Sports Medicine 2021 Self assessment exam

OrthoCash

Collected by :
Kardo jaf

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1- A 38-year-old man has increasing left knee pain and occasional
instability. Several years earlier he sustained a noncontact twisting injury
to his knee. He had initial soreness and pain but was able to resume his
normal activities while avoiding sports. On examination, he has medial
joint line tenderness, a grade 2+ Lachman, and a slight varus thrust. His
radiographs reveal mild-to-moderate medial compartment osteoarthritis
with varus alignment. In addition to ligament reconstruction, what
surgical treatment strategy is most likely to alleviate his pain and
instability?

A. Distal femoral osteotomy

B. Total knee replacement
C. High tibial osteotomy (HTO), lateral closing wedge
D. HTO, medial opening wedge with decreased tibial slope

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

2- A 14-year-old girl has a head-on-head collision while playing

basketball. She had no loss of consciousness but had persistent
headaches for 2 weeks. The patient is now back to school and has no
headaches. What is the best next step?

A. Return to full basketball activity

B. Start light aerobic activity
C. Obtain baseline neuropsychological testing
D. MRI scan of the brain

Mild traumatic brain injury is common in the adolescent child.

Neuropsychological examination is widely used but, in this case, the patient is
asymptomatic and has no baseline testing. There is a limited role for MRI in
the recovery process of concussions. Furthermore, higher levels of
physical/cognitive activity should be avoided due to their potential to increase
total recovery time. In this scenario, a graduated return to activity is most
appropriate thus, the next appropriate step is to start light aerobic activity.
Correct answer : B 2
 3- A 55-year-old woman with degenerative joint disease underwent total
shoulder arthroplasty (TSA). She was doing well without complications
at her 2-week visit (Figures 1 and 2). She returned at 6 weeks with
increased pain, shoulder clicking, and difficulty with forward elevation
and internal rotation. She recalls slipping, and to prevent a fall, moved
her arm suddenly to grab a rail. New radiographs are shown in Figures 3
and 4. What is the best next step?

A. Revision to reverse shoulder arthroplasty

B. Electromyography
C. Subscapularis tendon repair
D. Closed reduction

The patient underwent

TSA. At her regular 2-
week follow-up appoint-
ment, radiographs show
a reduced glenohumeral
joint. She then sustained
a traumatic injury and
the radiographs at her 6-week appointment show anterior subluxation of the
glenohumeral joint indicative of subscapularis insufficiency. Subscapularis repair is
the next best step in management, especially in this age group, with well-fixed and
well-aligned components.
Correct answer : C 3
4- Which factor increases the success rate associated with all-inside
lateral meniscal repair?

A. Concomitant anterior cruciate ligament (ACL) reconstruction

B. Concomitant medial meniscus repair
C. Older patient age
D. Varus knee alignment

Decreased patient age, neutral alignment, and a concomitant ACL tear are
associated with improved success rates of meniscal repair. Meniscus tears on
the contralateral side of the knee and articular cartilage defects are not
associated with improved healing rates.
Correct answer : A

5- A 39-year-old right-hand dominant woman presents with many years of

right shoulder instability. She tried physical therapy several times over
the years without any benefit. Figure 1 shows her current axillary
radiograph. Figures 2 and 3 are representative MR arthrogram images.
What is the best treatment plan?

A. Open Bankart repair and

capsular shift
B. Arthroscopic anterior labral
repair and remplissage
C. Coracoid transfer
D. Glenoid osteotomy

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

6- Figure 1 is the MRI scan of a high school hockey player who is

checked from behind and falls forward to the ice onto his flexed knees.
He complains of swelling and posterior knee pain. Nonoperative
treatment of the injured structure will most likely result in increased risk
of degenerative change in

A. medial and patellofemoral

compartments.
B. lateral and patellofemoral
compartments.
C. medial compartment only.
D. patellofemoral compartment
only.

The injury mechanism and MRI scans

demonstrate an isolated posterior
cruciate ligament (PCL) tear. PCL injury
may result in posterior translational
macro-instability of the knee, but may

also result in more subtle and subclinical increases in varus and posterior tibial
translation during normal gait and other activities of daily living. These changes
result in increased contact stresses in the medial (due to varus forces) and
patellofemoral (due to posterior forces) compartments, leading to an increased
risk of degenerative chondrosis in these areas.
Correct answer : A

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7- A 32-year-old man with a history of seizure disorders is evaluated in
the emergency department following a recent seizure. The patient
complains of new onset shoulder pain following the seizure. After
emergency department workup, he is discharged home. The patient
follows up in the office 2 weeks after the seizure with continued shoulder
pain. Radiographs obtained in the office are shown in Figures 1 through
4. What is the most likely diagnosis?

A. Anterior instability
B. Acromioclavicular joint separation
C. Rotator cuff tear
D. Posterior instability
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Radiographs reveal a reverse Hill-Sachs lesion. This can only occur following
a posterior shoulder dislocation. In this case, the patient sustained a posterior
shoulder dislocation secondary to seizure activity. The dislocated shoulder is
self-reduced. Seizures are a common mechanism for posterior instability
because of the severe posterior muscular contractions that occur. It is
important to evaluate radiographs for subtle signs of pathology. The axillary
image reveals the reason for this patient's shoulder pain showing a reverse
Hill-Sachs lesion.
Correct answer : D

8- Injury to the structure noted with an arrow in the MRI in Figure 1 would
lead to what clinical condition?

A. Pain in the elbow with resisted

wrist flexion
B. Pain in the elbow with resisted
wrist extension
C. Lateral elbow pain and instability
with varus elbow force
D. Medial elbow pain and instability
with valgus elbow force

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

9- A 54-year-old right-hand dominant man with a recent history of

cervical lymph node biopsy for suspected metastatic melanoma
complains of a 1-month history of atraumatic left shoulder pain and
weakness. He has difficulty lifting objects overhead. He denies any neck
pain or tingling/numbness in the extremities. He became concerned
regarding the asymmetry he notices in the mirror (Figures 1 and 2). What
physical examination finding is most likely to be seen? 7
 A. Lateral scapular winging
B. Medial scapular winging
C. Triceps weakness
D. Deltoid atrophy

Left-sided trapezial atrophy is shown in both images. Trapezial palsy is the

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

10- Figure 1 is the radiograph of a 12-year-old right-hand dominant

baseball pitcher who has had right shoulder pain for the past 3 months.
He recalls no specific injury. Pain initially occurred only with throwing,
but now is bothersome during daily activities. He denies neck pain, or
extremity numbness or tingling. Examination demonstrates a BMI of
31.5, a mild decrease in passive glenohumeral internal rotation with a
symmetric increase in external rotation, and normal neurovascular
findings. What factor most is likely related to the patient’s pain?
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A. Above average body weight
B. Use of breaking ball pitches
C. Number of innings pitched
D. Excessive glenohumeral external rotation

The description and radiograph

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

11- A coach of three football teams—the B team, junior varsity team, and
varsity team—wants to study the average times in the 40-yard dash for
his players. Which test would help him determine if the mean 40-yard
dash times for the athletes on one team are different from those on the
other teams?

A. Independent 2-sample t test

B. Analysis of variance (ANOVA)
C. Chi-square test
D. Fisher's exact test

Data collected in research studies fall into one of two categories—continuous or

discrete. Continuous data can be displayed on a curve. Examples include height,
weight, and time recorded in a 40-yard dash. Discrete data represent data that
fall into specific categories such as gender or the presence or absence of a risk
factor.
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ANOVA is used to determine statistical significance in mean values of
continuous data when there are more than two independent samples. The 2-
sample t test compares mean values of continuous data between two
independent groups. The Chi-square test and Fisher's exact tests are tests
used to analyze discrete data.
Correct answer : B

12- A 19-year-old female volleyball player presents after injuring her knee
playing volleyball. She has had two prior anterior cruciate ligament (ACL)
reconstruction procedures; the first with bone-patellar-tendon autograft,
the second procedure involved an Achilles allograft. She has a 2B
Lachman examination and asymmetric high-grade pivot shift. MRI and
CT scans are shown in Figures 1 through 3. She has instability with
activities of daily living. What is the best next step in management?

