immediate active range of motion exercises

 

Avulsion of the flexor digitorum profundus, or "jersey finger," is a common injury in football. Appropriate treatment includes surgical repair.Correct Answer: Surgical repair

 

 

 

2790. (241) Q7-352:

Catastrophic cervical spine injuries occurring during contact sports are most commonly a result of:

 

1) Hyperflexion

3) Flexion/compression

2) Hyperextension

5) Distraction

4) Rotation

 

Catastrophic injury of the cervical spine resulting in paralysis or death usually occurs from an axial loading mechanism, such as "spear" tackling in football. Controversy exists as to whether cervical spinal stenosis is a predisposing factor for catastrophic cervical spine injuries.Correct Answer: Flexion/compression

 

 

 

2791. (242) Q7-354:

A collegiate level sprinter sustains an acute nondisplaced fracture at the proximal metaphyseal-diaphyseal junction of the fifth metatarsal. Appropriate treatment for early return to play includes:

 

1) Observation

3) Short leg non-weightbearing cast

2) Short leg walking cast

5) Compression screw fixation

4) Application of an ultrasonic bone stimulator

 

Fractures of the metaphyseal-diaphyseal junction of the fifth metatarsal base, the Jones fracture, is treated more aggressively than its avulsed counterpart. In the acute situation, these fractures are treated in a non-weightbearing cast until union is obtained. Occasionally, an elite athlete will sustain a Jones fracture. It is important to determine whether this represents an acute injury or a stress fracture. Stress fractures are treated initially with non-weightbearing until union occurs and symptoms resolve. Acute Jones fractures in the athlete are best treated with compression screw fixation with bone graft to insure healing in a timely manner.Correct Answer: Compression screw fixation

 

 

2792. (243) Q7-355:

 

 

 

Figure 1

This is the radiograph of a right hand dominant 15-year-old baseball player who felt a pop when swinging a bat. There is pain in the upper portion of the first rib. Recommended treatment should consist of:

 

1) Immobilization in a shoulder spica cast

3) Open reduction internal fixation with bone graft

2) Immobilization in a sling

5) Observation

4) Open biopsy

 

First rib fractures in athletes are rare. These fractures are thought to be stress fractures, usually occurring in pitchers. Treatment is observation until the fracture is healed.Correct Answer: Observation

 

 

 

2793. (244) Q7-356:

A 10-year-old female gymnast twists her knee on her dismount from the balance beam. She hears a pop and has immediate swelling. She is unable to continue with activity. Physical examination reveals a positive Lachman test and positive pivot shift. She has no joint line tenderness. Radiographs are normal. After an initial period of ice and range of motion exercises, recommended treatment should include:

 

1) Direct repair of the anterior cruciate ligament

3) Reconstruction of the anterior cruciate ligament using hamstrings

2) Reconstruction of the anterior cruciate ligament using patellar tendon

5) Rehabilitation emphasizing hamstring strengthening

4) Extra-articular reconstruction

 

Anterior cruciate ligament injuries in children represent a vexing clinical problem. Standard anterior cruciate ligament reconstructions would involve drilling across an open physis, which may cause a growth disturbance. Results of direct repair or extra-articular reconstruction have been no better in children than in adults. The most reasonable initial treatment is rehabilitation. If despite adequate rehabilitation, the child continues to have instability, it is recommended that the child discontinues the activities that result in instability until skeletal maturity when a standard reconstruction can be performed, or when the child undergoes a physeal sparing reconstruction (i.e., Bergfeld's "tomato stake" reconstruction).Correct Answer: Rehabilitation emphasizing hamstring strengthening

 

 

 

2794. (245) Q7-357:

The most common location of osteochondritis dissecans in the knee is the:

 

1) Lateral aspect of the medial femoral condyle

3) Medial aspect of the medial femoral condyle

2) Medial aspect of the lateral femoral condyle

5) Lateral aspect of the femoral trochlea

4) Lateral facet of the patella

 

Osteochondritis dissecans affects adolescents, and the knee joint is the most commonly affected joint. The most common location in the knee is the lateral aspect of the medial femoral condyle at the intercondylar notch. Treatment varies with the stability of the lesion from observation to operative reduction and fixation.Correct Answer: Lateral aspect of the medial femoral condyle

 

 

A 15-year-old female volleyball player twisted her knee while planting her foot. She states she felt her knee give out. She had immediate swelling and was unable to continue participation. She denies hearing a pop. Physical examination reveals a large effusion with a range of motion from full extension to 80° flexion. She has marked tenderness along the medial retinaculum of her knee. She has no joint line tenderness. There is no pathologic laxity involving the collateral or cruciate ligaments. The most likely diagnosis is:

 

1) Partial anterior cruciate ligament tear

3) Medial collateral ligament sprain

2) Posterior cruciate ligament tear

5) Peripheral medial meniscal tear

4) Patellar subluxation

 

Patellar subluxation is a common injury in athletes. It generally presents with a large effusion. Patients usually have a limited arc of motion but can usually obtain full extension. In addition to medial retinacular tenderness, patients will have apprehension to attempts at lateral displacement of the patella. Treatment is initially nonoperative, emphasizing quadriceps strengthening.

Operative treatment is reserved for patients with continued instability despite appropriate rehabilitation.Correct Answer: Patellar subluxation

 

 

 

2796. (247) Q7-359:

The primary restraint to anterior translation of the abducted and externally rotated glenohumeral joint is the:

 

1) Coracohumeral ligament

3) Middle glenohumeral ligament

2) Superior glenohumeral ligament

5) Subscapularis muscle

4) Inferior glenohumeral ligament

 

The inferior glenohumeral ligament is the primary restraint to anterior translation of the abducted and externally rotated glenohumeral joint. The Bankart lesion is an avulsion of the inferior glenohumeral ligament and represents the primary pathoanatomy of traumatic anterior shoulder dislocation.Correct Answer: Inferior glenohumeral ligament

 

 

 

2797. (248) Q7-360:

The quadriceps angle or Q angle is defined as the angle formed by a line connecting the:

 

1) Anterior inferior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity

3) Anterior inferior iliac spine to the lateral aspect of the patella and a line connecting the center of the patella to the center of the tibial tuberosity

2) Anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity

5) Anterior inferior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the ankle

4) Anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the ankle

 

The quadriceps angle, or Q angle, is used to evaluate patellofemoral alignment. It is defined as the angle formed by a line connecting the anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity. A normal angle is up to 10° in men and up to 15° in women. Unfortunately, no standard technique exists for measuring the Q angle, and its reliability and usefulness have recently come under question.Correct Answer: Anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity

 

 

Innervation to the anterior cruciate ligament is provided by a branch of the:

 

1) Sciatic nerve

3) Saphenous nerve

2) Obturator nerve

5) Femoral nerve

4) Posterior tibial nerve

 

The posterior articular branch of the posterior tibial nerve provides pain fibers and mechanoreceptors to the anterior cruciate ligament.Correct Answer: Posterior tibial nerve

 

 

 

2799. (250) Q7-362:

All of the following represent mechanisms of injury to the posterior cruciate ligament except:

 

1) Posteriorly directed force on the anterior aspect of the flexed knee

3) Valgus force applied to a flexed and externally rotated knee

2) Fall onto a flexed knee

5) Hyperextension

4) Hyperflexion

 

All of the above except application of valgus force to a flexed and externally rotated knee have been described in posterior cruciate ligament injuries. Application of a valgus force to a flexed and externally rotated knee would more likely result in an anterior cruciate ligament injury.Correct Answer: Valgus force applied to a flexed and externally rotated knee

 

 

 

2800. (251) Q7-363:

Which of the following sets of compartment measurements confirms the diagnosis of exertional compartment syndrome:

 

1) Preexercise >10 mm Hg, 1-minute postexercise >20 mm Hg, 5-minute postexercise >15 mm Hg

3) Preexercise >20 mm Hg, 1-minute postexercise >20 mm Hg, 5-minute postexercise >20 mm Hg

2) Preexercise >15 mm Hg, 1-minute postexercise >30 mm Hg, 5-minute postexercise >20 mm Hg

5) Preexercise >15 mm Hg, 1-minute postexercise >30 mm Hg, 5-minute postexercise >10 mm Hg

4) Preexercise >10 mm Hg, 1-minute postexercise >30 mm Hg, 5-minute postexercise >10 mm Hg

 

If pressures at preexercise are >15 mm Hg, 1-minute postexercise >30 mm Hg, 5-minute postexercise >20 mm Hg, it will confirm a diagnosis of exertional compartment syndrome. Exertional compartment syndrome is becoming increasingly recognized as a source of pain in runners and cyclists. The onset of pain is gradual during exercise and ultimately restricts performance. Activity modification usually is effective. Refractory cases may require fasciotomy.Correct Answer: Preexercise >15 mm Hg, 1-minute postexercise >30 mm Hg, 5-minute postexercise >20 mm Hg

 

 

 

2801. (252) Q7-364:

The most common adverse side effect of dietary supplementation with creatine in athletes is:

 

1) Friable tendons

3) Myopathy

2) Muscle cramping

5) Osteoporosis

4) Diabetes

 

Creatine has recently become a popular dietary supplement among athletes. The long-term effects of creatine are not known. However, it appears to cause muscle cramping and heat intolerance.Correct Answer: Muscle cramping

 

 

When testing an elbow for insufficiency of the medial collateral ligament, valgus stress should be applied with the elbow positioned at:

 

1) Full extension

3) 45° of flexion

2) 30° of flexion

5) 90° of flexion

4) 60° of flexion

 

When testing the medial collateral ligament of the elbow, it is important to apply valgus stress with the elbow flexed approximately 20° to 30° to disengage the olecranon from the olecranon fossa. It is always important to examine and compare the injured and uninjured side.Correct Answer: 30° of flexion

 

 

 

2803. (543) Q7-759:

Internal impingement of the shoulder between the posterosuperior glenoid rim and the rotator cuff typically occurs with the arm in this position:

 

1) Abduction and internal rotation

3) Adduction and internal rotation

2) Adduction and external rotation

5) Abduction, external rotation, and flexion

4) Abduction, external rotation, and extension

 

Internal impingement of the shoulder occurs with the arm in the abducted, externally rotated, and extended position. This entity may be responsible for shoulder pain commonly occurring in overhead and throwing athletes. Initial treatment is focused on therapy that strengthens the anterior structures and scapular retractors and stretches the posterior structures. If nonoperative treatment fails, arthroscopic debridement, thermal capsular shrinkage, and humeral derotational osteotomy have all been used with varying degrees of success.Correct Answer: Abduction, external rotation, and extension

 

 

2804. (544) Q7-760:

The following structure is most responsible for anterior stability of the glenohumeral joint with the arm in 45° of abduction:

 

1) Inferior glenohumeral ligament

3) Superior glenohumeral ligament

2) Middle glenohumeral ligament

5) Subscapularis muscle and tendon

4) Coracohumeral ligament

 

The middle glenohumeral ligament, although absent in up to one third of shoulders, is the largest contributor to anterior stability of the shoulder with the arm abducted 45°. The inferior glenohumeral ligament is the primary restraint to anterior instability with the arm abducted to 90° and externally rotated.Correct Answer: Middle glenohumeral ligament

 

 

2805. (545) Q7-761:

The following structure is most responsible for resisting inferior translation of the glenohumeral joint with the arm at the side:

 

1) Inferior glenohumeral ligament

3) Coracoacromial ligament

2) Middle glenohumeral ligament

5) Subscapularis muscle and tendon

4) Coracohumeral ligament

 

The coracohumeral ligament coupled with the superior glenohumeral ligament provides the primary restraint to inferior translation of the glenohumeral joint with the arm at the side. The coracohumeral ligament also provides restraint to external rotation with the arm at the side.Correct Answer: Coracohumeral ligament

 

Maximal external rotation of the shoulder occurs during which phase of pitching:

 

1) Wind-up

3) Late cocking

2) Early cocking

5) Follow through

4) Deceleration

 

The pitching motion can be divided into 6 phases: wind-up, early cocking, late cocking, acceleration, deceleration, and follow through. Maximal external rotation at the shoulder occurs during late cocking.Correct Answer: Late cocking

 

 

2807. (547) Q7-763:

A 45-year-old avid golfer complains of pain at the medial aspect of his elbow with participation. He denies radiation of the pain to his hand. Recommended treatment at this time should include:

 

1) Subcutaneous transposition of the ulnar nerve

3) Medial epicondylectomy

2) Submuscular transposition of the ulnar nerve

5) Eccentric stretching and strengthening of the elbow and forearm

4) Surgical release of the medial epicondyle

 

The most likely diagnosis in this patient is medial epicondylitis. Absence of symptoms radiating to the hand is contrary to the diagnosis of ulnar nerve entrapment. Initial treatment of stretching and strengthening is usually successful in these patients. In patients failing nonoperative treatment, surgical release and debridement of the inflamed tissues usually results in a satisfactory outcome.Correct Answer: Eccentric stretching and strengthening of the elbow and forearm

 

 

2808. (548) Q7-765:

A 35-year-old avid rock climber complains of persistent anterior elbow pain with climbing, particularly when pulling himself up with his arms. The following muscle would most likely show increased activity on an electromyogram:

 

1) Long head of the biceps brachii

3) Brachialis

2) Short head of the biceps brachii

5) Flexor carpi ulnaris

4) Flexor carpi radialis

 

Brachialis tendonitis, or climberâs elbow, causes pain in the anterior elbow with the forearm in the pronated and flexed position. An electromyogram typically shows increased activity in the brachialis muscle.Correct Answer: Brachialis

 

 

2809. (549) Q7-766:

A 16-year-old baseball pitcher complains of dominant-sided elbow pain when pitching. He has recently been removed from the pitching rotation because of "control" problems. Physical examination reveals pain when a supinated, flexed, and valgus stressed elbow is brought into progressive extension. The most likely diagnosis is:

 

1) Posterolateral rotatory instability

3) Ulnar nerve entrapment

2) Ulnar collateral ligament tear

5) Radial nerve entrapment

4) Posteromedial impingement

 

The process described is posteromedial impingement syndrome of the elbow. It typically presents as vague elbow pain with loss of control in pitchers. The valgus extension overload test typically elicits pain and sometimes crepitus. The pathological changes in posteromedial impingement syndrome start with chondromalacia on the medial aspect of the trochlear groove and may progress to osteophyte formation and loose bodies necessitating arthroscopic debridement.Correct Answer: Posteromedial impingement

 

 

 

 

 

Figure 1

This slide is a computed tomogram of the shoulder of a 22-year-old rugby player. The most likely diagnosis is:

 

1) Anterior shoulder instability

3) Glenohumeral arthritis

2) Posterior shoulder instability

5) Subscapularis tear

4) Supraspinatus tear

 

The computed tomogram shows a posterior avulsion of the glenoid rim and an impaction fracture of the anterior aspect of the humeral head consisted with a prior posterior dislocation.Correct Answer: Posterior shoulder instability

 

 

2811. (551) Q7-768:

 

 

 

Figure 1

This slide is a computed tomogram of the dominant shoulder of a 45-year-old male tennis player. The most likely diagnosis is:

 

1) Osteosarcoma

3) Anterior glenoid fracture

2) Synovial osteochondromatosis

5) Rotator cuff tear arthropathy

4) Synovial cell sarcoma

 

Synovial osteochondromatosis is a rare condition typically affecting middle-aged men. The computed tomogram demonstrates the osteocartilaginous nodules. Early in the disease, arthroscopic removal of loose bodies and synovectomy usually results in an acceptable outcome. In cases of progressive disease resulting in secondary shoulder arthrosis, shoulder arthroplasty may be required.Correct Answer: Synovial osteochondromatosis

 

 

2812. (552) Q7-769:

Weight training that employs constant resistance throughout the arc of motion is referred to as:

 

1) Isometric

3) Isokinetic

2) Isotonic

5) Functional

4) Plyometric

 

Isotonic training employs a constant resistance throughout the arc of joint motionCorrect Answer: Isotonic

 

Weight training that employs a constant velocity and variable resistance is referred to as:

 

1) Isometric

3) Isokinetic

2) Isotonic

5) Functional

4) Plyometric

 

Isokinetic training employs constant velocity and variable resistance. Special equipment, such as a Cybex device (Cybex, Medway, Mass), is required for isokinetic training.Correct Answer: Isokinetic

 

 

2814. (554) Q7-772:

During arthroscopic repair of a medial meniscal tear, the following structure is at greatest risk for damage:

 

1) Popliteal artery

3) Saphenous nerve

2) Popliteal vein

5) Popliteus tendon

4) Sural nerve

 

No matter what technique for arthroscopic medial meniscal repair is used, the saphenous nerve must be protected to avoid a painful neuroma postoperatively.Correct Answer: Saphenous nerve

 

 

2815. (555) Q7-773:

During arthroscopic repair of a lateral meniscal tear, the following structure is at greatest risk for damage:

 

1) Popliteal artery

3) Peroneal nerve

2) Popliteal vein

5) Popliteus tendon

4) Sural nerve

 

When performing arthroscopic lateral meniscal repair, the peroneal nerve must be protected from insult.Correct Answer: Peroneal nerve

 

 

2816. (556) Q7-774:

A 15-year-old male football player is discovered to have a reproducible painless pop with meniscal testing during a routine preparticipation physical examination. The patient states that he has never experienced any knee problems other than an occasional audible pop. His family physician orders a magnetic resonance image. It shows a discoid lateral meniscus without evidence of tearing. Recommended management should include:

 

1) No intervention

3) Abstinence from participation in any sport requiring pivoting or

2) Abstinence from participation in football only

5) Lateral meniscectomy

4) Excision of the central portion of the discoid meniscus

 

A discoid lateral meniscus can be complete, incomplete, or a Wrisberg variant. If asymptomatic, the patient can simply be observed without restriction. In patients with symptoms, the preferred treatment is excision of the central portion of the meniscus. In individuals with a discoid meniscus and a peripheral tear, repair of the tear is performed with excision of the central portion of the meniscus.Correct Answer: No intervention

 

When performing anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft fixated with interference screws, up to how many degrees of divergence between the bone plug and the screw provides mechanically acceptable initial fixation strength on the femoral side?