A. Bone grafting and removal of hardware

B. Anterolateral ligament reconstruction
C. Open reduction and internal fixation (ORIF) of tibial plateau
D. Brace and return to play

Images show substantial tunnel widening 17 mm on coronal and 21 mm on

sagittal views. Generally, two-stage ACL revision is recommended for tunnels
>14 mm. Anterolateral ligament reconstruction or lateral-extra-articular
tenodesis alone would not be adequate to restore knee stability. There is no
fracture to necessitate ORIF. Bracing and return to play in a symptomatic, ACL
insufficient athlete is not recommended.
Correct answer : A
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 13- A 25-year-old male professional lacrosse player collides with another
player, with injury resulting from a knee impacting the athlete’s thigh. He
has immediate pain in the mid-thigh area and is unable to return to the
game because of difficulty with running. Examination reveals developing
swelling in the anterior mid-thigh area. The thigh compartments are soft,
and he is able to extend his knee against gravity. Knee flexion at 90°
gives him discomfort in the thigh but no knee pain. The knee and hip
examinations are otherwise unremarkable. Plain films of the femur are
negative. What is the best next step?

A. Intracompartmental pressure monitoring

B. Immobilization of the knee in a flexed position
C. Fasciotomy of the thigh
D. MRI scan of the femur

This athlete has experienced a quadriceps contusion with hemorrhage and

swelling into the anterior compartment of the thigh. Initial treatment for these
injuries is immobilization of the knee in flexion to reduce the amount of
bleeding into the anterior compartment. Rest and anti-inflammatory medication
may be used in the rehabilitation process but should not take the place of
immobilization in flexion. The compartments are soft and therefore, there is no
indication for fasciotomy. MRI scan of the femur may demonstrate hematoma
in the anterior thigh compartment but is not required to make the diagnosis.
Correct answer : B

14- The lesion seen in the MRI scan in Figure 1 is treated with a marrow
stimulation technique. The reparative tissue formed by this technique is
predominantly composed of

A. only type 1 collagen.

B. only type 2 collagen.
C. type 1 and type 2 collagen.
D. neither type 1 or type 2 collagen.

The MRI scan shows a full-thickness cartilage defect. When treated with a
marrow stimulation technique, such as a microfracture, the reparative tissue is
fibrocartilage. Unlike hyaline cartilage, which is composed of only type 2 collagen,
fibrocartilage is composed of both type 1 and type 2 collagen.
Correct answer : C 11
15- Figures 1 and 2 are the radiographs of a 58-year-old retired laborer
who has had many years of right shoulder pain. He initially experienced
relief with anti-inflammatory medication over the past year, but this no
longer provides him pain relief. He has pain with overhead activities and
is dissatisfied with his shoulder function. Examination indicates active
and passive forward elevation to 130°, full strength with external rotation,
and a negative belly press test. MRI demonstrates an intact rotator cuff.
What is the best next step in treatment?

A. Anatomic total shoulder arthroplasty (TSA)

B. Hemiarthroplasty
C. Reverse shoulder arthroplasty
D. Arthroscopy with debridement and biceps tenodesis

The patient has glenohumeral osteoarthritis based on the radiograph. His

examination demonstrates limited motion and no significant rotator cuff
pathology – full strength with external rotation, negative belly press, and no
pseudoparalysis. Of all the answer choices, an anatomic TSA would be the
most appropriate treatment option. Hemiarthroplasty does not address glenoid
pathology and provides inferior pain relief and function, compared with TSA. A
reverse shoulder arthroplasty is utilized for patients with degenerative shoulder
changes in conjunction with irreparable rotator cuff pathology. Shoulder
arthroscopy with debridement and biceps tenodesis is not appropriate for
those with severe degenerative changes of the shoulder.
Correct answer : A 12
16- According to the MRI scan shown in Figure 1, which pathologic
finding is expected to be encountered during arthroscopy?

A. Figure 2
B. Figure 3
C. Figure 4
D. Figure 5

The sagittal MRI scan is a clear

example of a double posterior
cruciate ligament (PCL) sign.
This sign has a high specificity for
a displaced bucket handle tear of
the medial meniscus as seen in
Figure 4. The other arthroscopic
images show a flap tear of the medial meniscus (Figure 2), anterior cruciate
ligament tear (Figure 3), and a full thickness articular cartilage defect
(Figure 5). Other less likely causes of a double PCL sign include
intermeniscal ligament, meniscofemoral ligaments, loose bodies,
osteophytes, and fracture fragments. Correct answer : C 13
17- Figures 1 and 2 are the radiographs of a 21-year-old football player
who underwent anterior cruciate ligament (ACL) reconstruction with
patellar tendon autograft 1 year ago. He reports mild stiffness in his
knee. Upon examination, he has a negative Lachman test, trace effusion,
and range of motion from 0 to 85° of knee flexion. Which factor is most
contributory to his examination findings?

A. Incorrect graft choice

B. Improper tunnel position
C. Tibial graft-tunnel mismatch
D. Femoral fixation at 80° flexion

Technical failure is the most common reason for ACL reconstruction failure.
Tunnel position is the most frequent cause of technical failure. Malpositioning
of the tunnel affects the length of the graft, causing either decreased range of
motion or increased graft laxity. This patient has anterior and vertical
placement of his femoral tunnel, which has been shown to cause stiffness in
knee flexion. Although graft choice is an important factor when planning ACL
reconstruction, overall outcomes with autograft tissues are fairly similar.
Fixation of the graft at the femoral or tibial end is not as important as tunnel
position. Fixing the graft in flexion can cause extension loss when isometry is
not achieved, but this condition is not touched upon in this scenario.
Correct answer : B
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18- Figure 1 is the MRI scan of a high school soccer player who
sustained a right knee injury during a game while making a cut toward
the ball. He felt a pop and his leg gave way. During physical examination,
as the knee is moved from full extension into flexion with an internal
rotation and valgus force, you notice a "clunk" within the knee. What is
the most likely biomechanical basis for the "clunk"?

A. n extension with internal

rotation/valgus force, the medial
tibial plateau is subluxated; with
flexion, the medial tibial plateau
reduces.
B. In extension with internal
rotation/valgus force, the medial
tibial plateau is reduced; with
flexion, the medial tibial plateau
subluxates.
C. In extension with internal
rotation/valgus force, the lateral
tibial plateau is reduced; with
flexion, the lateral plateau
subluxates.
D. In extension with internal
rotation/valgus force, the lateral
tibial plateau is subluxated; with
flexion, the lateral plateau reduces.
This patient sustained an isolated anterior cruciate ligament (ACL) injury
based upon the mechanism described and examination findings. The finding
that produces the “clunk” is the pivot-shift maneuver, which is positive in a
knee with an incompetent ACL. With an ACL-deficient knee in full extension
and internal rotation, the lateral tibial plateau subluxates anteriorly. As the knee
is flexed, the lateral tibial plateau slides posteriorly into a reduced position,
causing an audible clunk. Response D correctly describes the pathomechanics
that result in the audible clunk heard during the pivot-shift maneuver.
Responses A and B are incorrect because they describe the medial tibial
plateau, which is not part of the pathomechanics of the pivot shift. Response C
is incorrect because in extension, the lateral tibial plateau is subluxated, not
reduced.
Correct answer : D
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 19- Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain
with running for 5 months. What is the most appropriate treatment?

A. Arthroscopic or open reduction and

internal fixation
B. Arthroscopic loose body removal
C. Activity restriction for up to 9 months
D. Subchondral drilling

The MRI reveals an osteochondritis

dissecans (OCD) lesion that is unstable and
has a large osseous component. OCDs are
acquired lesions of the subchondral bone.
Patients with OCD initially report nonspecific
pain and variable amounts of swelling. Initial
radiographs help identify the lesion and
establish the status of the physes. An MRI scan is useful for assessing the
potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment
is appropriate for small, stable lesions in patients with open physes and focuses
on activity restriction for 3 to 9 months. Surgical treatment is necessary for
unstable or detached lesions. Stable lesions with intact articular cartilage can be
treated with subchondral drilling to stimulate vascular ingrowth, with
radiographic healing at an average of 4.4 months. Fixation is indicated for
unstable or hinged lesions, and stabilization of the fragment can be achieved
using a variety of implants through an arthroscopic or open approach. The
fragment should be salvaged, and the normal articular surface restored
whenever possible. In this patient, the fragment is unstable and therefore
stabilization of the fragment with internal fixation would be the best treatment
option.
Correct answer : A

20- A 20-year-old division 1 collegiate football player presents with an

acute left ankle injury. He states that as he was carrying the football, his
left foot became trapped under another player while his body was rotated
inward, causing a hyperexternal rotation moment to his ankle. He was
unable to return to the game secondary to pain and inability to bear
weight. Radiographs did not show any fracture. An external rotation
stress radiograph is shown in Figure 1. In comparison to screw fixation,
suture button fixation of this injury has demonstrated what clinical
outcomes? 16
 A. Decreased American Orthopaedic Foot
and Ankle Society (AOFAS) scores at 2-
year follow-up
B. Slower return to work
C. Increased rate of hardware removal
D. Decreased rate of syndesmotic
malreduction

The clinical vignette demonstrates an

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

21- A 26-year-old weightlifter has increasing pain in his left shoulder for 4
months. Nonsurgical treatment consisting of anti-inflammatory
medication, corticosteroid injections, and rest fails to alleviate his
symptoms. He undergoes an arthroscopic distal clavicle resection with
excision of the distal 8 mm of clavicle (Mumford procedure). Three
months after surgery, he reports mild pain and popping by his clavicle.
His clavicle demonstrates mild posterior instability on examination
without any obvious deformity on his radiographs. What structures were
compromised during his excision? 17
 A. Anterior and superior acromioclavicular joint ligaments
B. Posterior and superior acromioclavicular joint ligaments
C. Conoid ligament
D. Trapezoid ligament

The posterior and superior acromioclavicular ligaments provide the most

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

22- Figures 1 and 2 are the T2-weighted MRI scans of a 54-year-old

woman with medial knee pain and catching of 6 months’ duration. What
treatment option is most likely to be associated with a favorable
outcome?

A. Physical therapy
B. Meniscal repair
C. Meniscectomy
D. Reconstruction

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

22- A 24-year-old semiprofessional baseball player has noted increasing

medial elbow pain for the past 2 months. This has been associated with a
concomitant loss in velocity and control. He denies pain, numbness, or
tingling in the hand or digits. Examination demonstrates medial elbow
tenderness and swelling. Elbow range of motion is full. There is pain with
milking maneuver and valgus stress test. Tinel’s sign is negative over the
cubital tunnel, and there is no ulnar nerve subluxation. His MRI scan is
shown in Figure 1. After thorough discussion, the player elects to
undergo surgical intervention. What surgical variable has been
associated with inferior outcomes?
A. Use of palmaris autograft
B. Ulnar nerve transposition
C. Muscle-splitting approach
D. Use of a docking technique

The information and image provided

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

24- A 19-year-old collegiate lacrosse player stumbles to the sideline after

a collision with an opposing player during the first quarter of a game.
She complains of dizziness and is disoriented to place and time. She
initially shows disturbances in balance. The player is diagnosed as
having sustained a concussion and is removed from the rest of the
game. What should the coaching staff be advised of regarding the
player’s return to activity?

A. The player should be kept in dark, quiet rooms until she returns to
baseline function.
B. The player is eligible to return to play tomorrow if she remains
symptom-free.
C. The player needs to show return to baseline computerized
neuropsychological scores and then is cleared to play.
D. The player can return to sub-symptom threshold light aerobic
exercise after 24 to 48 hours if symptom-free.

Concussions can be defined as a traumatically induced transient disturbance

of brain function. There is currently no consensus regarding the definition of a
concussion, nor is a there a defined biomechanical threshold of a concussion.
Concussions occur when either linear and/or rotational forces are transmitted
to the brain. A complex disturbance in neurometabolic activity follows. Until
normal metabolic activity is restored, a second injury can result in worsening
metabolic changes and significant cognitive defects. Given this reasoning,
under no circumstances should an athlete be allowed same-day return to
physical activity. In terms of return to play, studies have shown that strict rest
may actually delay recovery and prolong symptoms. Most studies recommend
a 24 to 48 hour period of symptom limited cognitive and physical rest, followed
by sub-symptom threshold light aerobic activity.
Correct answer : D

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 25- A 19-year-old collegiate basketball player lands awkwardly after a
jump and feels a “pop” in the knee. She is unable to return to play and
develops a large effusion within 8 hours after injury. Physical
examination includes a positive Lachman's test and a positive lateral
McMurray's test. As part of her evaluation, her team physician orders
radiographs and an MRI scan. The abnormality present in Figure 1
represents injury to what structure?

A. Anterolateral ligament/capsule
B. Anteromedial bundle of the anterior
cruciate ligament (ACL)
C. Posterolateral bundle of the ACL
D. Lateral meniscus

The injury mechanism and examination

findings describe a classic ACL tear. The
positive lateral McMurray's test may
represent a lateral meniscus tear or may
result from the lateral compartment pivot-
shift contusion that typically
accompanies an ACL tear. The
anterolateral ligament (ALL) is an
accessory ligament coursing from the
lateral femoral epicondylar region to the
anterolateral tibial plateau. It tears
frequently, if not always, in association
with ACL tears. The abnormality shown in the radiograph is known as a “Segond
fracture.” This is a bony avulsion from the anterolateral tibial plateau and is
believed to represent avulsion of the ALL. A Segond fracture is thought to be
pathognomonic for the diagnosis of ACL tear.
Correct answr : A

27- A 16-year-old female high school soccer player presents with more
than one year of bilateral anterior and lateral lower extremity pain,
tightness and a heavy feeling in her lower legs that starts 5 minutes
after she begins running and resolves about 10 to 15 minutes after she
stops. She describes feeling as though her foot slaps down on the
ground when she is running. She failed extensive nonsurgical
management and was ultimately indicated for surgery. At the time of
endoscopically assisted treatment of this condition, damage to the
structure identified by an asterisk in Figure 1 would result in what
complication?

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A. Postoperative hematoma
B. Medial leg numbness
C. Weakness of foot eversion
D. Dorsal foot numbness

chronic exertional compartment

syndrome is commonly seen in
running athletes and causes a
constellation of lower leg pain,
weakness and/or
numbness/paresthesias. It is an
exercise-induced condition that
is thought to result from muscle
swelling during activity and
resultant hypoperfusion to the muscles and nerves within the compartment. The
description of this patient, with symptoms in the anterior and lateral areas of her
lower legs and the foot slap that she describes, indicates symptoms localized to
the anterior and lateral compartments as opposed to posterior compartment
symptoms. The anterior and lateral compartments would have been released in
this patient. The structure seen lays between two released muscular
compartments over the intermuscular septum and is the superficial peroneal
nerve, which pierces the fascia 10 to 12 cm proximal to the tip of the lateral
malleolus.

The structure that would cause medial leg numbness would be injury to the
saphenous nerve. Her symptom description is not consistent with posterior
compartment syndrome, and these compartments would not have been released
at the time of surgery. The structure is not a blood vessel.
Correct answer : D

27- Figures 1 and 2 are the MRI scans of a 57-year-old man who
dislocated his left shoulder after a fall while playing tennis. On
examination, he had full passive shoulder range of motion, but he was
unable to actively elevate his injured shoulder. Sensation was intact to
light touch over the lateral shoulder. What is the most likely etiology of
his shoulder weakness?