 

1) 5°

3) 15°

2) 10°

5) 30°

4) 20°

 

Biomechanical studies have shown that up to 30° of divergence between the femoral bone plug and interference screw can be accepted without significantly compromising initial fixation strength.Correct Answer: 30°

 

 

2818. (558) Q7-777:

A 20-year-old male collegiate basketball player experiences a near syncopal episode during a particularly rigorous conditioning session. Appropriate management should include:

 

1) More intensive conditioning

3) Discontinuation of participation for 1 week

2) A short break, allowing the athlete to return when he feels ready

5) Urgent neurological evaluation

4) Urgent cardiac evaluation

 

A near syncopal episode in a young athlete may be a sign of an underlying life threatening condition. Most commonly, this is related to cardiac pathology, such as hypertrophic cardiomyopathy, idiopathic hypertrophic subaortic stenosis, or arrhythmias. These conditions require urgent medical attention as they are frequently life threatening. The athlete should not be allowed to participate until a complete medical (including cardiac) work up has been performed.Correct Answer: Urgent cardiac evaluation

 

 

2819. (559) Q7-778:

On a cellular level, the nutritional supplement creatine has the following effect:

 

1) Increases water retention in cells

3) Causes hydrolysis of cells

2) Decreases water retention in cells

5) Causes decreased organelle production

4) Causes increased organelle production

 

Creatine is a popular nutritional supplement with athletes, and has a cellular effect of increasing water retention. This effect decreases the amount of free water available to the athlete and may result in cramping and dehydration. In season use of creatine is not recommended.Correct Answer: Increases water retention in cells

 

 

2820. (560) Q7-779:

A 20-year-old male weight-lifter complains of progressive right shoulder pain when performing bench presses. He recalls no specific injury, and physical examination reveals mild swelling and tenderness in the right acromioclavicular joint. He is otherwise healthy with no other findings or complaints. The most likely diagnosis is:

 

1) Acromioclavicular joint dislocation

3) Arthrosis

2) Septic acromioclavicular joint

5) Subacromial impingement syndrome

4) Distal clavicular fracture

 

Distal clavicular osteolysis most commonly occurs in weight-lifters and is most symptomatic while performing bench presses. There is usually no history of trauma. Symptoms may be bilateral in up to 40% of patients. Treatment initially involves modification of training regimens and anti-inflammatory medications. Failing nonoperative interventions, distal clavicle excision is usually successful in alleviating symptoms.Correct Answer: Arthrosis

 

When comparing open distal clavicle resection with arthroscopic distal clavicle resection for osteolysis of the distal clavicle, arthroscopic techniques:

 

1) Less reliably resect the appropriate amount of distal clavicle

3) Have a higher complication rate

2) Less reliably provide pain relief

5) Allow quicker return to activity

4) Require a longer hospital stay

 

A study comparing arthroscopic and open techniques of distal clavicular resection in the treatment of osteolysis of the distal clavicle found no difference in the amount of bone resected or amount of pain relief obtained. The arthroscopic group had a shorter hospital stay, less complications, and returned to activity nearly twice as fast as the open group.Correct Answer: Allow quicker return to activity

 

 

2822. (562) Q7-781:

Osteochondritis dissecans of the elbow most commonly occurs at this location:

 

1) Trochlea

3) Capitellum

2) Olecranon

5) Coronoid

4) Radial head

 

Osteochondritis dissecans of the elbow is most common in adolescent and pre-adolescent individuals who participate in sports that place an excessive amount of load on the radiocapitellar joint (e.g., baseball pitching, gymnastics). Factors involved in the development of this entity include repetitive microtrauma and a tenuous capitellar blood supply. Treatment may involve arthroscopic removal of loose bodies.Correct Answer: Capitellum

 

 

2823. (563) Q7-782:

Administration of the "relocation test" to an abducted and externally rotated arm is considered positive for anterior instability if it:

 

1) Relieves pain

3) Increases pain

2) Relieves apprehension

5) Causes an anterior subluxation

4) Increases apprehension

 

The "relocation test" consists of placing a posteriorly directed force at the anterior aspect of the glenohumeral joint with the arm in abduction and external rotation. A positive result is recorded when the patient experiences some relief from feelings of apprehension. Relief of pain would suggest a diagnosis of posterosuperior glenoid impingement, which may occur with or without anterior glenohumeral instability.Correct Answer: Relieves apprehension

 

 

2824. (564) Q7-783:

When examining an individual for suspected posterior instability of the glenohumeral joint, a posteriorly directed force is applied with the arm in this position:

 

1) Abduction, external rotation

3) Adduction, internal rotation

2) Abduction, internal rotation

5) Forward flexion, external rotation

4) Forward flexion, internal rotation

 

The appropriate position for testing posterior stability of the glenohumeral joint is 90° of forward flexion and internal rotation.Correct Answer: Forward flexion, internal rotation

 

Patellar tendinitis is associated with:

 

1) Pain at the insertion of the patellar tendon on the tibia

3) Lateral knee pain during downhill running

2) Pain at the insertion of the patellar tendon on the patella

5) "Giving way" of the knee during activity

4) Locking and popping of the knee during activity

 

Activities such as basketball, soccer, volleyball and track require repeated impact with the ground. This leads to micro-trauma, resulting in degeneration of the tendon and focal inflammation. Pain at the inferior pole of the patella is usually isolated with palpation along the tip of the kneecap.Correct Answer: Pain at the insertion of the patellar tendon on the patella

 

 

2826. (649) Q7-892:

Patellar tendinitis:

 

1) Is most frequently diagnosed in patients over 40 years old.

3) Frequently has consistent radiographic changes that are pathognomonic to the condition.

2) Occurs at the superior pole of the patella.

5) Occurs at the insertion of the patellar tendon into the tibia.

4) Leads to fibrinoid necrosis and mucinous degeneration in the deep fibers of the tendon origin at the inferior pole of the patella.

 

The deep fibers of the patellar tendon are less elastic and more susceptible to stresses that create the micro-traumatic damage. This repetitive stress leads to the focal degeneration and chronic inflammation.Correct Answer: Leads to fibrinoid necrosis and mucinous degeneration in the deep fibers of the tendon origin at the inferior pole of the patella.

 

 

2827. (875) Q7-1141:

Septic arthritis of the knee within 4 weeks following anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone autograft should initially be treated with:

 

1) Culture-specific intravenous antibiotics

3) Culture-specific intravenous antibiotics and surgical irrigation with graft removal

2) Culture-specific intravenous antibiotics and surgical irrigation with graft retention

5) Culture-specific intravenous antibiotics, surgical irrigation with graft removal, and delayed revision reconstruction

4) Culture-specific intravenous antibiotics, surgical irrigation with graft removal, and immediate revision reconstruction

 

In a recent study that surveyed surgeons with expertise in ACL reconstruction surgery, 85% of surgeons selected culture-specific intravenous antibiotics and surgical irrigation of the joint with graft retention as initial treatment for the infected patellar tendon autograft. Sixty-four percent of surgeons chose this regimen as treatment for the infected allograft.

 

Correct Answer: Culture-specific intravenous antibiotics and surgical irrigation with graft retention

 

 

2828. (876) Q7-1142:

In the setting of chronic anterior cruciate ligament (ACL) deficiency, which of the following meniscal tear patterns is most common:

 

1) Peripheral posterior horn tears of the medial meniscus

3) Peripheral anterior horn tears of the medial meniscus

2) Peripheral posterior horn tears of the lateral meniscus

5) Central posterior horn tears of the medial meniscus

4) Peripheral anterior horn tears of the lateral meniscus

 

Medial meniscal tears account for approximately 45% of acute tears and 70% of chronic tears in patients with ACL insufficiency. Peripheral posterior horn tears of the medial meniscus are the most common type of tear associated with chronic ACL deficiency.

Correct Answer: Peripheral posterior horn tears of the medial meniscus

 

 

 

1) Ulnar neuritis

3) Permanent flexor mass weakness

2) Injury to the medial antebrachial cutaneous nerve

5) Injury to the ulnar collateral ligament (UCL)

4) Injury to the posterior interosseous nerve (PIN)

 

The potential complications associated with the surgical treatment of medial tendon injuries primarily involve the structures surrounding the medial epicondyle. The most frequent complications involve the ulnar nerve. Careful dissection through the subcutaneous tissues must be performed so that the medial antebrachial cutaneous nerve can be isolated and protected.

Extensive release of the flexor-pronator mass can lead to permanent flexor weakness, as well as detachment of the UCL from the medial epicondyle. The PIN is located on the lateral side of the elbow and its injury is not a reported complication associated with medial epicondylar debridement.

 

Correct Answer: Injury to the posterior interosseous nerve (PIN)

 

 

2830. (878) Q7-1144:

In valgus extension overload of the elbow, impingement occurs between which of the following structures:

 

1) Ulnar nerve and ulnar collateral ligament

3) Posterolateral olecranon process and radial head

2) Posteromedial olecranon process and posteromedial olecranon fossa

5) Posteromedial olecranon process and ulnar nerve

4) Coronoid process and radial head

 

Valgus extension overload is unique to the throwerâs elbow. Valgus extension overload of the elbow involves attenuation and creep in the ulnar collateral ligament that transfers compressive forces to the lateral compartment of the elbow at the radiocapitellar joint. In the posterior elbow compartment, the valgus moment creates contact between the posteromedial aspect of the olecranon process and the posteromedial olecranon fossa.

 

Correct Answer: Posteromedial olecranon process and posteromedial olecranon fossa

 

 

2831. (879) Q7-1145:

Anteroposterior displacement of the acromion on the clavicle is most strongly resisted by which of the following structures:

 

1) The conoid ligament

3) The osseous articulation of the acromion on the clavicle

2) The acromioclavicular ligaments

5) The trapezoid ligament

4) The acromioclavicular meniscus

 

During high loads, the coracoclavicular ligaments (conoid and trapezoid ligament) resist vertical and compressive loads across the acromioclavicular joint. The conoid ligament is the strongest ligament resisting downward movement of the scapula relative to the clavicle. The acromioclavicular ligaments maintain alignment of the joint in the axial plane.

 

Correct Answer: The acromioclavicular ligaments

 

 

 

1) Rheumatoid arthrosis

3) Sarcoidosis

2) Diabetes mellitus

5) Repetitive microtrauma

4) Hyperparathyroidism

 

Osteolysis of the distal clavicle has been associated with various conditions. Among the most common causes is repetitive microtrauma from activities such as weight lifting, gymnastics, and swimming. Other causes include rheumatoid arthrosis and hyperparathyroidism. The diagnosis of sarcoidosis should be considered in bilateral cases. Diabetes mellitus has not been associated with this condition.

 

Correct Answer: Diabetes mellitus

 

 

2833. (882) Q7-1148:

Which of the following describes the correct relationship between the suprascapular nerve and the suprascapular vessels as they pass through the suprascapular notch:

 

1) The suprascapular nerve, artery, and vein all pass below the transverse scapular ligament.

3) The suprascapular nerve passes superficially to the transverse scapular ligament while the artery and vein pass deep to it.

2) The suprascapular nerve, artery, and vein all pass superficially to the transverse scapular ligament.

5) The suprascapular nerve passes deep to the transverse scapular ligament while the suprascapular artery and vein pass above it.

4) The suprascapular nerve and artery pass deep to the transverse scapular ligament while the suprascapular vein passes superficially to it.

 

The suprascapular nerve is a branch of the upper trunk of the brachial plexus at Erbâs point. The suprascapular nerve receives branches primarily from the fifth cervical nerve root. The nerve follows the omohyoid muscle laterally and passes beneath the anterior border of the trapezius muscle to the upper border of the scapula where it joins the suprascapular artery. It passes through the suprascapular notch deep to the transverse scapular ligament. The artery and vein pass superficial to the ligament and join the nerve distally in the suprascapular fossa. After innervating the supraspinatus muscle, the nerve passes around the lateral free margin of the scapular spine (spinoglenoid notch) to innervate the infraspinatus muscle.

 

Correct Answer: The suprascapular nerve passes deep to the transverse scapular ligament while the suprascapular artery and vein pass above it.

 

 

2834. (883) Q7-1149:

All of the following factors have been used to explain why exertional compartment syndrome is more common in the lower leg when compared to the upper arm except:

 

1) Muscle straining that occurs in the lower leg seldom occurs in the upper arm.

3) The brachialis fascia is less taut than the crural fascia.

2) Muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined to the compartment of the upper extremity.

5) The pulse pressure of the lower extremity is greater than that of the upper extremity.

4) The brachialis fascia yields more to increased intracompartmental pressure as compared to the crural fascia.

 

There are several reasons that have been offered as to why upper arm compartment syndromes are so rare. First, the brachialis fascia is less taut and contains less rigid ligaments than the fascia in the lower leg. Second, the brachialis fascia yields more to increased intracompartmental pressure as compared to the fascia of the lower leg. Third, the muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined enough to develop into a compartment syndrome. Finally, muscle stresses that occur in the lower leg during events such as prolonged march seldom occur in the arm.

 

Correct Answer: The pulse pressure of the lower extremity is greater than that of the upper extremity.

 

the peroneal nerve is to:

 

1) Fully extend the leg during the repair

3) Make a large incision to identify the nerve

2) Keep the knee flexed at least to 90° while performing the repair

5) Repair of the lateral meniscus should be done only with an inside-out technique to prevent injury to the peroneal nerve

4) Repair of the lateral meniscus should be done only with intra-articular arrows to prevent injury to the peroneal nerve

 

The most important consideration in arthroscopic repair of the lateral meniscus is to avoid injuring the peroneal nerve. This is done best by using an outside-in technique and flexing the knee to 90° while passing the needles. With flexion of the knee, the peroneal nerve falls posterior to the joint line. It is important to remember to keep the needles anterior to the biceps.Correct Answer: Keep the knee flexed at least to 90° while performing the repair

 

 

 

2836. (1025) Q7-1332:

A 20-year old female collegiate swimmer has suffered from pain in her right shoulder and inability to compete for the last 9 months. She has been diagnosed with multidirectional instability. Physical therapy for 7 months has failed, and she wishes to swim competitively again. Assuming the diagnosis is correct, the next step should be:

 

1) Bankhart capsulolabral repair

3) Bristow procedure (coracoid process transfer)

2) Posterior capsular shift

5) Superior capsular shift

4) Inferior capsular shift

 

Initial treatment of multidirectional instability is with rehabilitation. These patients, who have loose capsules, often rely on dynamic stabilizing mechanisms rather than tight ligamentous constraint. If surgery is to be performed, the procedure of choice is the inferior capsular shift, originally described by Neer. It reduces the volume of the glenohumeral joint inferiorly, anteriorly, and posteriorly by equalizing capsular tightness on all three sides.Correct Answer: Inferior capsular shift

 

 

 

2837. (1026) Q7-1333:

How is an anterior drawer test performed to evaluate the competence of the anterior talofibular ligament in a patient with a possible ankle sprain:

 

1) Knee bent, ankle dorsiflexed

3) Knee bent, ankle plantar flexed

2) Knee bent, ankle neutral

5) Knee extended ankle plantar flexed

4) Knee extended ankle neutral

 

The anterior drawer test should be performed with the patient sitting, the knee bent, and the ankle plantar flexed in a position of comfort. Flexing the knee relaxes the gastrocnemius. Plantar flexion relaxes the peroneals. The tibia is braced with one hand and the hindfoot is gently brought forward. The amount of anterior translation is compared between feet.Correct Answer: Knee bent, ankle plantar flexed

 

 

A 13-year-old female competitive gymnast has had pain in her lumbar spine and anterior thighs for 9 weeks. It has become significant enough to limit her activities. Radiographs of her lumbar and thoracic spine are normal and iliac crests show that she is not skeletally mature. Physical examination is essentially normal with no long tract or nerve tension signs present. What is the next appropriate step in a diagnostic work up:

 

1) Magnetic resonance image (MRI) of lumbar spine

3) CT of thoracic spine

2) Computed tomography (CT) scan of lumbar spine

5) Technetium bone scanning

4) MRI of thoracic spine

 

This athlete most likely has spondylolysis of the lumbar spine. Repetitive hyperextension of the lumbar spine with stress concentrated at the pars interarticularis can lead to stress fractures especially in the fourth or fifth lumbar vertebrae.

Spondylolysis is the most common bony injury in the athlete's spine. The most sensitive way to delineate this injury is with technetium bone scanning. CT and MRI are not as helpful in the diagnosis or treatment of spondylolysis, unless the patient has frank radicular symptoms.Correct Answer: Technetium bone scanning

 

 

 

2839. (1028) Q7-1335:

The posterior cruciate ligament sustains from 85% to 100% of the load of a posterior directed force at 90º of flexion. Which fibers of the ligament are responsible for this:

 

1) Anterolateral bundle

3) Posteromedial bundle

2) Anteromedial bundle

5) Anterolateral and posteromedial equally

4) Posterolateral bundle

 

The posterior cruciate ligament is the primary restraint to posterior tibial translation, sustaining the majority of force across the knee at 90º of flexion. The PCL has two functional components, an anterolateral portion, and a posteromedial portion. These two "bundles" are named according to their insertions. The anterolateral bundle is tight in flexion and is biomechanically superior to the posteromedial bundle. For this reason, "one bundle techniques" attempt to reproduce the anterolateral bundle.Correct Answer: Anterolateral bundle

 

 

 

2840. (1029) Q7-1336:

A fourteen-year-old little league pitcher has lateral elbow pain that is worsened by throwing. Plain radiographs demonstrate fragmentation of the capitellum with no evidence of a loose body. A presumptive diagnosis of osteochondritis dissecans of the capitellum has been made. He has undergone rest, followed by physical therapy over the past three months. Now range of motion is from 30 to 120, and pain is present when attempting to throw. The next appropriate step is:

 

1) Extension Dyna-Splint at night time

3) Rest until skeletal maturity is reached, and further re-evaluation

2) Aggressive range of motion with physical therapy and iontophoresis

5) Open reduction and internal fixation of capitellar fracture

4) Arthroscopy of the elbow with debridement of defect

 

This patient has osteochondritits dissecans of the capitellum from pitching. OCD of the capitellum differs from Panner's disease, which is a osteochondrosis of the capitellum which occurs at a younger age (7-12) and is less symptomatic. Initial treatment of osteochondritis dissecans of the capitellum is rest and occasional splinting. Arthroscopy is indicated for both detached lesions and those who have failed conservative therapy. The entire joint should be a assessed, loose fragments removed and the subchondral bone of the defect is debrieded to a healthy vascular bed.Correct Answer: Arthroscopy of the elbow with debridement of defect

 

 

The primary stabilizer of the elbow to valgus stress is:

 

1) The posterior bundle of the medial collateral ligament

3) The transverse bundle of the medial collateral ligament

2) The anterior bundle of the medial collateral ligament

5) The superior bundle of the medial collateral ligament

4) The inferior bundle of the medial collateral ligament

 

The medial collateral ligament complex of the elbow consists of three parts: the anterior, posterior, and transverse segments or bundles. The anterior bundle is the most distinct portion. The posterior bundle/segment is a thickening of the capsule and notable only at 90 degrees of flexion. The transverse component or ligament of Cooper appears to contribute little to elbow stability.

There are no inferior or superior bundles.Correct Answer: The anterior bundle of the medial collateral ligament

 

 

 

2842. (1031) Q7-1338:

A collegiate football player sustains a direct blow to his anterior shoulder. Physical examination reveals ecchymosis over the anterior shoulder and painful range of motion. Radiographs include an anteroposterior, scapular Y and an axillary lateral. The radiographs show the humeral head to be located with an isolated fracture at the base of the coracoid process. Treatment should consist of:

 

1) Screw fixation of the coracoid base

3) Sling immobilization with gradual progressive range of motion

2) Airplane type splinting at 90º of abduction for 6 weeks, followed by progressive range of motion

5) Costoclavicular ligament reconstruction

4) Costoclavicular screw fixation

 

Acute isolated fracture of the coracoid base is almost invariably treated conservatively with the expectation of a good result. If the acromioclavicular joint is sound, the basal fracture is splinted by the costoclavicular ligaments, and displacement is minimal.