22
 A. Axillary nerve injury
B. Cervical radiculopathy involving the C6 nerve root
C. Massive rotator cuff tear with loss of the transverse force couple
D. Long head of the biceps tendon rupture with loss of superior
stabilizing effect

This patient has a massive rotator cuff tear resulting in disruption of the
transverse force couple between the subscapularis anteriorly and the
infraspinatus and teres minor posteriorly. These muscles provide dynamic
shoulder stability throughout active elevation, and loss of the force couple
produces a pathologic increase in translation of the humeral head and
decreased active abduction. Active shoulder elevation <90° in the presence of
full passive motion is termed pseudoparalysis. The most common neurologic
deficit after shoulder dislocation is isolated injury to the axillary nerve. This
patient's sensory examination suggests that the axillary nerve is intact.
Cervical radiculopathy is less common after shoulder dislocation but has been
reported. Conflicting evidence exists regarding the contribution of the long
head of the biceps tendon to glenohumeral stability. One study reported
minimal electromyographic activity in the biceps during ten basic shoulder
motions.
Correct answer : C

23
28- A 14-year-old gymnast misses her dismount off of the uneven bars,
hits the mat face first, and loses consciousness for about 15 seconds.
She is dazed and confused for several minutes. She does not complain
of pain, numbness, or weakness and she is moving all extremities
without deficit. The athlete and coach would like to return to competition
that day. What is the best next step?

A. Advise that loss of consciousness precludes same day return to play.

B. Order an urgent MRI scan; if findings are normal, she can return to
play.
C. Order neurocognitive testing; if findings are normal, she can return to
play.
D. If she is symptom-free after a 15-minute exertional test, she may
return to play.

The National Collegiate Athletic Association's health and safety guidelines

regarding concussion management recommend no return to play on the same
day of an injury. In particular, athletes sustaining a concussion should not
return to play the same day as their injury. Before resuming exercise, athletes
must be asymptomatic or returned to baseline symptoms at rest and have no
symptoms with cognitive effort. They must be off of medications that could
mask or alter concussion symptoms. Neurocognitive testing can be a helpful
tool in determining brain function even after all symptoms of concussion have
resolved. With a comparison baseline test, this evaluation, in conjunction with
a physician's examination, may reduce risk for second impact syndrome. The
athlete's clinical neurologic examination findings (cognitive, cranial nerve,
balance testing) must return to baseline before resuming exercise. Research
has shown that among youth athletes, it may take longer for tested functions to
return to baseline (compared with the recovery rate in adult athletes). Brain
MRI scan has no role in evaluating athletes for return to play in this situation.
Correct answer : A

29- A 19-year-old linebacker underwent a coracoid transfer procedure for

recurrent anterior glenohumeral instability. At his 1-week postsurgical
check-up, his incision is healing well; however, he reports numbness
over the lateral aspect of his forearm. What nerve may have been injured
during his surgery?

A. Axillary
B. Median
C. Musculocutaneous
D. Radial
24
The patient has sustained an injury to the musculocutaneous nerve, which is
at risk during a coracoid transfer procedure. The terminal branch of this nerve
is the lateral antebrachial cutaneous nerve of the forearm. The axillary nerve
provides sensation to the lateral arm. The median nerve provides sensation
more distally. The radial nerve is not likely to be injured with a coracoid transfer
procedure; if it is, the injury would result in numbness near the wrist.in the
posterior forearm.
Correct answer : C

30- A 32-year-old volleyball player has dull posterior shoulder pain. An

examination reveals moderate external rotation weakness with his arm at
his side but normal strength on supraspinatus isolation. Deltoid and
supraspinatus bulk appear normal, although there appears to be mild
infraspinatus atrophy. Sensation is normal throughout the shoulder and
shoulder girdle. What is the most likely diagnosis?

A. Calcified transverse scapular ligament

B. Parsonage-Turner syndrome
C. Spinoglenoid notch cyst
D. Quadrilateral space syndrome

This clinical scenario describes a patient with an isolated injury affecting the
infraspinatus muscle. The anatomic location of such a lesion would be at the
spinoglenoid notch, at which the suprascapular nerve may be compressed
distal to its innervation of the supraspinatus but proximal to the infraspinatus
innervation. A calcified transverse scapular ligament would also affect the
suprascapular nerve but is proximal to the innervation of both muscles.
Quadrilateral space syndrome would affect innervation of the deltoid (and teres
minor). Parsonage-Turner syndrome is a more diffuse, and often severely
painful, brachial plexus neuropathy.
Correct answer : C

31- A patient underwent a right hip arthroscopy, CAM resection, and

labral repair while positioned supine on a fracture table with a perineal
post. The leg was in traction for 4 hours, and no intrasurgical
complications were noted. At the 2‐week follow‐up appointment, the
patient was experiencing numbness and tingling in the perineum on the
surgical side and noted pain predominantly while sitting. What is the
likely cause of these symptoms?

25
A. Traction injury to the sciatic nerve
B. Traction injury to the femoral nerve
C. Compression injury to the pudendal nerve
D. Direct injury to the lateral femoral cutaneous nerve

Although all of these responses are known complications related to hip

arthroscopy, the symptoms of perineal numbness and pain associated with
prolonged traction time indicate a compression injury to the pudendal nerve
against the perineal post used to provide counter traction. Perineal numbness
usually occurs on the surgical side, with pain in the area of the anus to the
penis/clitoris. Pain is predominantly experienced while sitting, but is relieved
when sitting on a toilet. Pain can be relieved with a diagnostic pudendal nerve
block. This injury is not unique to hip arthroscopy; it also is described in the
trauma literature. To prevent compression‐type injuries, a well‐padded post
larger than 9 cm in diameter should be positioned against the medial thigh.
Traction force should be kept to a minimum and the extremity positioned in
slight abduction. Continuous traction time should not exceed 2 hours, with
intermittent traction used during prolonged procedures.
Correct answer : C

32- An 18-year-old female collegiate soccer player presents with right

knee pain and swelling after a noncontact pivoting injury during a game.
Four years prior, she underwent successful anterior cruciate ligament
(ACL) reconstruction with hamstring autograft on the same knee.
Physical examination and MRI scan are consistent with ACL graft rupture
without associated meniscal tears. What statement can be made about
the graft options in counseling this patient on revision ACL
reconstruction?
A. Two-year sports function, as measured by International Knee
Documentation Committee (IKDC), is better with allograft.
B. At 1-year follow-up, there is greater knee laxity with the use of
autograft.
C. There is a higher infection rate with autograft.
D. Risk of graft rerupture is higher with allograft.

Based upon large multicenter studies and registries including the MARS group
and Danish registry, re-tear rates after revision ACL reconstruction are higher
when allograft is used as compared with autograft. Sport function, as assessed
by the IKDC, is better with the use of autograft. Furthermore, no differences in
retear rates or function have been shown between soft tissue and bone
patellar tendon bone autograft.
Correct answer : D
26
33- An investigation studying whether physical therapy or subacromial
injection can be successfully used to treat shoulder pain is conducted.
Two groups are identified. One group is prescribed physical therapy,
while the other receives a subacromial injection. The groups have similar
baseline demographics and shoulder pathologies. Ten patients are
randomized in each group and findings show that there is no significant
difference in any patient-reported outcome measure. An increase in
sample size would reduce the risk of what parameter?