Treatment with a sling for comfort is sufficient. Pendulum exercises are encouraged. Overhead elevation is restricted for 4-6 weeks to allow healing. Return to sports can occur after healing of the fracture and return to full, painless range of motion. This usually requires 6 to 8 weeks.Correct Answer: Sling immobilization with gradual progressive range of motion

 

 

 

2843. (1032) Q7-1339:

The infraspinatus is strengthened best by which exercise:

 

1) External rotation at 70º of elevation

3) External rotation at 0º of elevation

2) Internal rotation at 70º of elevation

5) Scapular elevation with internal humeral rotation

4) Internal rotation at 0º of elevation

 

The infraspinatus is primarily responsible for external rotation, humeral head depression, and posterior approximation at lower elevations, whereas the teres minor functions at higher elevations. Therefore, external rotation with the arm near the side of the body is optimal for strengthening the infraspinatus. External rotation at approximately 70º is more appropriate for strengthening the teres minor.Correct Answer: External rotation at 0º of elevation

 

 

When comparing male and female competitive athletes, what can be said regarding anterior cruciate ligament injuries:

 

1) Females have a lower relative risk for anterior cruciate ligament (ACL) injuries.

3) Males and female competitive athletes have equal risk for injuries.

2) Females have an increased relative risk for ACL injuries.

5) There have been no studies examining this association as it may be construed as sexist.

4) A comparison is difficult to make due to the different sports played by each sex.

 

It has been shown that competitive female athletes have an increased relative risk for anterior cruciate ligament injury in college sports as well as during military training. Possible causative factors have been suggested (body movement, muscular strength, joint laxity, limb alignment, notch dimensions, effects of estrogen), but none have been proven as of yet.Correct Answer: Females have an increased relative risk for ACL injuries.

 

 

 

2845. (1034) Q7-1341:

The most common location for a meniscal cyst is:

 

1) Middle third of the lateral meniscus

3) Posterior horn of the lateral meniscus

2) Middle third of the medial meniscus

5) Anterior horn of the medial meniscus

4) Anterior horn of the lateral meniscus

 

Mensical cysts are rather uncommon and occur most frequently in the middle third of the lateral meniscus. They are less common in the medial meniscus, where they tend to occur in the posterior horn. They are often associated with horizontal, cleavage type tears of the meniscus. Lateral cysts tend to be smaller and are localized to the joint line, where medial cysts can be large and may dissect through the capsule.Correct Answer: Middle third of the lateral meniscus

 

 

 

2846. (1035) Q7-1342:

If a distal biceps tendon avulsion is not repaired or reconstructed, what is the likely result:

 

1) Loss of 90% of flexion an 20 % of supination strength

3) 20% loss of flexion strength and no loss of supination strength

2) No loss of flexion strength and 40% loss of supination strength

5) 20% loss of flexion and 40% loss of supination strength

4) No significant clinical deficit will occur

 

Untreated distal biceps rupture results in a loss of about 20% flexion and 40% supination strength.Correct Answer: 20% loss of flexion and 40% loss of supination strength

 

 

 

2847. (1036) Q7-1343:

The best clinical test for diagnosis of an anterior cruciate ligament (ACL) rupture is:

 

1) Anterior drawer

3) Losee

2) Pivot shift

5) Single leg hop

4) Lachman

 

The Lachman test provides the best predictive value of all clinical tests for diagnosis of an anterior cruciate ligament rupture. The diagnosis of a complete ACL rupture can be reliably made clinically without the added expense of a preoperative magnetic resonance image.Correct Answer: Lachman

 

 

The reason a patient with an acute rupture of the anterior cruciate ligament will usually have a hemarthrosis is due to disruption of what main blood supply to the ligament:

 

1) Lateral superior geniculate artery

3) Middle geniculate artery

2) Medial superior geniculate artery

5) Lateral inferior geniculate artery

4) Medial inferior geniculate artery

 

The major blood supply to the anterior cruciate ligament arises from the ligamentous branches of the middle genicular artery, with minor contribution from the terminal branches of the medial and lateral inferior genicular arteries. The ACL is covered in a synovial fold that is richly supplied by the middle geniculate artery.Correct Answer: Middle geniculate artery

 

 

 

2849. (1038) Q7-1345:

A football player is down and unconscious after making a tackle. He is found lying supine. What initial management should be undertaken on the playing field:

 

1) Remove helmet, place cervical collar, check for breathing, place on spine board

3) Remove helmet and shoulder pads, hold cervical traction and place on spine board

2) Remove chinstrap only, check for breathing, place on spine board

5) Place on spine board immediately, check breathing once secured, with helmet on and chinstrap buckled, if airway problems noted, remove under in-line traction and assess further

4) Check breathing with helmet and chinstrap buckled, if airway problems are noted, remove facemask only, place on spine board

 

Prevention of further injury is the single most important objective in this patient. While maintaining immobilization of the head and neck check for airway, breathing and pulses (ABC), followed by level of consciousness. The chin strap and helmet fastened will support the head and neck, and keep it aligned with the body, thereby reducing the risk of spinal cord injury associated with unstable fractures and dislocations. The face mask must be removed from the helmet before rescue breathing can ensue.Correct Answer: Check breathing with helmet and chinstrap buckled, if airway problems are noted, remove facemask only, place on spine board

 

 

 

2850. (1039) Q7-1346:

A 30-year-old competitive body builder felt a severe pain in his proximal humerus after performing a bench press exercise. He has significant ecchymoses over the anterior aspect of his proximal arm and axilla. There is significant limitation of motion due to pain, with pain to palpation over the insertion of the pectoralis major and the axilla. A magnetic resonance image showed more than 80% avulsion of the pectoralis major from the humerus. What treatment should this patient undergo:

 

1) Subscapularis transfer

3) Wait until swelling decreases and range of motion returns to normal, then perform a primary repair

2) Primary repair of the tendon to bone through drill holes or with anchors

5) Semitendinosis augmentation with repair of the pectoralis tendon through drill holes once swelling and motion are normal

4) No treatment is necessary, the patient will have functional results with rehabilitation

 

A complete rupture of the pectoralis insertion demands early surgical treatment in the active athlete. Results of late repair are inferior when compared with primary repair. The tendon is either sutured to bone or anchors are placed to augment repair.

Results of those with surgery within one week of injury have been shown to be superior compared to those with delayed surgery or no surgery.Correct Answer: Primary repair of the tendon to bone through drill holes or with anchors

 

 

When making an anteromedial portal for ankle arthroscopy, which structure is most "at risk" for injury:

 

1) The superficial peroneal nerve

3) The extensor hallucis longus

2) The dorsalis pedis artery

5) The saphenous vein

4) The posterior tibial nerve

 

The anteromedial portal is adjacent to the saphenous vein, and injury may occur if care is not taken when creating the portal. A nick in the skin is made and then blunt hemostats are used to spread in line with the neurovascular structures to decrease the likelihood of injury. The anterolateral portal is associated with injury to the superficial peroneal nerve. The anterior-central portal is associated with injury to the dorsalis pedis artery.Correct Answer: The saphenous vein

 

 

 

2852. (1041) Q7-1348:

Fibrinous degradation in which muscle insertion most commonly characterizes lateral epicondylitis or tennis elbow:

 

1) Extensor carpi radialis brevis

3) Extensor carpi ulnaris

2) Extensor carpi radialis longus

5) Extensor digitourm longus complex

4) Brachioradialis

 

Degeneration at the extensor muscle group insertion to the lateral epicondyle, primarily the extensor carpi radialis brevis, can be a result of overuse or poor technique in racket sports. Tenderness to palpation at the insertion of the extensor carpi radialis brevis and pain with resisted wrist extension are common findings.Correct Answer: Extensor carpi radialis brevis

 

 

 

2853. (1042) Q7-1349:

A patient underwent bone-patellar-bone anterior cruciate ligament reconstruction. Postoperative radiographs show the femoral tunnel has been placed too far anteriorly. What is the most likely clinical result of anterior placement of the femoral tunnel:

 

1) Limited extension

3) Anterior knee pain

2) Anterior instability

5) Posterior instability

4) Limited flexion

 

A femoral tunnel that has been placed too anterior will limit extension. Numerous studies have shown the most common technical mistake intraoperatively is placement of either the tibial or the femoral tunnel, or both, too far anteriorly. Either of these aberrant placements may cause impingement of the graft and thus promote formation of a large lump of fibrous tissue, known as a Cyclops lesion. This lesion forms anterior to the graft, potentially blocking extension of the knee.Correct Answer: Limited extension

 

 

 

2854. (1043) Q7-1350:

During a wrist arthroscopy in a basketball player who has ulnar-sided wrist pain, the articular disk of the triangular fibrocartilage complex is observed. A probe is inserted and the disk is free floating without tension, (a negative "trampoline test"). What does this signify:

 

1) Flexor carpi ulnaris subluxation

3) Scapholunate instability

2) Distal radioulnar joint disruption

5) Ulnar abutment syndrome

4) Tear in either the central or peripheral portion of the TFCC

 

A probe should be used to test the integrity of the articular disc of the TFCC. This disk should be fairly taught, similar to a trampoline. When the articular disk is floppy and floating without tension, a tear in either the central or peripheral portion must be suspected.Correct Answer: Tear in either the central or peripheral portion of the TFCC

 

 

A football player has suffered a concussion. It is his first such injury. He suffered loss of consciousness for about 30 seconds and was confused after for 45 minutes. He is now fully asymptomatic at the end of the football game (1 hour after injury). When should he return to play:

 

1) The next day

3) In 1 week

2) After one month if computed tomography (CT) scan of the brain is negative

5) The next day, if CT scan of the brain is negative

4) He should sit out the rest of the season.

 

This patient has suffered a grade 2, or moderate concussion. These patients may return to play after one week if asymptomatic.

 

Grade 1: No LOC, posttraumatic amnesia <30 minutes; return to play when symptoms resolve

 

 

Grade 2: LOC <5 minutes or posttraumatic amnesia >30 minutes; return to play after one week if asymptomatic. Grade 3: LOC >5 minutes, or posttraumatic amnesia >24 hours; minimum delay of 1 month, then may return if asymptomatic.

 

Correct Answer: In 1 week

 

 

2856. (1045) Q7-1352:

A collegiate tennis player has undergone surgery for recalcitrant tennis elbow (lateral epicondylitis). He now complains of clicking, catching, and "slipping out of joint" of the elbow. Examination reveals a positive "pivot shift" test of the elbow with normal motion. Radiograph examination is normal. The primary stabilizer of the elbow that is damaged in this patient giving rise to his symptoms of posterolateral rotatory instability is:

 

1) Lateral ulnar collateral ligament

3) Medial collateral

2) Annular ligament

5) Common extensor muscle attachment to the lateral epicondyle

4) Posterior capsule of the elbow

 

This patient has incompetence of the lateral ligamentous constraint to the elbow. The most common causes for this injury are previous dislocations and iatrogenic approaches to the lateral elbow. Up to 25% of cases of failed tennis elbow surgery are associated with lateral ligamentous insufficiency. The lateral ulnar collateral ligament has been shown to be the primary restraint to posterolateral instability of the elbow.Correct Answer: Lateral ulnar collateral ligament

 

 

 

2857. (1046) Q7-1353:

A 56-year-old competitive triathelete fell off his bicycle and sustained a traumatic anterior shoulder dislocation. The dislocation was reduced in the emergency room. No associated fractures were noted. A magnetic resonance image examination would be judicious in this patient to:

 

1) Assess the capsuloligamentous integrity of the shoulder

3) Assess the integrity of the articular cartilage

2) Assess for glenoid labrum tears

5) Evaluate the bone for occult fractures

4) Assess the integrity of the rotator cuff

 

Rotator cuff tears may accompany anterior and inferior glenohumeral dislocations. The frequency of this complication increases with age. In patients older than 40 years incidence exceeds 30%; in patients older than 60 years, the incidence exceeds 80%. Shoulder ultrasound, arthrography or MRI is indicated in patients over 40 years of age, with a shoulder dislocation. Prompt repair of these lesions is usually indicated.Correct Answer: Assess the integrity of the rotator cuff

 

 

What is the mechanism of injury that leads to the clinical diagnosis of "turf toe":

 

1) Forced lateral stress

3) Forced plantarflexion

2) Forced medial stress

5) Forced dorsiflexion

4) Forced compression of the first MTP

 

Turf toe is a sprain of the plantar capsuloligamentous complex of the first MTP joint that is associated with play on artificial playing surfaces. The classic mechanism of injury is a forced hyperextension injury to the 1st MTP joint. Dorsiflexion in excess of a normal range of motion can lead to varying degrees of soft tissue capsular disruption or injury to the articular cartilage and subchondral bone. Factors that predispose a player to injury are increasing age, number of years in professional football, pes planus, and decreased range of motion in the ankle and/or 1st MTP joint.Correct Answer: Forced dorsiflexion

 

 

 

2859. (1048) Q7-1355:

The gold standard for evaluation of chronic compartment syndrome in the athlete is:

 

1) Clinical examination

3) Resting compartment measurements

2) Electromyogram post exercise

5) Elevated compartment pressures during exercise

4) Elevated post exercises compartment pressures

 

The gold standard for diagnosing chronic or exertional compartment syndrome in the athlete is demonstration of elevated compartment pressures post exercise. Normal increases in compartment pressures with exercise will decrease to normal within 2 minutes of exercise cessation. Pedowitz et al has developed a criteria for diagnosis with any of the following: pre-exercise pressure > 15 mm Hg, 1 minute post exercise pressure > 30 mm Hg, or 5 min post exercise of > 20 mm Hg.Correct Answer: Elevated post exercises compartment pressures

 

 

 

2860. (1444) Q7-1821:

Internal impingement of the shoulder between the posterosuperior glenoid rim and the rotator cuff occurs in which phase of throwing:

 

1) Wind-up

3) Late cocking

2) Early cocking

5) Follow-through

4) Acceleration

 

Internal impingement of the shoulder occurs with the arm in the abducted, externally rotated, and extended position that corresponds with the late cocking phase of throwing. Internal impingement is responsible for shoulder pain commonly occurring in overhead and throwing athletes. Initial treatment is focused on therapy that strengthens the anterior structures, stretches the posterior structures, and controls the scapular position in space. If nonoperative treatment fails, arthroscopic debridement, thermal capsular shrinkage, and humeral derotational osteotomy have been used with varying degrees of success.Correct Answer: Late cocking

 

 

 

2861. (1445) Q7-1822:

When comparing open distal clavicle resection with arthroscopic distal clavicle resection for osteolysis of the distal clavicle, arthroscopic techniques:

 

1) Less reliably resect the appropriate amount of distal clavicle

3) Have a higher complication rate

2) Less reliably provide pain relief

5) Have no different outcomes

4) Result in a longer delay in return to sports

 

A study comparing arthroscopic and open techniques of distal clavicular resection in the treatment of osteolysis of the distal clavicle found no difference in the amount of bone resected or amount of pain relief obtained. The arthroscopic group had a shorter hospital stay and less complications, and returned to activity nearly twice as fast as the open technique group.Correct Answer: Have no different outcomes

 

 

 

 

 

Slide 1

A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old minor league baseball pitcher is presented (Slide). He has been unable to pitch for the past 6 weeks secondary to pain. The recommended treatment includes:

 

1) Physical therapy for triceps strengthening

3) Ulnar nerve transpostion

2) Physical therapy for pronator strengthening

5) Ulnar collateral ligament reconstruction

4) Radial collateral ligament reconstruction

 

The MRI shows a disruption of the humeral attachment of the ulnar collateral ligament. The ulnar collateral ligament of the elbow is the most frequently observed ligamentous elbow injury in baseball pitchers. Recommended treatment in the throwing athlete is reconstruction of the ulnar collateral ligament with an autogenous palmaris longus graft.Correct Answer: Ulnar collateral ligament reconstruction

 

 

2863. (1447) Q7-1824:

Following acute lateral traumatic patellar dislocation, the surgical procedure that most closely reconstructs the injured structure is:

 

1) Arthroscopic lateral release

3) Medial patellofemoral ligament reconstruction

2) Vastus medialis obliquus advancement

5) Tibial tubercle transfer

1. Medial patellotibial ligament reconstruction

    

   The medial patellofemoral ligament is the primary restraint to lateral subluxation of the patella. The other structures contribute less substantially to patellofemoral stability. In the majority of cases of acute traumatic patellar dislocation, the medial patellofemoral ligament is disrupted.Correct Answer: Medial patellofemoral ligament reconstruction

    

    

   2864. (1448) Q7-1827:

   A 22-year-old male tennis player has dominant side shoulder pain when serving and hitting overheads. Despite a prolonged course of physiotherapy, he is unable to return to tennis because of shoulder pain. His treating physician recommends arthroscopy of his shoulder with debridement of associated lesions. What is the likelihood that he will be playing tennis at his preinjury level of competition at 1 year following surgery:

    

   1) 10%

   3) 50%

   2) 30%

2. 90%

4) 75%

 

This patient has internal impingement of the shoulder, presumably with associated labral and rotator cuff lesions. Sonnery-Cottet and colleagues reported results of 28 tennis players with internal impingement treated with arthroscopic debridement of associated lesions. Although 22 of the 28 tennis players were able to return to tennis following surgery, only 14 of the players were able to return to their preinjury level of competition.Correct Answer: 50%

 

 

 

 

 

Slide 1

A glenoid profile radiograph (Slide) of a 21-year-old male rugby player with multiple traumatic anterior shoulder dislocations is presented. Which of the following is the preferred treatment:

 

1. Sling for a period of 6 weeks

3) Capsular shift

2) Physiotherapy emphasizing strengthening of dynamic shoulder stabilizers

5) Bony augmentation procedure(iliac crest)

4) Bankart reconstruction

 

The radiograph demonstrates anterior glenoid rim insufficiency, which is a risk factor for failure of soft tissue reconstructions especially in contact athletes. The arrows on the figure represent the anterior border of the glenoid rim. A coracoid transfer procedure to reconstruct the anterior bony deficiency maximizes the possibility for successful restoration of shoulder stability.Correct Answer: Bony augmentation procedure(iliac crest)

 

 

2866. (1450) Q7-1830:

Which of the following statements is true regarding humeral retroversion in a throwerâs dominant shoulder:

 

1) Humeral retroversion in a throwerâs dominant shoulder is the same as in the nondominant shoulder.

3) Humeral retroversion in a throwerâs dominant shoulder is greater than humeral retroversion in the nondominant shoulder.

2) Humeral retroversion in a throwerâs dominant shoulder is less than humeral retroversion in the nondominant shoulder.

5) Humeral retroversion in a throwerâs dominant shoulder is less than humeral retroversion in a nonthrowerâs dominant shoulder.

4) Humeral retroversion in a throwerâs dominant shoulder is the same humeral retroversion in a nonthrowerâs dominant shoulder.

 

Throwers have increased humeral retroversion in their dominant shoulder compared to their contralateral shoulder and to the dominant shoulder of nonthrowers. This represents an adaptive change that probably occurs through the physis (a pathologic expression of this adaptation probably exists in the form of proximal humeral epiphysealysis or little leaguerâs shoulder) and has two benefits. First, humeral retroversion allows increased external rotation during throwing activities. Second, humeral retroversion acts as a protective mechanism against impingement of the greater tuberosity on the posterosuperior glenoid rim during throwing.Correct Answer: Humeral retroversion in a throwerâs dominant shoulder is greater than humeral retroversion in the nondominant shoulder.