A. Type I error
B. Type II error
C. Selection bias
D. Recall bias

This study represents a randomized clinical trial with two groups. However, the
sample size is small, increasing the risk for type II error, or false-negative
findings. Increasing the number of patients in each group would lead to
increased power, thereby reducing the risk of a type II error. A type I error is
the rejection of a true null hypothesis (false-positive). A randomized trial
reduces the risk of selection bias as patients are assigned to groups in a
random fashion. Recall bias occurs when participants do not accurately
remember previous events or experiences from the past.
Correct answer : B

34- A football player injures his knee when he is tackled and falls
awkwardly. He does not note any discreet “pop,” but pain prevents him
from returning to the game. An effusion is noted the following day and an
MRI scan is ordered. Selected images are shown in Figures 1 through 3.
Based on these images, physical examination findings likely include

27
A. positive Lachman test, normal posterior
drawer, positive pivot shift.
B. positive Lachman test, positive posterior
drawer, negative pivot shift.
C. normal Lachman test, positive posterior
drawer, positive pivot shift.
D. normal Lachman test, positive posterior
drawer, negative pivot shift.

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

35- A 20-year-old collegiate pitcher has had increasing pain over his
medial elbow for 3 months. He has point tenderness over his medial
epicondyle and reproduction of his symptoms with a moving valgus
stress test. What phase of the throwing cycle most likely will reproduce
his symptoms?
A. Early cocking
B. Late cocking
C. Acceleration
D. Deceleration

This patient is experiencing soreness over his medial (ulnar) collateral

ligament. Valgus overload is likely to reproduce his symptoms and is most
pronounced during the late cocking phase of the throwing cycle. In wind up,
very little elbow torque is required. In early cocking, the arm is getting loaded
and maximum valgus is not yet achieved at the elbow. In acceleration and
deceleration, more force is generated at the level of the shoulder joint.
Correct answer : B

28
36- Figures 1 and 2 are radiographs of a 25-year-old man who has had
persistent right hip pain for over a year. There was an acute injury and
the pain has progressively worsened and is now 9/10 in severity. The
pain interferes with activities of daily living and the patient's capacity to
participate in sports. The patient has failed nonsurgical treatment in the
form of physical therapy and activity modification. On physical
examination, forward flexion is limited to 90°, internal rotation is limited
to 10°, and flexion adduction internal rotation examination is positive.
The hip pain was relieved on physical examination after intra-articular
administration of local anesthetic. The patient had an MRI and CT scan.
What is the most appropriate surgical option?

A. Hip arthroscopy with labral repair, rim trimming and femoral

osteochondroplasty
B. Hip arthroscopy with labral repair and periacetabular osteotomy
with femoral osteochondroplasty
C. Open surgical hip dislocation with labral repair, rim trimming and
femoral osteochondroplasty
D. Hip arthroscopy with labral repair and reverse periacetabular
osteotomy with femoral osteochondroplasty
The radiographs show a large cam lesion on the anterosuperior aspect of the
femoral head, and this is confirmed by high alpha angle (76). Cam and pincer
lesions commonly cause labral tears and lead to femoroacetabular
impingement. After failure of nonoperative treatment, surgery involves hip
arthroscopy, labral repair or debridement, rim trimming (resection of
acetabulum), and femoral osteochondroplasty. A periacetabular osteotomy is
the preferred surgery in dysplastic patients. Dysplasia is defined as
undercoverage of the femoral head, typically a center-edge angle <25.
Reverse periacetabular osteotomy is used for a true retroverted acetabulum.
Lastly, open dislocation is the preferred method when the hip deformity is too
severe to treat arthroscopically or when the femoral head is significantly
overcovered by the acetabulum (center-edge angle >40).
Correct answer : A 29
A 50-year-old right-hand dominant man presents after a traumatic fall on
an outstretched right upper extremity. Based upon the MRI scans shown
in Figures 1 and 2, what examination test would be abnormal?

A. Belly press
B. Hornblower's test
C. External rotation strength
D. Empty can test

A fall on an outstretched upper extremity can commonly result in a traumatic

rotator cuff tear. The images require appropriate interpretation of an acute
subscapularis tendon rupture with medial subluxation of the biceps tendon.
Subscapularis tendon tears result in a positive belly press or lift-off test.
Hornblower's tests for external rotation strength with the arm abducted 90°
(teres minor weakness). Empty can tests supraspinatus strength. External
rotation strength with the arm at the side tests for infraspinatus weakness.
Correct answer : A

38- Videos 1 and 2 are the coronal plane MRI scan and arthroscopic
evaluation of a 48-year-old woman with 2 weeks of posterior knee pain
after feeling a “pop” in the knee while climbing stairs. Physical
examination reveals passive range of motion of +5° to 120°, with pain
limiting her in terminal extension. Failure of surgical repair of the injured
structure is most associated with

A. poor vascularity of the injured tissue.

B. BMI >35 kg/m^2.
C. valgus alignment >5°.
D. repair technique. 30
The MRI scan and surgical video are showing an example of a posterior
medial meniscal root tear/avulsion. Many studies have shown successful
treatment of these tears with repair using various techniques and minimal
progression to osteoarthritis (OA). Most studies exclude patients with high
BMI. Brophy and associates demonstrated in their series that high BMI was
associated with higher rates of clinical OA and need for subsequent surgery.

Multiple studies in the literature demonstrate good results with a variety of

techniques. A valgus alignment in this setting would be considered protective,
as opposed to a varus alignment >5°, which has also been associated with
worse outcomes. The vascularity of the meniscus is consistently poor
throughout most of its volume, including the root, and is not considered to be
significantly different from person to person and should affect all root repairs
equally.
Correct answer: B

39- A 47-year-old man who is an avid tennis player and laborer has had
one year of shoulder pain and weakness. His pain occurs at night and
radiates to the deltoid laterally. The patient denies any anterior based
pain. He reports no prior surgeries and has been managed with steroid
injections and physical therapy. On examination, he has full passive
motion with significant weakness with external rotation. His neurologic
examination is unremarkable. MRI evaluation reveals a posterior-
superior rotator cuff tear with Goutallier grade 4 fatty infiltrate in the
supraspinatus and infraspinatus with retraction beyond the glenoid. He
is concerned about the lack of rotation of his arm and reports that this
disability creates significant disability with his occupation as a mason.
What is the best next step?
A. Shoulder arthroscopy and subacromial
decompression
B. Tendon transfer
C. Total shoulder arthroplasty
D. Reverse total shoulder arthroplasty

In younger active patients, tendon transfer is considered a preferable

treatment option. The patient has failed a course of nonoperative
management. Subacromial decompression may offer pain relief but may not
be advisable in a patient with rotator cuff deficient shoulder. A total shoulder
arthroplasty requires functionality of the supraspinatus and infraspinatus. A
reverse total shoulder is an option to alleviate pain and perhaps improve
forward flexion height and strength; however, reverse arthroplasty would not
improve external rotation in this patient, and there is concern for longevity of
the implant in younger patient populations.
Correct answer : B 31
40- A multicenter prospective study of 7,500 patients that assesses
differences in rerupture rates after anterior cruciate ligament (ACL)
reconstruction using hamstring autograft shows a decreased rate of
rerupture when the graft diameter is >9.0 mm versus <9.0 mm (p = 0.05).
A follow-up study done at a single institution of 200 patients fails to show
any difference in rerupture rates based upon graft size. If the multicenter
trial is assumed to be accurate, which statistical error occurred in the
follow-up study?

A. Type-I error
B. Type-II error
C. Selection bias
D. Alpha error

Type-II errors, or beta errors, occur when the null hypothesis is accepted and
should have been rejected. An underpowered study is at risk of this type of
error. Power is defined as 1-probability of a type-II (beta error), and this is
generally set at a level of 80% for most studies. The type-II error occurs
when a study concludes that there is no association between the studied
variables when in fact one exists. The type-I error, or alpha error, is defined
as rejecting the null hypothesis when it should have been accepted. Alpha
errors occur when a study suggests an association does exist when in reality
it does not. Selection bias occurs when proper randomization is not
achieved and therefore, the study cohort is not representative of the
population intended to be analyzed.
Correct answer : B

41- A 17-year-old male soccer player sustains repeated lateral patellar

dislocations refractory to physical therapy, bracing, and taping. After a
workup including radiographs and MRI, the orthopaedic surgeon
considers an isolated tibial tubercle osteotomy (TTO). A 60-degree
anteromedialization is planned to address instability and to unload the
patellofemoral joint. What is a relative contraindication to this
procedure?
A. Grade III chondrosis of the proximal patella
B. Caton-Deschamps ratio of 1:1
C. Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm
D. Q angle of 17°

TO is a common treatment for patellofemoral instability. The angle of

correction must be customized to each patient’s anatomy. For this patient,
the orthopaedic surgeon plans an osteotomy that will both anteriorize and
medialize the tubercle. This will consistently result in a change of 32
patellofemoral kinematics and contact pressures. Medialization decreases
lateral and increases medial patellofemoral contact pressures, and
anteriorization shifts contact pressures from distal to proximal. Significant
anteriorization may not be desired in a patient with proximal patellar
chondrosis unless a concomitant chondral procedure is performed as well. The
patellar height (Caton-Deschamps ratio) is normal, precluding the need for
distalization but not medialization. The TT-TG distance, at more than 20 mm, is
a strong indication for osteotomy. The Q angle, although a less precise
indicator of malalignment, is also elevated and would be considered an
indication for osteotomy.
Correct answer : A

42- During preseason training camp, a 23-year-old football player comes

to the sideline complaining of nausea, dizziness and headache after a 2-
mile run. Vital signs include blood pressure 110/80, heart rate 115 bpm
and core body temperature of 39°C (102°F). He is otherwise alert and
oriented. What is the recommended initial treatment?

A. Immediate ice water bath immersion

B. Immediate return to training
C. Rehydration with a carbohydrate-
electrolyte beverage
D. Emergent transportation to a local
emergency department

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

43- Surgical repair of the injury shown in the MRI scans in Figures 1
through 4 through a single-incision approach has a higher incidence of

33
 A. heterotopic ossification.
B. posterior interosseous nerve injury.
C. secondary surgery.
D. lateral antebrachial cutaneous nerve
injury.

The MRI scans show a distal biceps tendon avulsion with significant retraction.
When addressing these injuries, a single-incision approach has been
associated with an increased risk of lateral antebrachial cutaneous nerve
injury. A two-incision approach has been associated with an increased risk of
heterotopic ossification, second surgeries and posterior interosseous nerve
injury.
Correct answer : D

34
 44- Figure 1 is the T2 coronal MRI scan of a 52-year-old woman with a 6-
month history of shoulder pain. She does not recall a history of trauma.
Physical therapy is recommended. What is the most significant predictor
of failure of nonoperative treatment?

A. Tear size
B. Pain scale score
C. Strength deficit
D. Patient expectations

The MRI reveals a large full thickness

supraspinatus tear. A large, prospective
study showed that physical therapy can
be effective in the treatment of
atraumatic full-thickness rotator cuff
tears. Patient expectations regarding
the role of rehabilitation were the
strongest predictor of surgery. Other
factors associated with surgery were higher activity level and not smoking.
Anatomic features of the rotator cuff tear and the severity of patient’s reported
pain did not predict failure of nonoperative treatment. Patients who have low
expectations regarding the effectiveness of physical therapy are more likely to fail
nonoperative treatment.
Correct answer : D

45- Figures 1 through 3 are the MRI scans of a 51-year-old active man
who injured his right shoulder after a fall while sailing 4 days ago.
Optimal surgical management of the patient’s pathology is expected to
involve

35
A. supraspinatus, infraspinatus and
subscapularis repair and biceps
tenodesis.
B. supraspinatus and subscapularis
repair and biceps tenodesis.
C. supraspinatus and infraspinatus
repair.
D. supraspinatus, infraspinatus and
teres minor repair.

The MRI scans show a full-thickness tear of the supraspinatus, infraspinatus,

subscapularis and medial subluxation of the long head of biceps tendon. Teres
minor appears intact on the images. Although the tear of the subscapularis is
not as well-visualized, medial subluxation of the long head of biceps is reliably
correlated with a subscapularis tear.
Correct answer : A

46- A 16-year-old swimmer has right shoulder pain with activity. She
describes the continued sensation that her shoulder is "loose." She has
been in physical therapy for 7 months to work on strengthening the
muscles around her shoulder and scapula. She denies being able to
voluntarily dislocate her shoulder. Upon examination, you can feel the
humeral head slide over the glenoid rim both anteriorly and posteriorly
with the load and shift test. She has a grade III sulcus sign. What is the
most appropriate next step?
A. Arthroscopic superior labrum anterior to
superior repair
B. Arthroscopic Bankart repair
C. Latarjet procedure
D. Capsulorrhaphy

Nonsurgical treatment with activity modification and physical therapy is

generally considered the first-line approach for young athletes with
multidirectional instability (MDI) of the shoulder. Physical therapy focuses on
exercises to strengthen the scapular stabilizers and rotator cuff muscles and
restore scapulohumeral rhythm. Although a definitive length of time to assess
physical therapy failure is not known, many surgeons believe that a patient
with MDI should undergo at least 6 months of physical therapy and activity
36
modification before considering surgery. Although an open inferior capsular
shift has historically been considered the gold standard for surgical treatment
for MDI, studies have shown good success rates for arthroscopic
capsulorrhaphy. Arthroscopy can allow a surgeon to assess all intra-articular
structures and address a patient’s particular problem based on arthroscopic
findings.
Correct answer : D

47- A 12-year-old boy who plays multiple sports has had insidious-onset
heel pain while running for 4 months. On examination, he had ankle
dorsiflexion of 5°. The squeeze test result was positive and the
Thompson test result was negative. He has no pain with forced ankle
plantar flexion. What is the most likely diagnosis?
A. Achilles rupture
B. Gastrocnemius strain
C. Calcaneal apophysitis
D. Os trigonum syndrome

Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in

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

48- A 21-year-old female cross-country runner is brought to the medical

tent after completing her run. The race took place during an
unseasonably warm day in August. The patient is disoriented upon her
arrival to the tent and cannot state the exact date. What is the next most
appropriate course of action?

37
A. Administration of intravenous fluids
B. Immediate transport by ambulance to the closest hospital
C. Immersion in a cold-water ice bath
D. Temperature check with an oral thermometer

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

49- A 14-year-old male high school wrestler presents to the training

room with the lesions seen in Figures 1 and 2. He reports that he had a
low-grade fever last week. Prior to the appearance of the lesions, he
was experiencing some itching and burning in the affected area. What
is the most appropriate treatment for this condition?

A. Oral trimethoprim-sulfamethoxazole
B. Oral acyclovir
C. Oral fluconazole
D. Topical mupirocin

38
The images are consistent with herpes gladiatorum. This condition is caused
by herpes simplex type 1 and occurs in 2% to 7% of wrestlers. It is spread via
direct skin contact and is generally seen on the head, neck and shoulders. The
lesions are characterized by fluid-filled blisters on an erythematous base.
Return to play is permitted after the patient has been treated for 5 days with
anti-viral medications, no new lesions are seen within 72 hours and previous
active lesions have scabbed over.
Correct answer : B

50- A 24-year-old former high school wrestler had anterior cruciate

ligament (ACL) reconstruction with hamstring autograft 6 years ago. He
now experiences daily instability of his knee with routine activities
including walking. Examination reveals a grade 3+ Lachman test with a
soft endpoint, varus laxity at 30°, and a positive dial test at 30° that
dissipates at 90° of knee flexion. He has mild medial joint line
tenderness. When walking, there is a slight varus thrust. Radiographic
alignment is neutral. What treatment is most likely to lead to a successful
outcome?