 

 

 

 

 

 

Slide 1

An arthroscopic photo (Slide) looking from the posterior portal is presented. The arrows point to which structure:

 

1) Superior glenohumeral ligament

3) Middle glenohumeral ligament

2) Inferior glenohumeral ligament

5) Coracoacromial ligament

4) Coracohumeral ligament

 

The middle glenohumeral ligament is readily visualized crossing the subscapularis from the posterior arthroscopic portal. The middle glenohumeral ligament may be absent in as many as 30% of shoulders.Correct Answer: Middle glenohumeral ligament

 

 

2868. (1452) Q7-1832:

When performing a Latarjet coracoid transfer for anterior shoulder instability with bony anterior glenoid rim insufficiency, glenoid surface of the coracoid transfer must be positioned.

 

1) Flush with the glenoid rim

3) 10 mm medial to the glenoid rim

2) 5 mm medial to the glenoid rim

5) 10 mm lateral to the glenoid rim

4) 5 mm lateral to the glenoid rim

 

Allain and colleagues have clearly demonstrated that a coracoid transfer overhanging laterally to the glenoid rim is associated with the development of arthritis. One of the functions of the coracoid transfer is to increase the anteroposterior diameter of the glenoid, not to serve as a âbone block.âCorrect Answer: Flush with the glenoid rim

 

 

2869. (1453) Q7-1833:

 

 

 

Slide 1

An arthroscopic photo (Slide) during shoulder arthroscopy looking from the posterior portal is presented. The arrows point to which structure:

 

1) Biceps tendon

3) Supraspinatus tendon

2) Subscapularis tendon

5) Inferior glenohumeral ligament

4) Teres minor tendon

 

The insertion of the supraspinatus tendon is readily visible through the posterior arthroscopic portal.Correct Answer: Supraspinatus tendon

 

 

 

 

 

Slide 1

An arthroscopic photo (Slide) of the shoulder looking from the posterior portal is presented. The large white structure at the top of the figure is the biceps tendon. The arrows point to which structure:

 

1) Middle glenohumeral ligament

3) Superior glenoid labrum

2) Inferior glenohumeral ligament

5) Ligamentous pulley

4) Anterior glenoid labrum

 

The arrows point to the ligamentous pulley. The ligamentous pulley is responsible for stabilizing the biceps within the bicipital groove of the humerus. An intact ligamentous pulley precludes arthroscopic diagnosis of superior subscapularis tendon tears.Correct Answer: Ligamentous pulley

 

 

2871. (1455) Q7-1836:

 

 

 

Slide 1

An arthroscopic photo (Slide) looking from the posterior portal is presented. The arrows point to which structure:

 

1) Biceps tendon

3) Supraspinatus tendon

2) Subscapularis tendon

5) Inferior glenohumeral ligament

4) Middle glenohumeral ligament

 

The identified structure is the subscapularis tendon, which is readily visible during shoulder arthroscopy. The middle glenohumeral ligament crosses the superior border of the subscapularis tendon.Correct Answer: Subscapularis tendon

 

 

 

 

 

Slide 1

An arthroscopic photo (Slide) looking from the posterior portal at the anterior inferior aspect of the glenoid is presented. What is the proper treatment in this case based on the finding:

 

1) Debridement

3) Open repair

2) Biceps tenotomy

5) No treatment necessary

4) Arthroscopic repair

 

The photo shows normal anterior inferior labrum; therefore, no treatment is necessary for this structure.Correct Answer: No treatment necessary

 

 

2873. (1457) Q7-1838:

 

 

 

Slide 1

An arthroscopic photo (Slide) looking from the posterior portal is presented. Identify the torn structure:

 

1) Middle glenohumeral ligament

3) Subscapularis tendon

2) Inferior glenohumeral ligament

5) Ligamentous pulley of long head biceps

4) Infraspinatus tendon

 

This photo demonstrates a torn ligamentous pulley that has possibly resulted in an unstable biceps tendon. Pathology of the ligamentous pulley is often associated with rotator cuff pathology.Correct Answer: Ligamentous pulley of long head biceps

 

 

2874. (1458) Q7-1839:

When comparing anterior cruciate ligament (ACL) reconstruction using autogenous hamstrings and ACL reconstruction using autogenous patellar tendon, the most consistent difference is:

 

1) The patellar tendon group has more patellofemoral pain.

3) The patellar tendon group is more likely to return to activity.

2) The hamstring group has more loss of motion.

5) The hamstring group has better results with arthrometer testing.

4) The hamstring group has a higher incidence of graft failures.

 

Shaieb and associates recently reported a prospective randomized study comparing autogenous hamstring ACL reconstruction to autogenous patellar tendon ACL reconstruction. The only significant differences that were elicited between the groups at a minimum of 2-yearsâ follow-up were the incidences of patellofemoral pain and loss of motion, both in favor of the hamstring group.Correct Answer: The patellar tendon group has more patellofemoral pain.

 

Muscle contusions are clinically graded according to:

 

1) Offending activity

3) Pain as determined by analog pain scale

2) Objective swelling

5) Range of motion of the adjacent joint

4) The degree of myositis ossificans

Muscle contusions are graded according to the range of motion of the adjacent joint. Mild muscle contusion â two-thirds normal range of motion

Moderate muscle contusion â one-third to two-thirds normal range of motion Severe muscle contusions â less than one-third normal range of motion

 

 

 

 

The offending activity does not determine the grade of injury. Although swelling is variable, it is not the final determinant of grading. Pain is variable and unreliable in classifying muscle contusion.

 

Although myositis ossificans is more often a result of more severe contusions, it is a later and infrequent finding.

Correct Answer: Range of motion of the adjacent joint

 

 

2876. (1460) Q7-1842:

The treatment protocol found to hasten recovery after quadriceps contusion is:

 

1) Extension protocol

3) Immobilization

2) Flexion protocol

5) Nonweight bearing protocol

4) Aggressive stretching protocol

 

An initial period of rest with the knee in flexion followed by rehabilitation focusing on regaining knee flexion has resulted in reduced morbidity and faster return to full activity.

 

 

 

Extension protocols are associated with resultant longer recovery times. Immobilization is not associated with early recovery.

 

 

Aggressive stretching increases morbidity and the formation of myositis ossificans. Nonweight bearing has not demonstrated decreased recovery times.

Correct Answer: Flexion protocol

 

 

2877. (1461) Q7-1843:

The differential diagnosis for patients presenting with radiographs consistent with myositis ossificans includes all of the following except:

 

1) Osteosarcoma

3) Osteomyelitis

2) Osteochondroma

5) Rhabdomyosarcoma

4) Chondrosarcoma

 

When evaluating a patient with calcification or ossification in abnormal regions, a thorough differential including all of the mentioned conditions should be considered.

 

 

 

Osteochondromas will typically have an intramedullary canal continuous with the adjacent bone. Osteomyelitis will sometimes have associated constitutional symptoms.

 

Osteosarcoma will typically have a radiodense center as opposed to the radiodense periphery of mature myositis ossificans.

 

Chondrosarcoma can be confused with myositis ossificans.

Correct Answer: Rhabdomyosarcoma

 

Findings associated with severe quadriceps contusions include:

 

1) Markedly decreased knee range of motion

3) Two-thirds of normal knee range of motion

2) Septic knee effusion

5) Decreased ankle range of motion

4) Decreased hip range of motion

 

A severe quadriceps contusion is defined as having less then one-third the normal knee range of motion and can be accompanied by a sympathetic knee effusion and, sometimes, a mild extensor lag.

 

 

Two-thirds the normal knee range of motion is classified as a moderate quadriceps contusion.

Correct Answer: Markedly decreased knee range of motion

 

 

2879. (1463) Q7-1845:

The proposed site of pathology for athletes with groin pain and diagnosed with athletic pubalgia is:

 

1) Direct inguinal hernia

3) Rectus abdominus insertion and adductor longus muscle origin

2) Indirect inguinal hernia

5) Sartorius muscle

4) Pectineus muscle

 

Athletic pubalgia syndrome is the result of trunk hyperextension and thigh hyperabduction. This can result in injury to the rectus abdominus insertion and origin of the adductor longus muscle.

 

 

By definition, a hernia is not present.

 

The pectineus and sartorius muscles are not implicated in athletic pubalgia.

Correct Answer: Rectus abdominus insertion and adductor longus muscle origin

 

 

2880. (1464) Q7-1846:

The initial management of athletic pubalgia consists of:

 

1) Modified Bassini hernia repair

3) Hip arthroscopy

2) Adductor release

5) Laparoscopic hernia repair

4) Core trunk stabilization and rest

 

The initial management of athletic pubalgia consists of a period of rest followed by core trunk stabilization, stretching, and gradual return to functional activities. Despite reports of low success rates after nonoperative treatment, this management must be instituted prior to surgical considerations.

 

 

Reattachment of the inferolateral edge of the rectus using a modified Bassini repair has resulted in return to sports activities for the majority of patients, but the procedure should follow a nonoperative trial.

 

 

Adductor release can be part of the operative approach after failure of nonoperative management. Hip joint pathology is not consistently associated with athletic pubalgia.

Correct Answer: Core trunk stabilization and rest

 

The most common physical finding in patients with athletic pubalgia is:

 

1) Tenderness over the pubic tubercle

3) Tenderness to palpation of the adductor longus

2) Inguinal hernia

5) Pain with resisted sit-ups

4) Pain with resisted hip adduction

 

In a series of 157 high-performance athletes diagnosed with athletic pubalgia, 88% of patients had pain with resisted hip adduction. Peripubic tenderness was found in one-fourth of patients. By definition, a hernia is not present. Less than one-third of patients had tenderness at the origin of the adductor longus, and less than one-half of patients had pain with resisted sit-ups.Correct Answer: Pain with resisted hip adduction

 

 

2882. (1466) Q7-1849:

Magnetic resonance imaging (MRI) of the pelvis in patients with athletic pubalgia reveals:

 

1) Pathology at the rectus abdominus in the majority of patients

3) Labral pathology

2) No abnormalities

5) Rectus abdominus pathology in 12% of patients and nonspecific findings in 90% of patients

4) Nonspecific findings in 25% of patients

 

Although only 12% of patients with athletic pubalgia will demonstrate MRI abnormalities, more than 90% of patients will have nonspecific findings localized to the symptomatic side. Labral pathology is not a common finding in patients diagnosed with athletic pubalgia.Correct Answer: Rectus abdominus pathology in 12% of patients and nonspecific findings in 90% of patients

 

 

2883. (1467) Q7-1850:

Adductor longus tenotomy in athletes with chronic adductor pain resistant to nonoperative treatment results in:

 

1) Full objective strength

3) Return to full sports for most athletes despite decreased objective adductor strength

2) Return to sport at a lower level of play for most athletes

5) Unacceptable complication rates

4) Inability to return to sports

 

In a series of 16 athletes undergoing adductor tenotomy for chronic adductor symptoms, 12 patients returned to competitive sports at a mean 14 weeks after surgery. A decrease in objective strength was noted that did not affect functional results.Correct Answer: Return to full sports for most athletes despite decreased objective adductor strength

 

 

2884. (1468) Q7-1851:

In order of frequency, the most common compartments involved in chronic exertional compartment syndrome are:

 

1) Deep posterior and anterior compartments

3) Anterior and superficial posterior compartments

2) Anterior and lateral compartments

5) Lateral and deep posterior compartments

4) Anterior and deep posterior compartments

 

The most common compartment involved in chronic exertional compartment syndrome in athletes is the anterior compartment followed by the deep posterior compartment and lateral compartments. The superficial posterior compartment is only rarely involved.Correct Answer: Anterior and deep posterior compartments

 

The resting pressure criteria for diagnosing chronic exertional compartment syndrome in athletes is equal to or greater than:

 

1) 10 mm Hg

3) 20 mm Hg

2) 15 mm Hg

5) 30 mm Hg

4) 25 mm Hg

 

The criteria for diagnosing chronic exertional compartment syndrome from compartment pressure measurements include one or more of the following:

 

 

More than or equal to 15 mm Hg resting pressure

 

 

A 1-minute postexercise pressure of more than or equal to 30 mm Hg A 5-minute postexercise pressure of more than or equal to 20 mm Hg

Correct Answer: 15 mm Hg

 

 

2886. (1470) Q7-1853:

The postexercise pressure measurement criteria for diagnosing chronic exertional compartment syndrome are:

 

1) More than 30 mm Hg at 1 minute

3) More than 20 mm Hg at 1 minute

2) More than 10mm Hg at 5 minutes

5) More than 10 mm Hg at 1 minute

4) More than 10 mm Hg at 10 Minutes

 

The criteria for diagnosing chronic exertional compartment syndrome from compartment pressure measurements includes one or more of the following:

 

 

More than or equal to 15 mm Hg resting pressure

 

 

A 1-minute postexercise pressure of more than or equal to 30 mm Hg A 5-minute postexercise pressure of more than or equal to 20 mm Hg

Correct Answer: More than 30 mm Hg at 1 minute

 

 

2887. (1471) Q7-1854:

Success rates after fasciotomy for chronic exertional compartment syndrome are highest for which compartment:

 

1) Deep posterior compartment

3) Anterior compartment

2) Superficial posterior compartment

5) Equally successful for any compartment

4) Fasciotomy shown to be unsuccessful

 

In a series of patients undergoing fasciotomy for anterior or deep posterior chronic exertional compartment syndrome, satisfactory results were obtained in 96% and 65% of patients, respectively. The superficial posterior compartment is rarely involved.Correct Answer: Anterior compartment

 

 

2888. (1472) Q7-1855:

Which of the following is not a common finding in patients presenting with chronic exertional compartment syndrome:

 

1) Aching or cramping pain during exercise

3) Numbness or weakness on initial examination

2) Relief with rest

5) Occasional numbness with activity

4) Increased compartment pressure post exercise

 

Patients with chronic exertional compartment syndrome will give a history of cramping or aching pain and occasional numbness with exercise. The symptoms typically resolve within minutes of rest. Most patients will have a normal initial examination unless they have exercised minutes prior to evaluation. Increased postexercise compartment pressures are diagnostic.Correct Answer: Numbness or weakness on initial examination

 

 

2889. (1473) Q7-1856:

The initial recommended treatment for a grade 3 acute lateral ankle sprain is:

 

1) Acute lateral ankle reconstruction

3) Functional bracing and rehabilitation

2) Acute lateral ankle repair (modified Brostrom)

5) Weight bearing cast for 6 weeks

4) Nonweight bearing cast for 3 months

 

A review of 12 prospective studies comparing surgery, casting, and functional bracing with early range of motion revealed 75% to 100% excellent or good results regardless of treatment. The final recommendation was functional bracing.Correct Answer: Functional bracing and rehabilitation

 

 

2890. (1474) Q7-1857:

Earlier return to work and sport is reported after which treatment for acute lateral ligament sprain:

 

1) Acute lateral ankle reconstruction

3) Functional bracing and rehabilitation

2) Acute lateral ankle repair (modified Brostrom)

5) Weight bearing cast for 6 weeks

4) Nonweight bearing cast for 3 months

 

Studies comparing surgery, immobilization, and early weight bearing and range of motion have shown that early weight bearing and range of motion result in earlier return to sport and work when compared to acute operative management or cast immobilization.Correct Answer: Functional bracing and rehabilitation

 

 

2891. (1475) Q7-1858:

Which of the following leads to lower success rates after lateral ankle ligament repair (modified Brostrom):

 

1) Recurrent instability

3) Male gender

2) Younger age

5) History of bilateral ankle sprains

4) Generalized ligamentous laxity

 

Patients with generalized ligamentous laxity have fewer satisfactory results after a modified Brostrom repair. Overall, 91% of patients had good to excellent results after this procedure, but none of the five patients with generalized ligamentous laxity had an excellent result.Correct Answer: Generalized ligamentous laxity

 

 

2892. (1476) Q7-1859:

With regard to the level of athletics, which group of patients can be expected to have less satisfactory results after lateral ankle repair using a modified Brostrom technique:

 

1) Professional dancers

3) Non-athletes

2) Recreational athletes

5) All groups can be expected to have similar success

4) Professional athletes

 

In a series of 28 ankles undergoing a modified Brostrom repair for lateral ankle instability, there were no significant differences in outcome whether the patients were professional dancers, athletes, or non-athletes.Correct Answer: All groups can be expected to have similar success

 

The foot and ankle position that is most likely to result in disruption of the anterior talofibular ligament is:

 

1) Plantarflexion and eversion

3) Plantarflexion and inversion

2) Dorsiflexion and inversion

5) The anterior talofibular ligament is uncommonly injured after an ankle sprain.

4) Dorsiflexion and eversion

 

Strain in the anterior talofibular ligament increases with plantarflexion, inversion, and internal rotation. It is the primary restraint to anterior displacement, internal rotation, and inversion of the talus at all angles of flexion and is the most commonly injured ligament as a result of inversion ankle sprains.Correct Answer: Plantarflexion and inversion

 

 

2894. (1478) Q7-1861:

Which of the following arteries provides the primary blood supply to the supraspinatus tendon:

 

1) Scapular circumflex artery

3) Suprascapular artery

2) Anterior humeral circumflex artery

5) Posterior humeral circumflex artery

4) Thoracoacromial artery

 

The suprascapular artery provides the primary vascular supply to the supraspinatus tendon. The vascularity predominates on the bursal side, while the articular side is hypovascular.Correct Answer: Suprascapular artery

 

 

2895. (4043) Q7-1863:

Thermal shrinkage of the shoulder capsule imparts which of the following properties on the capsule:

 

1) Increased strength

3) Increased collagen crosslinking

2) Decreased compliance

5) Decreased stiffness

4) Increased stiffness

 

Thermal shrinkage reliably decreases capsular stiffness (increasing compliance). The resultant tissue is biomechanically weaker than normal tissue.Correct Answer: Decreased stiffness

 

 

2896. (1479) Q7-1864:

Ligaments and joint capsule are primarily composed of collagen. What is the predominant type of collagen in these structures:

 

1) Type I

3) Type V

2) Type II

5) Type IX

1. Type VI

    

   As thermal modification of soft tissue becomes a common procedure, orthopedic surgeons must have an understanding of collagen. Type I collagen predominates in ligaments, joint capsule, bone, tendon, meniscus, annulus of intervertebral disks, and skin. Type II collagen predominates in articular cartilage and nucleus pulposus of intervertebral disks. Type V collagen is found in small amounts in articular cartilage, as is types VI and IX.Correct Answer: Type I

    

   Magnetic resonance imaging will demonstrate labral abnormalities in the throwing shoulder in approximately what percentage of asymptomatic professional baseball pitchers:

    

   1) 10%

   3) 50%

   2) 30%

2. 90%

4) 75%

 

Miniaci and colleagues discovered that 79% of asymptomatic professional baseball pitchers had labral abnormalities on magnetic resonance imaging. They further discovered that the incidence of labral lesions was similar between throwing and nonthrowing shoulders in this population.Correct Answer: 75%

 

 

2898. (1481) Q7-1869:

To avoid injury associated with repetitive internal impingement, the pitcherâs long humeral axis must be in which position during the late cocking phase of throwing:

 

1. 20° extended relative to the plane of the scapula

3) Parallel to the plane of the scapula

2) 10° extended relative to the plane of the scapula

5) 20° flexed relative to the plane of the scapula

4) 10° flexed relative to the plane of the scapula

 

Hyperangulation during the late cocking phase of throwing can result in impingement of the greater tuberosity on the posterosuperior glenoid rim leading to labral or rotator cuff lesions. Positioning of the humeral axis parallel to the plane of the scapula is recommended to avoid injury associated with internal impingement.Correct Answer: Parallel to the plane of the scapula

 

 

2899. (1482) Q7-1870:

Which of the following factors is related to recurrence after primary anterior shoulder dislocation:

 

1) Type of sport practiced

3) Treatment with physical therapy

2) Treatment with immobilization

5) Patient age

4) Patient gender

 

The only known factor that statistically correlates with recurrence of anterior shoulder instability is patient age at the time of initial dislocation. A recent study demonstrated that patients having an initial dislocation during the third decade have more than a 60% chance of redislocating. The type of sport practiced, type of nonoperative treatment, and patient gender do not influence recurrence rate.Correct Answer: Patient age

 

 

2900. (1483) Q7-1872:

Use of functional knee bracing after anterior cruciate ligament (ACL) reconstruction will most likely result in which of the following scenarios:

 

1) Better range of motion at the 2-year follow-up

3) Better knee function at the 2-year follow-up

2) Better knee stability at the 2-year follow-up

5) More quadriceps atrophy at the 3-month follow-up

4) More knee pain at the 3-month follow-up

 

Two-year follow-up has failed to show any differences in range of motion, stability, function, strength, pain, or atrophy in patients who were braced after ACL reconstruction vs. patients who were treated without a brace. The only difference between the two groups is that the braced group has better knee function in the early postoperative period, despite having more quadriceps atrophy.Correct Answer: More quadriceps atrophy at the 3-month follow-up

 

The stabilizing ligamentous pulley of the long head of the biceps at the shoulder is composed of fibers from all of the following structures except:

 

1) Superior glenohumeral ligament

3) Coracohumeral ligament

2) Middle glenohumeral ligament

5) Supraspinatus tendon

4) Subscapularis tendon

 

The stabilizing ligamentous pulley system of the long head of the biceps at the shoulder is a coalescence of the coracohumeral ligament and superior glenohumeral ligament. It also receives fiber contributions from the supraspinatus and subscapularis tendons.Correct Answer: Middle glenohumeral ligament

 

 

2902. (1485) Q7-1875:

Which of the following is the principal function of the biceps during throwing:

 

1) Elbow flexion

3) Arm deceleration

2) Shoulder stabilization

5) Shoulder flexion

4) Humeral head depression

 

The function of the biceps at the shoulder is controversial, especially in the throwing athlete. The biceps may act as a secondary shoulder stabilizer, weak shoulder flexor, arm decelerator, or weak depressor of the humeral head. However, it is widely agreed upon that the biceps principal function during throwing is elbow flexion.Correct Answer: Elbow flexion

 

 

2903. (1486) Q7-1876:

Which of the following arteries provides the main vascular supply to the humeral head:

 

1) Ascending branch of the posterior humeral circumflex artery

3) Ascending branch of the anterior humeral circumflex artery

2) Descending branch of the posterior humeral circumflex artery

5) Ascending intramedullary artery

4) Descending branch of the anterior humeral circumflex artery

 

The ascending branch of the anterior humeral circumflex artery provides the main vascular supply to the humeral head. Disruption of this blood supply can result in osteonecrosis of the humeral head.Correct Answer: Ascending branch of the anterior humeral circumflex artery

 

 

2904. (1487) Q7-1877:

When assessing patient outcomes after rotator cuff repair, which of the following is not related to poor functional outcome:

 

1) Workmanâs compensation

3) Male gender

2) Revision rotator cuff repair

5) Age younger than 55 years at the time of repair

4) Age older than 55 years at the time of repair

 

A large outcome study of more than 600 rotator cuff repairs demonstrated that workmanâs compensation, revision surgery, male gender, and age younger than 55 years at the time of repair are factors contributing to poor functional outcome and decreased workability following rotator cuff repair.Correct Answer: Age older than 55 years at the time of repair

 

When using open measurement as the standard, which of the following is the most reliable instrument to measure rotator cuff tear size:

 

1) Arthroscopy

3) Ultrasonography

2) Magnetic resonance imaging

5) Clinical examination

4) Computed tomography

 

Of the modalities listed, arthroscopy most closely estimates the actual size of a rotator cuff tear. Magnetic resonance imaging and ultrasound are similar in their ability to determine rotator cuff tear size. Computed tomography (without arthrography) is poor in evaluation of the rotator cuff. A detailed clinical examination is helpful in determining which tendons are torn, however elucidation of the specific size of the tear on physical examination is unlikely.Correct Answer: Arthroscopy

 

 

2906. (1489) Q7-1879:

When biomechanically comparing reconstruction of the anterior band of the medial collateral ligament of the elbow to the intact ligament, the reconstructed ligament behaves nearly identical to the intact ligament when subjected to valgus stress at all of the following degrees of elbow flexion except:

 

1) 0°

3) 60°

2) 30°

5) 120°

4) 90°

 

Mullen and associates biomechanically compared reconstruction of the medial collateral ligament of the elbow to the intact ligament at 30°, 60°, 90°, and 120° of elbow flexion. They identified a significant difference in displacement with an applied valgus load at 120° of elbow flexion, leading them to conclude that medial collateral ligament reconstruction is a biomechanically sound procedure.Correct Answer: 120°

 

 

2907. (1490) Q7-1880:

Which of the following is the most commonly reported cause of nontraumatic humeral head osteonecrosis:

 

1) Alcohol abuse

3) Gaucherâs disease

2) Corticosteroid therapy

5) Hemoglobinopathies

4) Smoking

 

Corticosteroid therapy is the most commonly reported cause of osteonecrosis of the humeral head. Other risk factors include alcohol abuse, hemoglobinopathies, Gaucherâs disease, dysbarism, connective tissue disorders, arteritis, vasculitis, hypercoagulability, prior radiation, pregnancy, and pancreatitis.Correct Answer: Corticosteroid therapy

 

 

2908. (1491) Q7-1881:

The microfracture technique for articular cartilage lesions is most successful for which chondral lesions:

 

1) 2 cm diameter

3) Kissing lesions

2) Smaller than a 2 cm diameter

5) Partial thickness chondral lesions

4) Loss of subchondral bone integrity

 

The inventors of the microfracture technique described a 70% to 80% success rate after microfracture of lesions smaller than 2 cm in diameter. The technique involves maintenance of some subchondral bone integrity and is indicated for full thickness chondral lesions. Lesions involving both the tibia and femur have resulted in less satisfactory outcomes.Correct Answer: Smaller than a 2 cm diameter

 

The results of anteromedial tibial tubercle transfer for patellar malalignment are best when patellar lesions are located:

 

1) Distally on the lateral facet

3) Proximally on the medial facet

2) Proximally on the lateral facet

5) Proximally on either facet

4) Distally on the medial facet

 

A study revealed that results after tibial tubercle anteromedialization are best if patellar lesions are located distally or laterally. The results were poor when the lesions were located proximally or on the medial facet.Correct Answer: Distally on the lateral facet

 

 

2910. (1493) Q7-1883:

The following structures are found in the superficial layer of the posterolateral corner:

 

1) The biceps tendon and fabellofibular ligament

3) The iliotibial tract and biceps tendon

2) The patellofemoral ligaments and quadriceps retinaculum

5) The popliteofibular ligament and biceps tendon

4) The joint capsule and fabellofibular ligament

 

An anatomic study described three distinct layers that compose the posterolateral corner of the knee. Layer one includes the biceps tendon, the iliotibial tract, the prepatellar bursa, and peroneal nerve. Layer two includes the quadriceps retinaculum and patellofemoral ligaments. Layer three, the deepest layer, includes the lateral part of the joint capsule, the popliteus tendon passing through the hiatus, the fibular collateral ligament, the fabellofibular ligament, arcuate complex, and popliteofibular ligament.Correct Answer: The iliotibial tract and biceps tendon

 

 

2911. (1494) Q7-1884:

The following structures are found in the second, or middle layer, of the posterolateral corner:

 

1) The biceps tendon and fabellofibular ligament

3) The iliotibial tract and biceps tendon

2) The patellofemoral ligaments and quadriceps retinaculum

5) The popliteofibular ligament and biceps tendon

4) The joint capsule and fabellofibular ligament

 

An anatomic study described three distinct layers that compose the posterolateral corner of the knee. Layer one includes the biceps tendon, the iliotibial tract, the prepatellar bursa, and peroneal nerve. Layer two includes the quadriceps retinaculum and patellofemoral ligaments. Layer three, the deepest layer, includes the lateral part of the joint capsule, the popliteus tendon passing through the hiatus, the fibular collateral ligament, the fabellofibular ligament, arcuate complex, and popliteofibular ligament.Correct Answer: The patellofemoral ligaments and quadriceps retinaculum

 

 

2912. (1495) Q7-1885:

The following structures are found in the deep layer of the posterolateral corner:

 

1) The biceps tendon and fabellofibular ligament

3) The iliotibial tract and biceps tendon

2) The patellofemoral ligaments and quadriceps retinaculum

5) The popliteofibular ligament and biceps tendon

4) The joint capsule and fabellofibular ligament

 

An anatomic study described three distinct layers that compose the posterolateral corner of the knee. Layer one includes the biceps tendon, the iliotibial tract, the prepatellar bursa, and peroneal nerve. Layer two includes the quadriceps retinaculum and patellofemoral ligaments. Layer three, the deepest layer, includes the lateral part of the joint capsule, the popliteus tendon passing through the hiatus, the fibular collateral ligament, the fabellofibular ligament, arcuate complex, and popliteofibular ligament.Correct Answer: The joint capsule and fabellofibular ligament

 

Sectioning the posterolateral structures alone affects lateral tibial plateau translation with:

 

1) Increased anterior translation at 30° knee flexion

3) Increased posterior translation at 30° knee flexion

2) Increased posterior translation at 90° knee flexion

5) No change in translation of the knee

4) Increased anterior translation at 90° knee flexion

 

Biomechanical studies show that sectioning the posterolateral structures alone results in increases in posterior translation of the lateral tibial plateau primarily at 30° of knee flexion.Correct Answer: Increased posterior translation at 30° knee flexion

 

 

2914. (1497) Q7-1887:

Sectioning the posterolateral structures and posterior cruciate ligament results in:

 

1) Increased posterior tibial translation at 30°

3) Increased posterior tibial translation at 30° and 90°

2) Increased posterior tibial translation at 90

5) Increased anterior tibial translation at 30° and 90

4) No increase in tibial translation

 

Biomechanical studies show that sectioning the posterolateral structures and posterior cruciate ligament results in increases in posterior translation of the medial and lateral tibial plateaus at 30° and 90° of knee flexion.Correct Answer: Increased posterior tibial translation at 30° and 90°

 

 

2915. (1498) Q7-1888:

The maximal restraint to varus stress provided by the posterolateral structures of the knee is at what degree of knee flexion:

 

1) 0°

3) 45°

2) 30°

5) 90°

4) 60°

 

Biomechanical studies show that sectioning the posterolateral structures results in increases in varus rotation of the knee from 0º to 30° of knee flexion, with maximal increase observed at 30°.Correct Answer: 30°

 

 

2916. (1499) Q7-1889:

The reverse pivot shift is most useful for diagnosing which of the following knee injuries:

 

1) Anterior cruciate ligament injuries

3) Medial collateral ligament injuries

2) Posterior cruciate ligament injuries

5) Meniscal injuries

4) Posterolateral corner injuries

 

The reverse pivot shift is positive if there is a palpable shift or jerk as the lateral tibial plateau reduces while bringing the knee from 90° of flexion to full extension with the foot in external rotation. This is indicative of posterolateral corner knee injury but has been reported to be positive in 11% to 35% of normal asymptomatic patients.Correct Answer: Posterolateral corner injuries

 

When using the tibial external rotation test on a patient, increased external rotation at 30° but not at 90° of knee flexion is indicative of:

 

1) Anterior cruciate ligament injury

3) Isolated posterolateral corner injury

2) Posterior cruciate ligament injury

5) Anterior cruciate and posterior cruciate ligament injury

4) Posterior cruciate and posterolateral corner injury

 

The tibial external rotation test is performed at 30° and 90° of knee flexion. The degree of foot external rotation with regard to the femur is evaluated. Increased external rotation at 30° is consistent with an isolated posterolateral corner injury. Increased external rotation at 30° and 90° is consistent with a combined posterolateral and posterior cruciate ligament injury.Correct Answer: Isolated posterolateral corner injury

 

 

2918. (1501) Q7-1891:

When using the tibial external rotation test on a patient, increased external rotation at 30° and 90° of knee flexion is indicative of:

 

1) Anterior cruciate ligament injury

3) Isolated posterolateral corner injury

2) Posterior cruciate ligament injury

5) Anterior cruciate and posterior cruciate ligament injury

4) Posterior cruciate and posterolateral corner injury

 

The tibial external rotation test is performed at 30° and 90° of knee flexion. The degree of foot external rotation with regard to the femur is evaluated. Increased external rotation at 30° is consistent with an isolated posterolateral corner injury. Increased external rotation at 30° and 90° is consistent with a combined posterolateral and posterior cruciate ligament injury.Correct Answer: Posterior cruciate and posterolateral corner injury

 

 

2919. (1502) Q7-1893:

The recommended treatment for an acute combined anterior cruciate ligament and complete posterolateral corner disruption in a young athlete is:

 

1) Anterior cruciate ligament reconstruction alone

3) Anterior cruciate ligament reconstruction and posterolateral corner repair

2) Nonoperative treatment emphasizing quadriceps strengthening

5) Posterolateral corner repair alone

4) Anterior cruciate ligament repair and posterolateral corner repair

 

In cases of combined cruciate ligament and posterolateral corner injuries, most surgeons recommend addressing both injuries. In one study, the most common cause of anterior cruciate ligament failure was unrecognized and untreated concomitant posterolateral corner injuries.Correct Answer: Anterior cruciate ligament reconstruction and posterolateral corner repair

 

 

2920. (1503) Q7-1894:

The ideal timing for repair of an acute posterolateral corner knee injury is:

 

1) In the first 3 weeks

3) 8 to 12 weeks

2) 4 to 6 weeks

5) Surgery is rarely needed for complete posterolateral corner injuries.

4) Acute repair is unsuccessful, and late reconstruction is recommended.

 

Surgical repair of posterolateral corner injuries is recommended within the first several weeks because dissection can be difficult and can result in the need for a reconstruction with longer delays. Results of chronic posterolateral corner injury repairs are inferior to those for acute posterolateral corner injuries.Correct Answer: In the first 3 weeks

 

Which of the following exercises must be delayed for up to 3 months after posterolateral corner repair or reconstruction of the knee:

 

1) Range of motion exercises

3) Closed chain quadriceps exercises

2) Isometric quadriceps exercises

5) All of the above answers should be started immediately

4) Hamstring exercises

 

Postoperative rehabilitation for posterolateral corner repair or reconstruction involves early protected or nonweight bearing, early range of motion exercises, and quadriceps exercises. Avoidance of hamstring exercises for up to 12 weeks is recommended to decrease external rotational torque and posterior subluxation forces at the knee joint.Correct Answer: Hamstring exercises

 

 

2922. (1505) Q7-1896:

For patients who sustain a knee dislocation, the role of clinical history, physical examination, and magnetic resonance imaging (MRI) is:

 

1) Both physical examination and MRI are important, but physical examination is much more accurate.

3) Both physical examination and MRI are important, but MRI is more accurate.

2) Neither physical examination or MRI is very accurate.

5) Clinical history is the more important than MRI.

1. There is no role for MRI.

    

   In a study of 17 knee dislocations, the accuracy of clinical examination ranged from 53% to 82% correct compared to an accuracy of 85% to 100% with MRI. The limitations of clinical examination were mainly due to associated injuries.Correct Answer: Both physical examination and MRI are important, but MRI is more accurate.

    

    

   2923. (1506) Q7-1897:

   After high velocity knee dislocations, there is serious injury to the popliteal vessels in approximately what percentage of patients:

    

   1) 5%

   3) 30%

   2) 10%

2. More than 90%

4) 75%

 

After reviewing several series from 1963 to 1992, investigators found serious injury to the popliteal vessels in approximately 30% of cases and peroneal nerve injuries in 25% of cases. The incidence of arterial and nerve injury with lower velocity mechanisms (some athletic injuries) is lower.Correct Answer: 30%

 

 

2924. (1507) Q7-1898:

After high velocity knee dislocations, there is serious injury to the peroneal nerve in approximately what percentage of patients:

 

1. Serious injury has not been reported.

   3) 25%

2. 5%

5) More than 90%

4) 75%

 

After reviewing several series from 1963 to 1992, investigators found serious injury to the popliteal vessels in approximately 30% of cases and peroneal nerve injuries in 25% of cases. The incidence of arterial and nerve injury with lower velocity mechanisms (some athletic injuries) is lower.Correct Answer: 25%

 

The strongest bundle in the posterior cruciate ligament is the:

 

1) Anteromedial bundle

3) Anterolateral bundle

2) Posteromedial bundle

5) Both bands are of equal strength

4) Posterolateral bundle

 

The posterior cruciate ligament is made up of two bundles (anterolateral and posteromedial) that are named according to their origin on the femur and insertion on the tibia. The anterolateral bundle is the larger and stronger of the two bundles. The anterolateral bundle is tight in flexion, and the posteromedial bundle is tight in extension.Correct Answer: Anterolateral bundle

 

 

2926. (1509) Q7-1900:

In the posterior cruciate ligament the anterolateral bundle is tight in      and the posteromedial bundle is tight in      :

 

1) Flexion, extension

3) Extension, extension

2) Extension, flexion

5) Neither bundle tightens throughout the kneeâs range of motion.