A. Revision ACL reconstruction

B. Revision ACL reconstruction and posterior cruciate ligament (PCL)
reconstruction
C. Revision ACL reconstruction and posteromedial corner
reconstruction
D. Revision ACL reconstruction and posterolateral corner
reconstruction

The patient underwent an ACL reconstruction that has now failed. Based on
his examination, he also has a posterolateral corner injury. Because this
concomitant injury was not treated, the patient had undue strain on his graft,
resulting in ultimate failure. Hamstring grafts are as effective as other graft
types for ACL reconstruction. The medial meniscus provides secondary
stabilization to the knee; however, this patient has a missed lateral
ligamentous injury, and meniscus tears do not result in the development of a
varus thrust. An unrecognized PCL tear likely results in mild-to-moderate
medial and patellofemoral osteoarthritis without significant lateral laxity and
thrust.
Correct answer : D

39
51- Figure 1 is the anteroposterior radiograph of a 20-year-old dancer
who fell during his routine and injured his right foot. What is the most
appropriate treatment?

A. Closed reduction and cast

B. Open reduction and internal fixation
C. In situ percutaneous pinning
D. Posterior splint immobilization and controlled ankle motion (CAM) walker
ambulation

This patient has sustained a Lisfranc fracture dislocation of the forefoot. To

fully restore foot function, an open reduction and internal fixation should be
performed to anatomically reduce this dislocation. Closed reduction is unlikely
to restore normal foot biomechanics and would likely result in delayed arthritis
and joint incongruity. Posterior splint immobilization, CAM walker ambulation,
and in situ percutaneous pinning will not adequately reduce the fracture and
restore normal function to the foot.
Correct answer : B

52- A 38-year-old woman underwent left knee anterior cruciate ligament

(ACL) reconstruction with patellar tendon autograft and medial meniscus
repair 11 years ago. She has no complaints of instability since surgery.
She presents with left knee pain, swelling and the inability to extend her
knee after getting up from a kneeling position one week prior. She
reports feeling a pop in her knee at the time of injury. On examination
she lacks 5° of extension and has a symmetric Lachman test. Figure 1 is
the radiograph of her knee. Figures 2 through 4 show the findings at the
time of arthroscopy. What is the most appropriate treatment?

40
 A. artial lateral meniscectomy
B. Revision ACL reconstruction and medial meniscus repair
C. Lateral meniscus repair
D. Partial medial meniscectomy

The arthroscopic images and the patient's history are consistent with a bucket
handle tear of the medial meniscus. The ACL graft is intact and well-
vascularized as shown in the arthroscopic image. The morphology of the
meniscus and that the images are one of a left knee allows the determination
that this is a tear of the medial and not the lateral meniscus. The image of the
reduced bucket handle medial meniscus tear reveals plastic deformation and
a large overlapping peripheral remnant that would make the possibility of
healing after revision medial meniscus repair unlikely or suboptimal. The best
treatment option for this patient is partial medial meniscectomy.
Correct answer : D
41
53- A 19-year-old running back lands directly on his anterior knee after
being tackled. He has mild anterior knee pain, a trace effusion, a 2+
posterior drawer, a grade 1A Lachman, no valgus laxity, and negative dial
tests at 30° and 90°. What is the best treatment strategy at this time?

A. Physical therapy with a focus on quadriceps strengthening

B. Physical therapy and delayed posterior cruciate ligament (PCL)
reconstruction
C. PCL reconstruction
D. PCL and posterolateral corner reconstruction

This patient has likely sustained an isolated PCL injury. The examination is
consistent with a grade II injury to the PCL. In patients with isolated PCL
injuries, such as this scenario, the best initial option is nonsurgical treatment
and return to play as symptoms subside and strength improves. Physical
therapy and delayed PCL reconstruction is not the answer because this patient
can likely be treated without surgery. The absence of valgus laxity and
negative dial testing findings suggest that an injury to the posteromedial and
posterolateral corners has not occurred. Initial nonsurgical treatment is
indicated for this patient. If he completes rehabilitation and experiences
persistent disability with anterior and/or medial knee discomfort or senses the
knee is "loose," PCL reconstruction should be considered at that time.
Correct answer : A

54- Figure 1 is the MRI scan of a 61-year-old man who had left shoulder
pain with a massive rotator cuff tear. Active forward elevation was 120°.
Arthroscopic examination revealed that the rotator cuff tear was
irreparable. The articular surfaces of the glenohumeral joint have a
normal appearance without significant degenerative changes. What is
the most appropriate treatment option for pain relief in this patient?

A. Biceps tenotomy
B. Loose body removal
C. Latissimus dorsi transfer
D. Reverse total shoulder arthroplasty

42
The MRI scan shows medial subluxation of the biceps tendon. Biceps
tenotomy has been an effective treatment option for patients with large to
massive rotator cuff tears when the tear is irreparable and pain is the main
symptom. There is no evidence of a loose body on the MRI. Patients with
severe external rotation deficit and a deficient teres minor may experience a
better functional result with latissimus dorsi transfer. Reverse total shoulder
arthroplasty is an option in patients with cuff tear arthropathy and
pseudoparalysis.
Correct answer : A

55- Figure 1 is the MRI scan of a 52-year-old runner who has right knee
pain that has been occurring 10 minutes into her run for 2 months. On
examination, she has tenderness over the lateral epicondyle. Her Ober
test result is positive. What is the most appropriate initial treatment?

A. liotibial band bursectomy

B. Z-lengthening of the iliotibial band
C. Partial excision of the iliotibial band
D. Home stretching program and cross
training

Iliotibial band syndrome (ITBS) is a common cause of lateral knee pain in

runners. Potential etiologies for the pain include repetitive friction,
compression, and bursal inflammation. An Ober test is used to assess iliotibial
band tightness. With the patient lying on the unaffected side, the affected leg is
abducted and extended. The test result is positive if the examiner is unable to
adduct the leg from this position. An MRI scan can be helpful in making the
diagnosis, but a negative MRI scan does not rule out ITBS. Studies have
reported increased signal intensity on T2-weighted images deep to the iliotibial
band adjacent to the lateral epicondyle, with thickening of the iliotibial band.
Nonsurgical treatment is most appropriate initially and involves activity
modification, ice, anti-inflammatory medications, and stretching. Corticosteroid
injection to the iliotibial bursa is also an option to treat acute pain. After the
initial inflammation improves, a strengthening program is started. Multiple
surgical procedures have been described for recalcitrant cases, including
iliotibial band excision, Z-lengthening, and iliotibial band bursectomy.
Correct answer :D
43
56- A 43-year-old mechanic presents with acute onset right elbow pain
after attempting to lift a heavy car bumper while at work during which he
felt an immediate sharp pain and snapping sensation deep within the
elbow. An MRI scan of his injury is shown in Figure 1. When considering
operative management for this injury, what operative technique has been
shown to increase supination strength?

A. Utilization of the single-incision technique

B. Repairing the tendon in an ulnar position on the radial tuberosity
footprint with the forearm in supination
C. Repairing the tendon through a bone-tunnel technique
D. Utilizing a cortical suspensory button for tendon fixation

The increase in available options for fixation regarding distal biceps tendon
repair has led to an abundance of literature comparing various surgical
techniques over the past 20 years. Distal biceps tendon tears most commonly
occur in the dominant extremity of males in their 40s. Nonoperative
management leads to a 40% loss of supination strength and a 30% loss in
flexion strength. The injury frequently occurs during eccentric contraction of the
biceps muscle. The tendon insertion is comprised of both the long- and short-
head insertions. The short head inserts distally on the radial tuberosity acting
as a better flexor, whereas, the long head inserts on the apex of the radial
tuberosity acting as a better supinator.

Prud’homme-Foster and associates demonstrated that a more anatomic

reconstruction on the ulnar aspect of the radial tuberosity is essential to
restore maximal supination strength. Both single- and dual-incision techniques
44
have demonstrated excellent outcomes; however, each has been shown to
have a unique complication profile, which should be taken into consideration
when considering operative intervention.