4) Flexion, flexion

 

The posterior cruciate ligament is made up of two bundles (anterolateral and posteromedial) that are named according to their origin on the femur and insertion on the tibia. The anterolateral bundle is the larger and stronger of the two bundles. The anterolateral bundle is tight in flexion, and the posteromedial bundle is tight in extension.Correct Answer: Flexion, extension

 

 

2927. (1576) Q7-1970:

When applying valgus stress, over which arc of motion is the anterior band of the anterior oblique component of the ulnar collateral ligament of the elbow under tension:

 

1) 0° to 20°

3) 0° to 85°

2) 0° to 45°

5) 55° to 145°

4) 55° to 115°

 

Biomechanical studies demonstrate that the anterior band of the oblique component of the ulnar collateral ligament of the elbow is at greatest tension from full extension to 85° of elbow flexion.Correct Answer: 0° to 85°

 

 

2928. (1577) Q7-1971:

When applying valgus stress, over which arc of motion is the posterior band of the anterior oblique component of the ulnar collateral ligament of the elbow under tension:

 

1) 0° to 35°

3) 0° to 85°

2) 0° to 65°

5) 55° to 145°

4) 55° to 85°

 

Biomechanical studies demonstrate that the posterior band of the oblique component of the ulnar collateral ligament of the elbow is at greatest tension from 55° to full elbow flexion.Correct Answer: 55° to 145°

 

Which of the following structures is the main stabilizer of the elbow to valgus stress:

 

1) Anterior oblique component of the ulnar collateral ligament

3) Transverse oblique component of the ulnar collateral ligament

2) Posterior oblique component of the ulnar collateral ligament

5) Radiohumeral articulation

4) Ulnohumeral articulation

 

The anterior oblique component of the ulnar collateral ligament is the most important stabilizer of the elbow to valgus stress. The most important secondary stabilizer is the radiohumeral articulation. The transverse oblique component of the ulnar collateral ligament imparts little stability to the elbow.Correct Answer: Anterior oblique component of the ulnar collateral ligament

 

 

2930. (1579) Q7-1973:

Disruption of which of the following ligaments represents the primary lesion in posterolateral rotatory instability of the elbow:

 

1) Radial collateral ligament

3) Annular ligament

2) Radial ulnohumeral ligament

5) Ulnohumeral articulation

4) Accessory radial collateral ligament

 

OâDriscoll and associates demonstrated that the radial ulnohumeral ligament must be disrupted to produce posterolateral rotatory instability of the elbow.Correct Answer: Radial ulnohumeral ligament

 

 

2931. (1580) Q7-1974:

Elbow injury usually occurs during which phase of throwing:

 

1) Wind-up

3) Late cocking

2) Early cocking

5) Follow through

4) Acceleration

 

Peak valgus stresses on the elbow occur during the acceleration phase of throwing making it the phase during which the elbow is most vulnerable to injury.Correct Answer: Acceleration

 

 

2932. (1581) Q7-1975:

Which of the following structures is the most important dynamic stabilizer of the elbow to valgus stresses during throwing:

 

1) Anterior oblique component of the ulnar collateral ligament

3) Flexor-pronator musculature

2) Posterior oblique component of the ulnar collateral ligament

5) Biceps brachii

4) Brachialis

 

The flexor-pronator muscle mass on the medial side of the elbow dynamically resists valgus stresses during throwing. Compromise or fatigue of this muscle group with activity may be a predecessor to injury to the ligamentous stabilizing structures.Correct Answer: Flexor-pronator musculature

 

 

 

 

 

Slide 1

The following is a hip magnetic resonance image (MRI) of a 28-year-old male triathlete who has noticed progressive activity-related left hip pain. Recommended treatment includes:

 

1) Arthroscopic debridement

3) Percutaneous pinning in situ

2) Open reduction internal fixation

5) Continuation of current training regimen

4) Period of nonweight bearing with continued observation

 

The MRI depicts a compression sided incomplete femoral neck fracture. Compression sided fractures of the femoral neck are treated with nonweight bearing and close observation. In the advent of fracture line extension, these fractures must be urgently percutaneously pinned. Complete stress fractures and incomplete tension sided fractures of the femoral neck must be urgently percutaneously pinned.Correct Answer: Period of nonweight bearing with continued observation

 

 

2934. (1583) Q7-1977:

 

 

 

Slide 1 Slide 2

The following radiographs are of a 19-year-old female collegiate distance runner who complained of pain in her right distal tibia. She reports having shin splints 2 years earlier that affected her right proximal tibia. She has been unable to run secondary to symptoms for 3 weeks. She reports being amenorrheic for approximately the last 3 years. Which of the following should be included in her initial treatment regimen:

 

1) Treatment with nonsteroidal anti-inflammatory medications

3) Intramedullary nailing with bone grafting

2) Localized steroid injection

5) Initiation of hormone replacement therapy

4) Continuation of current training regimen

 

This individual has a distal tibial stress fracture as evidenced by the early periosteal reaction shown on radiography. Radiographs also show a healed proximal tibial stress fracture. Amenorrhea is a risk factor for stress fractures and should be addressed with hormone replacement therapy. The other possible answers are inappropriate for initial treatment.Correct Answer: Initiation of hormone replacement therapy

 

 

 

 

 

Slide 1

The following figure is the magnetic resonance image (MRI) of a 40-year-old avid female water-skier who felt a pop in her left hip as she was pulled over the front of her ski. Recommended treatment includes:

 

1) Percutaneous pinning

3) Physical therapy

2) Nonweight bearing crutch ambulation

5) Reassurance and symptomatic treatment

4) Operative repair of the injured structures

 

The MRI shows a complete avulsion of the hamstring tendons off the ischial tuberosity. In active individuals, operative repair is recommended for complete avulsions. Nonoperative treatment of complete hamstring avulsion injury yields a low rate of return to sport at preinjury activity level.Correct Answer: Operative repair of the injured structures

 

 

2936. (1585) Q7-1979:

During which phase of throwing is the flexor-pronator muscle mass most electrically active:

 

1) Wind-up

3) Late cocking

2) Early cocking

5) Follow through

4) Acceleration

 

Peak valgus stresses on the elbow occur during the acceleration phase of throwing making it the phase during which the elbow is most vulnerable to injury. The flexor-pronator muscle mass peaks in activity during the acceleration phase to dynamically stabilize the elbow.Correct Answer: Acceleration

 

 

2937. (1586) Q7-1980:

Which of the following is a risk factor for anterior cruciate ligament (ACL) injury in noncontact athletes:

 

1) Smaller than average cross sectional size of the ACL

3) Smaller than average diameter of the femoral notch

2) High shoe-surface coefficient of friction

5) Failure to modify activity of female athletes during certain phases of the menstrual cycle

4) Failure to use a knee brace

 

A high coefficient of friction at the shoe-surface interface is a risk factor for ACL injury in noncontact athletes. Insufficient evidence exists to definitively implicate the other possible answers as risk factors.Correct Answer: High shoe-surface coefficient of friction

 

Which of the following regimens is recommended for maintenance of cadiorespiratory fitness:

 

1) 30 to 60 minutes of exercise 3 to 5 days per week at 60% to 90% of maximum heart rate

3) 90 to 120 minutes of exercise 3 to 5 days per week at 60% to 90% of maximum heart rate

2) 30 to 60 minutes of exercise 7 days per week at 20% to 50% of maximum heart rate

5) 15 to 20 minutes of exercise 3 to 5 days per week at 60% to 90% of maximum heart rate

4) 30 to 60 minutes of exercise 1 day per week at 60% to 90% of maximum heart rate

 

Current recommendations for maintenance of cardiorespiratory fitness include 30 to 60 minutes of exercise 3 to 5 days per week at 60% to 90% of maximum heart rate.Correct Answer: 30 to 60 minutes of exercise 3 to 5 days per week at 60% to 90% of maximum heart rate

 

 

2939. (1588) Q7-1982:

All of the following muscles act in scapular retraction except:

 

1) Trapezius

3) Rhomboideus minor

2) Rhomboideus major

5) Pectoralis minor

4) Levator scapulae

 

The trapezius, rhomboids, and levator scapulae all provide some degree of scapular retraction. The pectoralis minor is a scapular protractor.Correct Answer: Pectoralis minor

 

 

2940. (1589) Q7-1983:

A 20-year-old male distance runner complains of pain on the lateral aspect of his knee that reliably occurs 3 miles into his run and eventually causes him to terminate his run. The pain is made worse by running downhill. He recalls no injury to his knee and has noticed no swelling. What is the most likely diagnosis:

 

1) Lateral meniscus tear

3) Iliotibial band tendinitis

2) Lateral collateral ligament sprain

5) Exertional compartment syndrome

4) Lateral parapatellar plica

 

Iliotibial band tendinitis is the most common cause of lateral knee pain in runners. It generally occurs a few miles into a run and is exacerbated with downhill running. Iliotibial band tendinitis generally responds to nonoperative treatment consisting of stretching and nonsteroidal anti-inflammatory drugs but may require a corticosteroid injection or, rarely, surgical treatment.Correct Answer: Iliotibial band tendinitis

 

 

2941. (1590) Q7-1984:

Outcome following arthroscopic treatment of superior labrum anterior to posterior (SLAP) lesions is most affected by which of the following factors:

 

1) Patient gender

3) Participation in overhead sports

2) Level of sports participation

5) Time to return to activity following surgery

4) Dominance of involved arm

 

Kim and colleagues reported on the results of 34 patients who underwent arthroscopic treatment of SLAP lesions and discovered that results were good in all patients, but individuals who participated in overhead sports did not have outcomes as good as those not participating in these types of activities.Correct Answer: Participation in overhead sports

 

Inversion injury of a plantarflexed foot results in disruption of the anterolateral capsuloligamentous structures in a sequential fashion. Which of the following is the order in which this disruption occurs:

 

1) Anterolateral joint capsule, anterior talofibular ligament, calcaneofibular ligament

3) Anterolateral joint capsule, calcaneofibular ligament, anterior talofibular ligament

2) Anterior talofibular ligament, anterolateral joint capsule, calcaneofibular ligament

5) Calcaneofibular ligament, anterolateral joint capsule, anterior talofibular ligament

4) Calcaneofibular ligament, anterior talofibular ligament, anterolateral joint capsule

 

Inversion injury to the plantarflexed foot results in a predictable, sequential pattern of injury. Injury is initiated anteriorly with disruption of the anterolateral joint capsule and progresses posteriorly to the anterior talofibular ligament and ultimately to the calcaneofibular ligament.Correct Answer: Anterolateral joint capsule, anterior talofibular ligament, calcaneofibular ligament

 

 

2943. (1592) Q7-1986:

When treating recurrent inversion ankle sprains, physiotherapy should be directed at strengthening of which muscle or muscle group:

 

1) Gastrosoleus

3) Tibialis posterior

2) Tibialis anterior

5) Flexor digitorum longus

4) Peroneals

 

The peroneals provide dynamic resistance to inversion of the ankle. Therapy programs designed for treating lateral ankle instability must attempt to maximize the function of these dynamic stabilizers.Correct Answer: Peroneals

 

 

2944. (1593) Q7-1987:

All of the following are either primary or secondary stabilizers of the knee to posterior translation except:

 

1) Posterior cruciate ligament

3) Medial collateral ligament

2) Anterior cruciate ligament

5) Posterolateral corner

4) Lateral collateral ligament

 

The posterior cruciate ligament is the primary stabilizer to posterior translation of the knee. Secondary stabilizers include the medial and lateral collateral ligaments and the posterolateral corner.Correct Answer: Anterior cruciate ligament

 

 

2945. (1594) Q7-1988:

Which of the following most accurately describes the location of the tibial attachment of the posterior cruciate ligament:

 

1) At the level of the tibial plateau

3) 5 mm to 10 mm inferior to the level of the tibial plateau

2) 0 mm to 5 mm inferior to the level of the tibial plateau

5) 15 mm to 20 mm inferior to the level of the tibial plateau

4) 10 mm to 15 mm inferior to the level of the tibial plateau

 

The tibial attachment of the posterior cruciate ligament is usually 10 mm to 15 mm inferior to the joint line. Reconstructions of the posterior cruciate ligament should attempt to replicate this tibial attachment site.Correct Answer: 10 mm to 15 mm inferior to the level of the tibial plateau

 

Which of the following is the most accurate clinical examination tool in detecting disruption of the posterior cruciate ligament:

 

1) Posterior drawer test

3) Posterior sag test

2) Quadriceps active drawer test

5) Reverse Lachman test

1. Reverse pivot shift test

    

   The posterior drawer test is the most accurate method of clinically diagnosing posterior cruciate ligament disruption. Although the quadriceps active drawer test and the posterior sag test are useful, their reported accuracy is less than that of the posterior drawer test. The reverse pivot shift test evaluates posterolateral corner injuries.Correct Answer: Posterior drawer test

    

    

   2947. (1596) Q7-1990:

   Completely lacerated muscles recover    % of their strength and    % of their ability to shorten:

    

   1) 50, 80

   3) 10, 90

   2) 25, 25

2. 90, 90

4) 90, 10

 

Completely lacerated muscles recover 50% of their strength and 80% of their ability to shorten. Complete laceration is uncommon and is seen more often after trauma than after athletic accidents.Correct Answer: 50, 80

 

 

2948. (1597) Q7-1991:

Muscles at increased risk for injury include:

 

1. Muscles that cross a single joint and act concentrically.

3) Muscles that cross two joints and act concentrically.

2) Muscles that cross a single joint and act eccentrically.

5) Muscle injury is independent of the number of joints crossed and type of contraction.

4) Muscles that cross two joints and act eccentrically.

 

Muscles that cross two joints and that are acting in an eccentric fashion are at increased risk for injury. Frequently injured muscles also have a high percentage of type II (fast twitch) fibers.Correct Answer: Muscles that cross two joints and act eccentrically.

 

 

2949. (1598) Q7-1992:

Histology 7 days after muscle strain will most likely reveal:

 

1) Inflammatory reaction

3) Complete muscle regeneration

2) Fibrous tissue replacing the inflammatory reaction

5) Acute hemorrhage

4) No reaction

 

Inflammatory reaction is seen after 2 days. At 1 week, the inflammatory reaction is replaced by fibrous tissue, and some muscle regeneration may be evident. Muscle strains and tears heal through scarring with minimal replacement with normal muscle tissue.Correct Answer: Fibrous tissue replacing the inflammatory reaction

 

 

 

1) Rest, heat, and elevation

3) Heat, rest, and aggressive stretching

2) Ice, rest, and aggressive stretching

5) Ice, rest, and elevation

4) Ice, elevation, and aggressive stretching

 

The usual initial treatment after a muscle strain involves rest, ice, compression, and elevation (RICE). Although gentle range of motion exercises can be instituted as tolerated, aggressive stretching may cause further hemorrhage and muscle injury.Correct Answer: Ice, rest, and elevation

 

 

2951. (1600) Q7-1994:

Which of the following are important in prevention of muscle injury:

 

1) Improved muscle endurance

3) Minimal warm up

2) Inflexibility

5) Rapid muscle fatigue

4) Decreased muscle tone

 

Factors that decrease muscle injury include adequate warm up; a strong, flexible muscle; and improved muscle endurance. Fatigued muscles have diminished load to failure, total deformation, and energy to absorption prior to failure.Correct Answer: Improved muscle endurance

 

 

2952. (1601) Q7-1995:

Fatigued muscles are characterized as having:

 

1) Lower propensity for injury

3) Diminished energy to absorption

2) Greater flexibility

5) Increased muscle tone

1. Less flexibility

    

   Factors that decrease muscle injury include adequate warm up; a strong, flexible muscle; and improved muscle endurance. Fatigued muscles have diminished load to failure, total deformation, and energy to absorption prior to failure.Correct Answer: Diminished energy to absorption

    

    

   2953. (1602) Q7-1996:

   Reported hamstring strength deficit by isokinetic testing after complete proximal rupture is approximately:

    

   1) 10%

   3) 60%

   2) 20%

2. No deficit

4) 90%

 

In a series of 12 patients with complete or near complete proximal hamstring ruptures, the mean strength deficit measured 61% for the hamstring and 23% for the quadriceps musculature.Correct Answer: 60%

 

 

 

1. High jumping

3) Water skiing

2) Skating

5) Basketball

4) Swimming

 

Water skiing is associated with proximal hamstring ruptures in both novice and experienced skiers. The mechanisms, however, are reported to be different depending on the level of skier. The novice skier typically sustains the injury while trying to get up on one or two skis from a submerged position, whereas the injury is typically the result of a fall in an experienced skier.Correct Answer: Water skiing

 

 

2955. (1604) Q7-1998:

Patients with symptomatic chronic proximal hamstring ruptures typically complain of:

 

1) Anterior thigh cramping with running

3) Difficulty ascending stairs

2) Difficulty decelerating the leg during running

5) Difficulty accelerating the leg during running

4) Difficulty descending stairs

 

Patients typically complain of a pulling sensation or cramping in the posterior thigh with vigorous activity. In addition, they may describe difficulty controlling the leg, which has been attributed to the impaired deceleration of the thigh as a result of the complete rupture.Correct Answer: Difficulty decelerating the leg during running

 

 

2956. (1605) Q7-1999:

The recommended treatment of a complete proximal hamstring rupture with 4-cm retraction in a young athletic adult is:

 

1) Nonoperative rehabilitation

3) Surgical reattachment of the proximal hamstrings

2) Nonoperative rehabilitation followed by surgical repair if there is continued disability

5) Complete proximal hamstring ruptures have not been reported

4) No rehabilitation or surgery is indicated

 

Patients with disability secondary to chronic complete proximal hamstring ruptures have been increasingly identified. Because of the reports of continued weakness and poor leg control, more authors are recommending acute repair of these injuries. Chronic repairs are reported to be much more difficult although good results are reported.Correct Answer: Surgical reattachment of the proximal hamstrings

 

 

2957. (1606) Q7-2000:

When comparing operative to nonoperative treatment of Achilles tendon ruptures, the major difference in outcome reported in the literature is:

 

1) Return to full activity

3) Rerupture rate

2) Plantarflexion strength

5) There are no reported differences in results.

4) Ultimate range of motion

 

In a review of the literature, the rerupture rate after nonoperatively treated Achilles tendon ruptures was 13.4% compared to 1.4% for operative treatment. A prospective randomized study also substantiated these findings. Although the number of patients returning to full sporting activity and plantarflexion strength measurements was higher in the operative group, the differences were not as marked as the rerupture rate.Correct Answer: Rerupture rate

 

 

 

1) Abnormal fiber structure

3) Vascular proliferation

2) Focal hypercellularity

5) All of the above are noted

4) Abundant inflammatory cells

 

Histological analysis of Achilles tedinosis has revealed abnormal fiber structure, focal hypercellularity, and vascular proliferation. Inflammatory cells are not present in patients with chronic Achilles tendinosis.Correct Answer: Abundant inflammatory cells

 

 

2959. (1608) Q7-2002:

Initial management of a symptomatic Haglundâs deformity in a runner consists of:

 

1) Intratendinous steroid injection

3) Excision of the posterosuperior calcaneal prominence

2) Debridement of the tendon

5) A firm heel counter and medial heel wedge

4) Heel lift and soft shoe counter

 

Haglundâs deformity is characterized by a prominence about the posterosuperior calcaneus that can lead to retrocalcaneal bursitis and Achilles tendon injury just proximal to its insertion. The initial treatment involves relieving pressure from the affected area with a heel lift and soft heel counter. Resistant cases may benefit from excision of the prominence and debridement of the bursa and tendon.Correct Answer: Heel lift and soft shoe counter

 

 

2960. (1609) Q7-2003:

Which of the following is not consistent with a complete rupture of the Achilles tendon:

 

1) A palpable defect 3 cm to 4 cm proximal to the Achilles insertion

3) Sensation of being kicked in the calf

2) Ability to plantarflex the foot against gravity

5) No previous symptoms of Achilles related pain

4) Plantarflexion of the foot with the Thompson test

 

Patients who sustain an Achilles tendon rupture will often feel as if they were kicked in the back of the leg. They experience the sudden onset of pain and may present with a palpable defect. The patients may note plantarflexion weakness but may demonstrate active plantarflexion of the foot as a result of other muscles that cross posterior to the ankle such as the flexor hallucis longus and tibialis posterior muscles. The Thompson test (midcalf squeeze) will typically illicit no plantarflexion of the foot.Correct Answer: Plantarflexion of the foot with the Thompson test

 

 

2961. (1610) Q7-2004:

The primary collagen type found in the knee meniscus is:

 

1) Type I

3) Type III

2) Type II

5) Type VI

4) Type V

 

Type I collagen makes up 90% of the collagen in the meniscus. The remainder is made up of types II, III, V, and VI collagen. Type II makes up the majority of collagen in articular cartilage.Correct Answer: Type I

 

 

 

1) Anterior horn lateral meniscus

3) Posterior horn lateral meniscus

2) Anterior horn medial meniscus

5) None of the above

4) Posterior horn medial meniscus

 

Although the majority of the time the anterior horn of the medial meniscus has a firm bony attachment, the transverse intermeniscal ligament is the only site of anterior attachment in 3% to 14% of cases.Correct Answer: Anterior horn medial meniscus

 

 

2963. (1612) Q7-2006:

With regard to the meniscofemoral ligaments, the ligament of Humphrey runs    to the posterior cruciate ligament (PCL) and the ligament of Wrisberg runs     to the PCL.

 

1) Posterior, anterior

3) Anterior, anterior

2) Anterior, posterior

5) Medial, lateral

4) Posterior, posterior

 

The anterior meniscofemoral ligament of Humphrey runs from the femur to the posterior horn of the lateral meniscus anterior to the PCL. The ligament of Wrisberg runs posterior to the PCL. It is occasionally the only posterior horn attachment site for a discoid lateral meniscus and can result in excessive motion and posterior horn instability.Correct Answer: Anterior, posterior

 

 

2964. (1613) Q7-2007:

The ligament that has an association with an unstable lateral discoid meniscus is:

 

1) Ligament of Humphrey

3) Lateral collateral ligament

2) Medial collateral ligament

5) Anterior cruciate ligament

4) Ligament of Wrisberg

 

The anterior meniscofemoral ligament of Humphrey runs from the femur to the posterior horn of the lateral meniscus anterior to the posterior cruciate ligament (PCL). The ligament of Wrisberg runs posterior to the PCL. It is occasionally the only posterior horn attachment site for a discoid lateral meniscus and can result in excessive motion and posterior horn instability. The medial and lateral collateral ligaments are not the attachment sites for the posterior horn of some lateral discoid meniscal variants.Correct Answer: Ligament of Wrisberg

 

 

2965. (1614) Q7-2008:

Vascularity of the adult meniscus is limited to the:

 

1) Inner 10% to 30%

3) Peripheral 10% to 30%

2) Inner 30% to 50%

5) Entire meniscus is vascular

4) Peripheral 30% to 50%

 

Studies show that only the peripheral 10% to 25% of the lateral meniscus and 10% to 30% of the medial meniscus is vascular. The vascularity arises from the medial and lateral genicular arteries.Correct Answer: Peripheral 10% to 30%

 

 

 

1) Anterior horn medial meniscus

3) Posterior horn medial meniscus

2) Anterior horn lateral meniscus

5) Lateral collateral ligament

1. Posterior horn lateral meniscus

    

   One study evaluated the role of the meniscus in anteroposterior stability of the ACL-deficient knee. The researchers found that the posterior horn of the medial meniscus was the most important structure resisting an applied anterior tibial force in an ACL-deficient knee. The peripheral portion of the meniscus is essential for both load transmission and stability.Correct Answer: Posterior horn medial meniscus

    

    

   2967. (1874) Q7-2279:

   Approximately what percentage of middle-aged tennis players are able to return to tennis after rotator cuff surgery:

    

   1) 20%

   3) 60%

   2) 40%

2. 100%

4) 80%

 

In a series evaluating the results of surgical treatment of rotator cuff tears in 51 middle-aged tennis players, Sonnery-Cottet and colleagues discovered that approximately 80% of patients returned to tennis at latest follow-up.Correct Answer: 80%

 

 

2968. (1875) Q7-2281:

 

 

 

Slide 1

Proximal humeral anatomy is variable. Which of the following measurements most accurately describe the range of diameters of the humeral head (length of line AB):

 

1. 25 mm to 35 mm

3) 45 mm to 55 mm

2) 35 mm to 45 mm

5) 35 mm to 55 mm

4) 25 mm to 45 mm

 

Proximal humeral anatomy is variable. The high variability is the basis for radical changes in design of shoulder arthroplasty. The diameter of the humeral head ranges from approximately 35 mm to 55 mm.Correct Answer: 35 mm to 55 mm

 

 

2969. (1876) Q7-2283:

Which of the following statements best describes the relationship of humeral head diameter to humeral head thickness:

 

1) Humeral head diameter and humeral head thickness are independent of one another.

3) Humeral head diameter and humeral head thickness have an inversely proportional linear relationship.

2) Humeral head diameter and humeral head thickness have a directly proportional linear relationship.

5) Humeral head diameter and humeral head thickness have an inversely proportional logarithmic relationship.

4) Humeral head diameter and humeral head thickness have a directly proportional logarithmic relationship.

 

Humeral head diameter and humeral head thickness have a directly proportional linear relationship.Correct Answer: Humeral head diameter and humeral head thickness have a directly proportional linear relationship.

 

2970. (1877) Q7-2284:

 

 

 

Slide 1

Proximal humeral anatomy is variable. Which of the following measurements most accurately describe the range of radius of curvature of the humeral head (length of line AB):

 

1) 5 mm to 10 mm

3) 15 mm to 20 mm

2) 10 mm to 15 mm

5) 30 mm to 40 mm

4) 20 mm to 30 mm

 

Proximal humeral anatomy is variable. This high variability is the basis for radical changes in design of shoulder arthroplasty. The humeral head radius of curvature ranges from approximately 20 mm to 30 mm.Correct Answer: 20 mm to 30 mm

 

 

2971. (1878) Q7-2286:

The proximal humeral articular surface can be described as a portion of a sphere. The center of this sphere has which of the following anatomic relationships to the long axis of the humerus:

 

1) The center of this sphere lies on the long axis of the humerus.

3) The center of this sphere is offset posteriorly with respect to the long axis of the humerus.

2) The center of this sphere is offset medially with respect to the long axis of the humerus.

5) The center of this sphere is offset medially and posteriorly with respect to the long axis of the humerus.

4) The center of this sphere is offset anteriorly with respect to the long axis of the humerus.

 

Anatomically, a sphere can be fit to the proximal humerus with the articular surface comprising a portion of that spher The center of this sphere is offset 3 mm to 11 mm medially and 1 mm to 6 mm posteriorly with respect to the long axis of the humerus.Correct Answer: The center of this sphere is offset medially and posteriorly with respect to the long axis of the humerus.

 

 

2972. (1879) Q7-2287:

Which of the following pitch types is associated with the development of shoulder pain in baseball pitchers between the ages of 9 and 14 years:

 

1) Fastball

3) Curveball

2) Change-up

5) Knuckle ball

4) Slider

 

A study following 476 young baseball pitchers for one season demonstrated that the use of the curveball in this age group was associated with a 52% increased risk of the development of shoulder pain.Correct Answer: Curveball

 

Which of the following pitch types is associated with the development of elbow pain in baseball pitchers between the ages of 9 and 14 years:

 

1. Fastball

   3) Curveball

   2) Change-up

   5) Knuckle ball

   1. Slider

       

      A study following 476 young baseball pitchers for one season demonstrated that use of the slider in this age group was associated with an 86% increased risk of the development of elbow pain.Correct Answer: Slider

       

       

      2974. (1881) Q7-2289:

      It is recommended to limit youth baseball pitchers (9 to 14 years of age) to how many pitches per game

       

      1) 25

      3) 75

      2) 50

   2. 125

   4) 100

    

   In young baseball pitchers, high pitch counts are associated with increased risk of shoulder pain. Based on a study of 476 youth baseball pitchers, it is recommended to limit pitch counts to 75 pitches per gamCorrect Answer: 75

    

    

   2975. (1882) Q7-2290:

   It is recommended to limit youth baseball pitchers (9 to 14 years of age) to how many game situation pitches per baseball season:

    

   1) 200

   3) 600

2. 400

   5) 1000

   4) 800

    

   In young baseball pitchers, high pitch counts are associated with increased risk of shoulder pain. Based on a study of 476 youth baseball pitchers, it is recommended to limit pitch counts to 600 game situation pitches per season.Correct Answer: 600

    

    

   2976. (1883) Q7-2292:

   Which of the following statements is true regarding traumatic anterior shoulder instability:

    

   1. Abnormal glenohumeral translation occurs mainly in the provocative position of 90° abduction and external rotation, and this translation is corrected by contraction of the dynamic shoulder stabilizers.

3. Abnormal glenohumeral translation occurs mainly in the provocative position of 90° abduction and external rotation, and this translation is not corrected by contraction of the dynamic shoulder stabilizers.

   1. Abnormal glenohumeral translation occurs in multiple arm positions, and this translation is corrected by contraction of the dynamic shoulder stabilizers.

   5) No abnormal glenohumeral translation occurs in traumatic shoulder instability.

   4) Abnormal glenohumeral translation occurs in multiple arm positions, and this translation is not corrected by contraction of the dynamic shoulder stabilizers.

    

   A study evaluating glenohumeral translation and muscle activity related traumatic and atraumatic shoulder instability demonstrated that patients with traumatic shoulder instability have abnormal glenohumeral translation mainly in the provocative position of 90° abduction and external rotation. This translation is corrected by contraction of the dynamic shoulder stabilizers.Correct Answer: Abnormal glenohumeral translation occurs mainly in the provocative position of 90° abduction and external rotation, and this translation is corrected by contraction of the dynamic shoulder stabilizers.

    

   Which of the following is the most common radiographic finding in patients with lateral epicondylitis:

    

   1) Soft tissue calcification at the lateral aspect of the elbow

   3) Olecranon osteophyte

   2) Coronoid osteophyte

   5) Osteochondritis dessicans

   4) Intraosseous cyst

    

   In a radiographic analysis of 294 patients with lateral epicondylitis, 20 patients had lateral soft tissue calcification, 14 patients had coronoid osteophytes, nine patients had olecranon osteophytes, two patients had intraosseous cysts, and two patients had osteochondritis dessicans. The author concluded that routine radiography is not warranted in the initial management of lateral epicondylitis.Correct Answer: Soft tissue calcification at the lateral aspect of the elbow

    

    

   2978. (1885) Q7-2294:

   A 32-year-old male recreational tennis player presents with a 4-week history of progressive activity-related elbow pain in his dominant upper extremity. Clinical examination demonstrates marked tenderness at the lateral epicondyle and pain at the lateral epicondyle with resisted wrist extension. No instability is detected on clinical examination. The next step in management is:

    

   1) Routine radiography

   3) Activity modification, nonsteroidal anti-inflammatory agents, and physical therapy

   2) Magnetic resonance imaging

   5) Arthroscopic surgical excision of pathological tissue

   4) Open surgical excision of pathological tissue

    

   This patient has lateral epicondylitis. A recent radiographic analysis of lateral epicondylitis showed that radiographs taken at initial presentation did not alter the initial management. Most patients with lateral epicondylitis respond to nonoperative treatment.

   Surgical treatment should only be considered after failure of a prolonged course (at least 6 months) of nonoperative treatment.Correct Answer: Activity modification, nonsteroidal anti-inflammatory agents, and physical therapy

    

    

   2979. (1886) Q7-2295:

   During diagnostic elbow arthroscopy, which of the following nerves is at the greatest risk for injury:

    

   1) Ulnar nerve

   3) Radial nerve

   2) Median nerve

   5) Anterior interosseous nerve

   4) Posterior interosseous nerve

    

   The radial nerve is at the greatest risk for injury during elbow arthroscopy. Injury usually occurs during creation of the anterolateral portal.Correct Answer: Radial nerve

    

    

   2980. (1887) Q7-2296:

   Which of the following elbow arthroscopic portals is correctly matched to the nerve at risk during portal creation:

    

   1) Anteromedial portal â ulnar nerve

   3) Posterior portal â ulnar nerve

   2) Anteromedial portal â radial nerve

   5) Posterior portal â radial nerve

   4) Anterolateral portal â median nerve

    

   Incorrect placement of the anterolateral portal places the radial nerve at risk. Incorrect placement of the anteromedial portal places the median and ulnar nerves at risk. The posterior portal is not associated with neural injury.Correct Answer: Anteromedial portal â ulnar nerve

    

   Which of the following statements is true regarding the use of a two-incision technique vs a single-incision technique for distal biceps repair:

    

   1) The two-incision technique is associated with increased risk of neural injury, while the single-incision technique is associated with an increased risk of heterotopic ossification.

   3) The two-incision technique is associated with increased risk of neural injury, while the risk of heterotopic ossification is the same for both procedures.

   2) The two-incision technique is associated with increased risk of heterotopic ossification, while the single-incision technique is associated with an increased risk of nerve injury.

   5) The risk of nerve injury and heterotopic ossification is the same for both procedures.

   1. The two-incision technique is associated with increased risk of heterotopic ossification, while the risk of nerve injury is the same for both procedures.

       

      Successful treatment of distal biceps tendon tears include dual- and single-incision techniques. The two-incision technique is associated with increased risk of heterotopic ossification, whereas the single-incision technique is associated with an increased risk of nerve injury.Correct Answer: The two-incision technique is associated with increased risk of heterotopic ossification, while the single-incision technique is associated with an increased risk of nerve injury.

       

       

      2982. (1889) Q7-2298:

      Approximately what percentage of supination strength is lost with an unrepaired distal biceps tendon rupture:

       

      1) 5%

      3) 40%

      2) 20%

   2. 80%

4. 60%

 

The biceps provides approximately 40% of supination strength to the forearm.Correct Answer: 40%

 

 

2983. (1890) Q7-2299:

The anterior cruciate ligament is composed of which of the following bundles:

 

1. Anterolateral, posteromedial

3) Mediolateral, posteromedial

2) Anteromedial, posterolateral

5) Medial, lateral

1. Anterior, posterior

    

   The anterior cruciate ligament consists of two bundles. The anteromedial bundle is tight in flexion, and the posterolateral bundle is tight in extension.Correct Answer: Anteromedial, posterolateral

    

    

   2984. (1891) Q7-2300:

   The anterior cruciate ligament (ACL) provides what percent of the stability to anterior tibial translation with the knee flexed 30Â

   °:

    

   1) 10%

   3) 50%

   2) 25%

2. 85%

4) 65%

 

The ACL functions as the primary stabilizer to anterior tibial translation providing more than 85% of stability with the knee in 30° of flexion.Correct Answer: 85%

 

Which of the following positions of knee flexion produces the greatest strain in the anterior cruciate ligament with anterior loading of the tibia:

 

1. 30° (Lachman test)

3) 55°

2) 45°

5) 90° (anterior drawer test)

4) 75°

 

Clinical and biomechanical studies show that anterior loading of the tibia in 30° of knee flexion produces greater strain and elongation of the normal anteromedial bundle than loading in 90° of knee flexion.Correct Answer: 30° (Lachman test)

 

 

2986. (1893) Q7-2302:

Anterior cruciate ligament (ACL) injuries are almost       in women than in their male counterparts in collegiate basketball players:

 

1) Four times less common

3) Eight times more common

2) One and a half times more common

5) Half as common

4) Equal in prevalence

 

Female collegiate basketball players are almost eight times as likely to sustain ACL injuries as their male counterparts.Correct Answer: Eight times more common

 

 

2987. (1894) Q7-2303:

Which of the following is not considered an intrinsic risk factor for anterior cruciate ligament (ACL) injury:

 

1) Narrow notch width index

3) All of the above

2) Altered neuromuscular control

5) Male gender

4) Increased laxity

 

Intrinsic risk factors for ACL injury include a narrow notch width index, a weak or small native ACL, knee joint anteroposterior laxity, malalignment of the lower extremity, pelvic position, navicular drop, and subtalar joint pronation. Male gender is not a risk factor for ACL injury.Correct Answer: Male gender

 

 

2988. (1895) Q7-2304:

Anterior cruciate ligament (ACL) injury is most commonly the result of:

 

1) A valgus load as a result of contact

3) A varus load as a result of contact

2) A hyperextension as a result of contact

5) Penetrating trauma

4) A noncontact injury

 

An ACL injury is commonly the result of a noncontact mechanism. Two common mechanisms that have been described include a valgus force to a flexed knee with the leg in external rotation and knee hyperextension with the leg internally rotated.Correct Answer: A noncontact injury

 

The incidence of meniscal injury with a concomitant ACL tear is reported to be nearly    , with the     meniscus more commonly injured in the acute setting:

 

1) 30%, medial

3) 30%, lateral

2) 70%, medial

5) 70%, lateral

4) 50%, lateral

 

The incidence of meniscal tear after acute anterior cruciate ligament (ACL) injury is reported to be approximately 70%. The lateral meniscus is more often injured in the acute setting, and the medial meniscus is more often injured in the chronically ACL-deficient kneCorrect Answer: 70%, lateral

 

 

2990. (1897) Q7-2306:

The healing rate of meniscal repairs in association with acute anterior cruciate ligament (ACL) reconstruction is      that reported for isolated meniscal repairs:

 

1) Higher than

3) Equal to

2) Lower than

5) Unknown

4) Meniscal repairs are not recommended in this situation

 

The results with respect to healing of meniscal repairs in the association of an acute ACL injury are reported to be better than in other situations (92% vs 67%).Correct Answer: Higher than

 

 

2991. (1898) Q7-2307:

The typical locations for bone contusions as viewed on magnetic resonance imaging after anterior cruciate ligament (ACL) injury are the:

 

1) Medial femoral condyle and medial tibial plateau

3) Middle third of the lateral femoral condyle and posterolateral tibia

2) Anterior third of the lateral femoral condyle and posterolateral tibia

5) Patellofemoral compartment

1. Posterior third of the lateral femoral condyle and posterolateral tibia

    

   The typical locations for bone contusions after an ACL injury are the middle third of the lateral femoral condyle and the posterolateral tibia.Correct Answer: Middle third of the lateral femoral condyle and posterolateral tibia

    

    

   2992. (1899) Q7-2308:

   The sensitivity of the Lachman test is reported to be up to:

    

   1) 30%

   3) 78%

   2) 55%

2. 98%

4) 85%

 

Physical examination of the knee includes performing a Lachman test, which has a reported sensitivity of up to 98%.Correct Answer: 98%

 

The optimal timing for performing anterior cruciate ligament reconstruction after an acute injury is:

 

1. Within 24 hours

3) After 4 to 6 weeks

2) Within the first 3 weeks

5) Timing has not been shown to effect outcomes

4) After return of full knee range of motion

 

Shelbourne noted a decrease in the incidence of postoperative stiffness to less than 1% and faster return of strength when surgery is performed after obtaining full knee range of motion including hyperextension of the knee.Correct Answer: After return of full knee range of motion

 

 

2994. (1901) Q7-2310:

The most common technical errors when performing anterior cruciate ligament reconstruction are:

 

1) Excessively anterior tunnels

3) Iatrogenic posterior cruciate ligament injury

2) Intraoperative fracture

5) Excessively medial tunnels

4) Excessively posterior tunnels

 

The most common technical errors involve excessively anterior placement of the tunnels. Anterior tibial tunnel and femoral tunnel placement can result in graft impingement, inability to fully extend the knee, and eventual failure. Excessively anterior femoral tunnel placement can also result in capturing the knee with difficulty in gaining full flexion and eventual stretching or rupture of the graft with attempts at gaining full flexion.Correct Answer: Excessively anterior tunnels

 

 

2995. (1902) Q7-2311:

All of the following is used to identify the appropriate position for anterior cruciate ligament (ACL) tibial tunnel placement except:

 

1) Inner rim of the anterior horn and lateral meniscus

3) Medial tibial spine

2) 7 mm anterior to the posterior cruciate ligament (PCL)

5) Inner rim of the anterior horn of the medial meniscus

4) ACL stump/footprint

 

Tibial tunnel misplacement can be avoided by using the appropriate landmarks (inner rim of the anterior horn of the lateral meniscus, referencing off of the PCL, the medial tibial spine, and the ACL stump).Correct Answer: Inner rim of the anterior horn of the medial meniscus

 

 

2996. (1903) Q7-2312:

Adequate bone plug length for interference screw fixation during bone-tendon-bone anterior cruciate ligament reconstruction is:

 

1) At least 5 mm in length

3) At least 15 mm in length

2) At least 10 mm in length

5) Bone plug length is not related to fixation strength.

4) No less than 20 mm in length

 

Graft fixation is the weak point in the early postoperative period. Researchers have reported that the optimal bone plug length is at least 1 cm. Bone plugs of shorter lengths have decreased peak load to failure, but bone plugs of greater length did not have significantly increased peak loads to failure.Correct Answer: At least 10 mm in length

 

Anterior knee pain was noted in all of the following situations except:

 

1) Anterior cruciate ligament (ACL) reconstruction with bone-tendon-bone autograft

3) After nonoperative treatment of the ACL injury

2) ACL reconstruction with hamstrings

5) Following acute patellar dislocation

4) In meniscal tears treated nonoperatively

 

Anterior knee pain was reported after patellar tendon and hamstring ACL reconstruction. Although some reports show increased pain with kneeling after patellar tendon ACL reconstruction, it is important to note the development of anterior knee pain in patients with ACL injuries treated nonoperatively. Anterior knee pain after ACL injury with or without reconstruction is not well understood and is likely multifactorial in nature.Correct Answer: In meniscal tears treated nonoperatively

 

 

2998. (1905) Q7-2314:

Accelerated rehabilitation after anterior cruciate ligament reconstruction has resulted in:

 

1) Increased graft failure rates

3) Increased rates of stiffness

2) Decreased time to full activity

5) Increased meniscal tears

4) Prolonged time to full activity

 

Accelerated rehabilitation focusing on gaining and maintaining full extension, early unrestricted range of motion, and progression of rehabilitation based on achieving functional goals rather than a strict timeline has resulted in earlier return to sporting activities without compromising the ultimate result.Correct Answer: Decreased time to full activity

 

 

2999. (1906) Q7-2315:

Strain in the anterior talofibular ligament (ATFL)       as the ankle moves from dorsiflexion to plantarflexion.

 

1) Increases

3) Remains unchanged

2) Decreases

5) Increases initially then decreases

4) Has not been evaluated

 

The ATFL primarily functions to restrict internal rotation of the talus in the mortis Strain in the ATFL increases as the ankle moves from dorsiflexion and plantarflexion, and it is the primary restraint to anterior translation and adduction in this position.Correct Answer: Increases

 

 

3000. (1907) Q7-2316:

The most commonly injured ligament after inversion ankle sprains is the:

 

1) Anterior tibiofibular ligament

3) Anterior talofibular ligament

2) Calcaneofibular ligament

5) Deltoid ligament

4) Posterior talofibular ligament

 

Isolated anterior talofibular ligament (ATFL) injuries are reported to occur in 67% of ankle sprains. The anterior talofibular ligament is the most commonly injured ligament after inversion ankle sprains.Correct Answer: Anterior talofibular ligament

 

The recommended treatment for grade 1 and 2 lateral ankle sprains includes:

 

1) Cast immobilization

3) Functional bracing

2) Surgical repair and cast immobilization

5) Surgical reconstruction with peroneal tendon transfer

4) Surgical repair and functional bracing

 

Although some authors have recommended surgical treatment of acute grade III (unstable) ankle sprains, recent studies have reported less pain, decreased atrophy, earlier return to sport, and no increased incidence of late instabilities with nonsurgical treatment (functional bracing) compared to surgical treatment. In studies comparing cast immobilization and functional bracing, patients in the functional bracing group return to sporting activities significantly earlier than the cast group without compromising mechanical stability.Correct Answer: Functional bracing

 

 

3002. (1909) Q7-2318:

Associated lesions in the presence of chronic lateral ankle instability include all of the following except:

 

1) Peroneal tenosynovitis

3) Anterolateral impingement lesion

2) Talar osteochondritis dissecans (OCD) lesions

5) Plantar fascitis

4) Loose bodies

 

One study evaluating chronic lateral ankle instability found the following associated lesions: peroneal tenosynovitis (77%), anterolateral impingement lesion (67%), attenuated peroneal retinaculum (54%), ankle synovitis (49%), loose bodies (26%), talar OCD (23%), medial ankle tendon tenosynovitis (5%).Correct Answer: Plantar fascitis

 

 

3003. (2038) Q7-2454:

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. Identify the structure marked by the asterisk.

 

1) Subscapularis muscle

3) Infraspinatus muscle

2) Biceps muscle

5) Trapezius muscle

4) Deltoid muscle

 

The asterisk marks the infraspinatus muscle.Correct Answer: Infraspinatus muscle

 

 

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. Identify the structure marked by the asterisk.

 

1) Subscapularis muscle

3) Biceps muscle

2) Trapezius muscle

5) Deltoid muscle

4) Supraspinatus muscle

 

 

 

 

The asterisk marks the supraspinatus muscle.Correct Answer: Supraspinatus muscle 3005. (2040) Q7-2458:

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. Identify the structure marked by the asterisk.

 

1) Teres minor muscle

3) Triceps muscle

2) Teres major muscle

5) Deltoid muscle

4) Infraspinatus muscle

 

The asterisk marks the teres minor muscle.Correct Answer: Teres minor muscle

 

 

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. All of the following structures have an attachment to the structure marked by the asterisk except:

 

1) Coracobrachialis

3) Biceps brachii

2) Coracoacromial ligament

5) Pectoralis major

4) Pectoralis minor

 

The asterisk marks the coracoid process. All of the listed structures have a coracoid attachment except the pectoralis major.Correct Answer: Pectoralis major

 

 

3007. (2042) Q7-2460:

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. Identify the structure marked by the arrow.

 

1) Superior glenohumeral ligament

3) Long head of the biceps tendon

2) Middle glenohumeral ligament

5) Coracohumeral ligament

4) Short head of the biceps tendon

 

The arrow marks the long head of the biceps tendon.Correct Answer: Long head of the biceps tendon

 

 

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. Identify the structure marked by the arrows.

 

1) Subscapularis tendon

3) Long head of the biceps tendon

2) Supraspinatus tendon

5) Coracohumeral ligament

4) Short head of the biceps tendon

 

 

 

 

The arrows mark the subscapularis tendon.Correct Answer: Subscapularis tendon 3009. (2044) Q7-2462:

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. Identify the structure marked by the arrows.

 

1) Subscapularis tendon

3) Long head of the biceps tendon

2) Supraspinatus tendon

5) Coracohumeral ligament

4) Short head of the biceps tendon

 

The arrows mark the subscapularis tendon.Correct Answer: Subscapularis tendon

 

 

 

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. The structure marked by the arrows is innervated by which of the following structures:

 

1) Musculocutaneous nerve

3) Branch of the lateral cord of the brachial plexus

2) Branch of the posterior cord of the brachial plexus

5) Branch of the superior trunk of the brachial plexus

4) Branch of the medial cord of the brachial plexus

 

The arrows mark the subscapularis tendon. The subscapularis muscle is innervated by the upper and lower subscapular nerves. The upper and lower subscapular nerves are branches from the posterior cord of the brachial plexus.Correct Answer: Branch of the posterior cord of the brachial plexus

 

 

3011. (2046) Q7-2464:

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. The structure marked by the arrow is innervated by which of the following structures:

 

1) Musculocutaneous nerve

3) Branch of the lateral cord of the brachial plexus

2) Branch of the posterior cord of the brachial plexus

5) Branch of the superior trunk of the brachial plexus

4) Branch of the medial cord of the brachial plexus

 

The arrow marks the long head of the biceps tendon. The biceps muscle is innervated by the musculocutaneous nerve.Correct Answer: Musculocutaneous nerve

 

 

 

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. The structure marked by the asterisk is innervated by which of the following structures:

 

1) Musculocutaneous nerve

3) Branch of the lateral cord of the brachial plexus

2) Branch of the posterior cord of the brachial plexus

5) Branch of the superior trunk of the brachial plexus

4) Branch of the medial cord of the brachial plexus

 

The asterisk marks the supraspinatus muscle. The supraspinatus muscle is innervated by the suprascapular nerve. The suprascapular nerve is a branch from the superior trunk of the brachial plexus.Correct Answer: Branch of the superior trunk of the brachial plexus

 

 

3013. (2048) Q7-2466:

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. The structure marked by the asterisk is innervated by which of the following structures:

 

1) Musculocutaneous nerve

3) Branch of the lateral cord of the brachial plexus

2) Branch of the posterior cord of the brachial plexus

5) Branch of the superior trunk of the brachial plexus

4) Branch of the medial cord of the brachial plexus

 

The asterisk marks the infraspinatus muscle. The infraspinatus muscle is innervated by the suprascapular nerve. The suprascapular nerve is a branch from the superior trunk of the brachial plexus.Correct Answer: Branch of the superior trunk of the brachial plexus

 

 

 

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. The structure marked by the asterisk is innervated by which of the following structures:

 

1) Musculocutaneous nerve

3) Branch of the lateral cord of the brachial plexus

2) Branch of the posterior cord of the brachial plexus

5) Branch of the superior trunk of the brachial plexus

4) Branch of the medial cord of the brachial plexus

 

The asterisk marks the teres minor muscle.The teres minor muscle is innervated by the axillary nerve. The axillary nerve is a terminal branch from the posterior cord of the brachial plexus.Correct Answer: Branch of the posterior cord of the brachial plexus

 

 

3015. (2050) Q7-2468:

 

 

 

Slide 1

A magnetic resonance image of a patientâs right shoulder is shown. The structure marked by the asterisk is innervated by which of the following structures:

 

1) Musculocutaneous nerve

3) Branch of the lateral cord of the brachial plexus

2) Branch of the posterior cord of the brachial plexus

5) Branch of the superior trunk of the brachial plexus

4) Branch of the medial cord of the brachial plexus

 

The asterisk marks the deltoid muscle. The deltoid muscle is innervated by the axillary nerve. The axillary nerve is a terminal branch from the posterior cord of the brachial plexus.Correct Answer: Branch of the posterior cord of the brachial plexus

 

 

 

 

 

 

Slide 1

A 40-year-old athletic man with no history of traumatic injury and progressive shoulder pain over the past 2 years comes into your clinic for examination. He has had no previous surgery. A computed tomography scan of his shoulder is performed. Which of the following is the most likely scenario:

 

1) Gradual resolution of the symptoms without further treatment

3) Recurrent posterior glenohumeral dislocations/subluxations

2) Recurrent anterior glenohumeral dislocations/subluxations

5) Development of glenohumeral arthritis

4) Development of rotator cuff tear arthropathy

 

This patient has static posterior subluxation of the humeral head. Walch and colleagues described this entity as most likely being the first stage in the development of primary glenohumeral osteoarthritis. In this particular case, the patient already has thinning of the articular cartilage posteriorly.Correct Answer: Development of glenohumeral arthritis

 

 

3017. (2052) Q7-2470:

 

 

 

Slide 1

This clinical photograph (Slide) depicts the examination of a 41-year-old man. What is the structure or clinical findings being tested

 

1) Anterior shoulder instability

3) Multidirectional shoulder instability

2) Posterior shoulder instability

5) Biceps tendon rupture

4) Subscapularis tendon tear

 

This patient exhibits a positive "belly press" test. As he attempts to press on his abdomen, his wrist goes into flexion and his arm goes into extension because of subscapularis insufficiency.Correct Answer: Subscapularis tendon tear

 

 

 

 

 

Slide 1

This clinical picture (Slide) depicts the examination of a 28-year-old man as he tries to lift his hand away from his lumbar spin What structure or clinical entity is being tested?

 

1) Anterior shoulder instability

3) Multidirectional shoulder instability

2) Posterior shoulder instability

5) Biceps tendon rupture

4) Subscapularis tendon tear

 

This patient exhibits a positive "lift-off" test. He lacks adequate internal rotation strength to lift his hand off of his back indicating subscapularis insufficiency.Correct Answer: Subscapularis tendon tear

 

 

3019. (2054) Q7-2472:

A 21-year-old male distance runner has lateral sided knee pain when running. Running downhill makes the pain worse. He has minimal rest pain. He recalls no specific injury and denies any swelling. What is the most likely diagnosis:

 

1) Lateral meniscus tear

3) Iliotibial band friction syndrome

2) Lateral collateral ligament strain

5) Lateral hamstring tear

4) Plica

 

Iliotibial band friction syndrome is the most common cause of knee pain in runners. In the absence of trauma and swelling, iliotibial band friction syndrome is the most likely diagnosis in this patient.Correct Answer: Iliotibial band friction syndrome

 

 

3020. (2055) Q7-2473:

A 21-year-old male distance runner has lateral sided knee pain when running. Pain increases when running downhill. He has minimal rest pain. He recalls no specific injury and denies any swelling. What is the most appropriate initial management:

 

1) Arthroscopic partial lateral menisectomy

3) Anterior cruciate ligament reconstruction

2) Lateral collateral ligament reconstruction

5) Activity modification, physical therapy, and anti-inflammatory medications

4) Iliotibial band release

 

Iliotibial band friction syndrome is the most common cause of knee pain in runners. In the absence of trauma and swelling, iliotibial band friction syndrome is the most likely diagnosis in this patient. Preferred initial treatment is nonoperative.Correct Answer: Activity modification, physical therapy, and anti-inflammatory medications

 

The major medial soft-tissue restraint that prevents lateral displacement of the patella is the:

 

1) Lateral patellofemoral ligament

3) Medial patellomeniscal ligament

2) Medial patellotibial ligament

5) Lateral patellotibial ligament

4) Medial patellofemoral ligament

 

The medial patellofemoral ligament (MPFL), which is in the second layer, is the major medial soft-tissue restraint that prevents lateral displacement of the patell The MPFL extends from the adductor tubercle to the superomedial border of the patell The medial patellomeniscal ligament and medial patellotibial ligament also contribute varying degrees of medial patellar restraint.Correct Answer: Medial patellofemoral ligament

 

 

3022. (2057) Q7-2476:

All of the following factors are associated with an increased risk of recurrent patellar dislocation except:

 

1) Excessive Q angle or lateralization of the tibial tubercle in relation to the trochlea

3) Patella alta

2) Excessive foot pronation or knee angular deformities

5) Male gender

4) Hypoplastic lateral femoral condyle

 

Multiple factors are associated with an increased risk of recurrent patellar dislocation. Excessive Q angle or lateralization of the tibial tubercle in relation to the trochlea, excessive foot pronation or knee angular deformities, patella alta, hypoplastic lateral femoral condyle, vastus medialis oblique dysplasia, and hyperlaxity have been reported to contribute to recurrent patellar dislocationCorrect Answer: Male gender

 

 

3023. (2058) Q7-2477:

Studies show that recurrent patellar dislocation predominates in the:

 

1) Second decade of life

3) Fourth decade of life

2) Third decade of life

5) Sixth decade of life

1. Fifth decade of life

    

   Studies show that recurrent patellar dislocation predominates in the second decade of life.Correct Answer: Second decade of life

    

    

   3024. (2059) Q7-2478:

   Osteochondral lesions that involve the lateral femoral condyle and medial patella are noted in approximately what percentage of cases of patella dislocation:

    

   1) 5%

   3) 35%

   2) 15%

2. 95%

4) 70%

 

Radiographic plain films are helpful to rule out osteochondral fractures of the medial patella or lateral femoral condyle. In one study, osteochondral lesions involving the lateral femoral condyle and medial patella were noted in 68% of cases.Correct Answer: 70%

 

In the literature, the patella redislocation rate for conservatively treated patients ranges from:

 

1. 5% to 10%

3) 15% to 45%

2) 10% to 20%

5) 75% to 90%

4) 40% to 70%

 

The patella redislocation rate for conservatively treated patients ranges from 13% to 44% in the literature. The treatment varies from casting to an elastic bandage and early range of motion.Correct Answer: 15% to 45%

 

 

3026. (2061) Q7-2480:

Of patients treated surgically for patella dislocation, the recurrence rates range from:

 

1) 0% to 15%

3) 30% to 50%

2) 15% to 30%

5) 75% to 90%

4) 50% to 75%

 

Of patients treated surgically for patella dislocation, the recurrence rates range from 0% to 14%. The operative procedures have included medial patellofemoral ligament repair or reconstruction, medial reefing, lateral release, and tibial tubercle transfers. The optimal operative procedure remains controversial for first time dislocators. Patients must be evaluated on a case-by-case basis.Correct Answer: 0% to 15%

 

 

3027. (2062) Q7-2481:

After anteromedialization of the tibial tubercle, patients with which patellar lesions were found to have better outcomes:

 

1) Medial facet and distal lesions

3) Medial facet and proximal lesions

2) Lateral facet and distal lesions

5) Medial and lateral facet lesions

4) Lateral facet and proximal lesions

 

A study examining chondral lesions of the patella and anteromedialization of the tibial tubercle found that better results were obtained in patients with central or distal lesions and lateral facet chondral pathology than in patients with proximal patellar chondral or medial damage. The most effective treatment has been shown with lesions of the distolateral patella, and least efficacious when arthritic lesions are present throughout the patella or those that involve the trochlea. It has also been shown by contact pressures, that lesions of the proximal and medial patella could potentially fare the worst with an anteromedialization procedure since this procedure shifts the contact pressures preferentially to the proximal-medial patella postsurgically. The proximal-medial patellar lesions are not contraindications to the AMZ procedure, however.âCorrect Answer: Lateral facet and distal lesions

 

 

 

3028. (2063) Q7-2482:

What percentage of patients with chronic exertional compartment syndrome report bilateral symptoms:

 

1) 10% to 20%

3) 40% to 55%

2) 30% to 45%

5) 100%

4) 75% to 95%

 

Up to 75% to 95% of patients with chronic exertional compartment syndrome report bilateral symptoms.Correct Answer: 75% to 95%

 

The differential diagnosis for chronic exertional compartment syndrome includes all of the following except:

 

1) Tibial stress fracture

3) Popliteal artery entrapment

2) Medial tibial periostalgia

5) Femoral neck stress fracture

4) Fascial herniations

 

The differential diagnosis for chronic exertional compartment syndrome includes stress fractures, medial tibial periostalgia, tendinitis, nerve entrapment disorders, fascial herniations, vascular or neurogenic claudication, popliteal artery entrapment, and venous stasis.Correct Answer: Femoral neck stress fracture

 

 

3030. (2065) Q7-2484:

The most commonly affected compartment in chronic exertional compartment syndrome is the:

 

1) Anterior compartment

3) Superficial posterior compartment

2) Lateral compartment

5) Medial compartment

4) Deep posterior compartment

 

The most commonly affected compartments in chronic exertional compartment syndrome are the anterior followed by the deep posterior, lateral, and rarely, the superficial posterior compartment. The medial compartment does not exist.Correct Answer: Anterior compartment

 

 

3031. (2066) Q7-2485:

 

 

 

Slide 1

The appropriate treatment for a distance runner with leg pain (Slide) includes:

 

1) Intramedullary nailing

3) Continued running with orthotics

2) Bone grafting

5) No alteration in training

4) Keeping activities at a pain free level with return to full activity likely in 6 to 8 weeks

 

The magnetic resonance image shows a typical posteromedial tibial stress fractur This patient should have a period of relative rest with activities kept at a pain free level. A pneumatic leg brace was shown to result in an earlier return to full activity for posteromedial tibial stress fractures.Correct Answer: Keeping activities at a pain free level with return to full activity likely in 6 to 8 weeks