In a meta-analysis, Amin and associates demonstrated that lateral

antebrachial cutaneous neuropraxia is the most common complication of the
single-incision technique and heterotopic ossification was the most common
complication of the dual-incision technique. The complication rate following
single-incision technique is higher than that of the dual-incision technique
secondary to the high frequency of lateral antebrachial cutaneous nerve
neuropraxia.

In a study of complications over 784 procedures, Dunphy and associates

demonstrated higher rates of posterior interosseus nerve palsy, heterotopic
bone formation and reoperation with the dual-incision technique. There was no
significant difference in tendon rerupture rates. Biomechanical studies have
demonstrated increased pullout strength with the use of a cortical suspensory
button versus transosseous bone tunnels or suture anchors.
Correct answer : B

57- A 21-year-old Division 1 collegiate track and field athlete has had
acute worsening right anterior shin pain for the past week. He reports
having shin pain since sophomore year of high school but has continued
to run through the pain. Upon presentation, he was diagnosed with a
tibial stress fracture and underwent 8 weeks of nonoperative treatment
and correction of vitamin D levels. His follow-up radiograph is shown in
Figure 1. In counseling the patient about his surgical treatment options,
what information should be discussed regarding the risks of
compression plating versus intramedullary (IM) nailing in the treatment
of this injury?

45
 A. Compression plating results in a lower rate of symptomatic
hardware.
B. IM nailing allows for faster time to radiographic union.
C. Risk of fracture progression or completion is greater after
compression plating.
D. There is a lower rate of anterior knee pain after compression plating.

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

58- A star high school pitcher comes to see you in clinic for shoulder
pain with throwing. He has been a pitcher since Little League. He has had
pain for approximately one year, typically not during normal activities.
On examination, his scapula is protracted on his throwing arm, and he
has a positive Mayo dynamic shear test. Figure 1 shows the point in the
throwing motion when he is having pain. Figure 2 is an arthroscopic
image from the posterior portal. What phenomenon is most directly
responsible for the findings on examination and on arthroscopic
evaluation?

46
 A. Subacromial impingement
B. Internal impingement
C. Anterior instability
D. Posterior instability
Internal impingement is the direct contact of the undersurface of the posterior
supraspinatus on the posterosuperior labrum in late cocking during the typical
throwing motion. This can result in labrum tearing, undersurface rotator cuff
tearing or both in their respective locations (as illustrated in Figure 2). Anterior
glenohumeral instability (or microinstability) can happen in the setting of
throwing for many years as the anterior capsule stretches in the throwing
position. This is thought to be exacerbated by posterior capsule tightness that
can occur from repetitive microtrauma and scarring during the latter stages of
throwing. Posterior instability and subacromial impingement are not typical
pathology in the thrower's shoulder and are not exemplified in the throwing
motion or arthroscopic images.
Correct answer : B

59- Figure 1 is the MRI scan of a 16-year-old high school football player
who sustained a traumatic dominant shoulder dislocation during a game.
On-field reduction was unsuccessful. The shoulder is reduced in the
emergency department, and the player and his family follow-up in clinic.
Which factor is most associated with failure of surgical treatment in this
scenario?

47
 A. Dominant shoulder
B. Age
C. Size of labral tear
D. Periosteal stripping

The MRI scan reveals a Bankart

lesion. Arthroscopic Bankart repair
failure likelihood is increased by
numerous factors. Age, number of
recurrences, and bony defects are
most associated with failure of
arthroscopic repair. Shoulder
dominance, amount of periosteal
stripping, and difficulty of reduction
do not correlate with increased
recurrence risk following surgery.
Correct answer : B

60- Figure 1 is the radiograph of a 13-year-old right-hand dominant male

baseball pitcher who presents with new onset right shoulder pain. Over
the past month, he has participated in several tournaments. He was
unable to complete his most recent game secondary to continued pain
while throwing. Examination reveals a healthy, adolescent male in no
apparent distress. Range-of-motion examination of the bilateral
shoulders is symmetric with mild pain at the end points of motion. He
reports pain on palpation over the lateral aspect of his deltoid. What
pathologic process is most likely responsible for this patient's pain?

A. Posterior capsular tightness

B. Excessive humeral retroversion
C. Internal impingement of the articular
side of supraspinatus
D. Microtrauma to proximal humeral
physis

48
The clinical vignette describes a 13-year-old boy with Little Leaguers’ shoulder.
This is an injury to the proximal humerus growth plate specifically involving the
hypertrophic zone of the physis. This condition is considered a Salter-Harris 1
injury to the proximal humerus physis and most commonly affects male
throwing athletes ages 11 to 16. The proximal humerus growth plate closes
between the ages of 18 to 21. The mechanism of injury involves microtrauma
to the growth plate from exposure to excessive rotational torque and
distraction forces during the late cocking; early acceleration and deceleration
phases of throwing, respectively. High pitch counts have been implicated as
risk factors for injury. The diagnosis is frequently made clinically; however,
radiographs of the shoulder may reveal widening of the proximal humeral
physis in comparison with the contralateral side. Treatment includes cessation
of throwing for 3 to 6 months. The patient should be asymptomatic prior to
return to a throwing program. Physical therapy and a program of guided return
to throwing that enforces proper pitching mechanics can be helpful during a
return to play. Following established pitch counts and allowing for appropriate
rest before throwing can help to prevent future recurrence.
Correct answer : D

61- A 25-year-old woman has lower leg pain during exercise without
numbness, tingling, or weakness. The symptoms resolve within 45
minutes of exercise cessation. Compartment pressure measurements
obtained 1 minute after exercise are shown in Figure 1. She undergoes
anterior compartment fasciotomy with complete resolution of symptoms.
Two years later, she has recurrent pain and tightness with exercise.
Radiographs, a technetium bone scan, and noninvasive vascular study
findings are normal. Compartment pressure measurements obtained 1
minute after exercise are shown in Figure 2. What is the most likely
etiology for her recurrent symptoms?

A. Misdiagnosis
B. Hematoma formation
C. Postsurgical fibrosis
D. Failure to recognize involvement of other compartments
49
Exertional compartment syndrome involves an increase in compartment
pressure caused by exercise or sports activity that restricts blood flow in the
compartment, resulting in pain with continued activity. Compartment pressures
of at least 15 mm Hg measured at rest, at least 30 mm Hg measured 1 minute
after exercise, and at least 20 mm Hg measured 5 minutes after exercise are
diagnostic. Surgical fasciotomy for exertional compartment syndrome is
successful for the majority of patients, but recurrence rates as high as 20%
have been reported. Scar formation within the fascial defect can result in
recurrent symptoms and/or nerve entrapment, and recurrence is typically
observed after an initial symptom-free period. In a series of 18 patients,
recurrent symptoms occurred at a mean of 23.5 months after the index
procedure. Other potential causes of recurrence include inadequate fascial
release, failure to recognize involvement of other compartments, nerve
compression, and misdiagnosis. Surgical complications after fasciotomy
include hemorrhage leading to excessive fibrosis, neurovascular injury, and
hematoma or seroma formation.
Correct answer : C

62- Figure 1 is the T2 axial MRI scan of a 21-year-old man who was
injured while playing for his college football team. His pain was
aggravated with blocking maneuvers and alleviated with rest, and he had
to stop playing because of the pain. What examination maneuver most
likely will reproduce his pain?

A. Forward elevation in the

scapular plane
B. External rotation and
abduction
C. Flexion, adduction, and
internal rotation
D. Flexion and abduction

This patient has a mechanism of injury and MRI scan consistent with a
posterior labral tear and posterior instability. Flexion, adduction, and internal
rotation produce a net posterior vector on the glenohumeral joint and should
reproduce this patient's symptoms. Pain or instability with the arm elevated in
the scapular plane describes an impingement sign. Pain or instability with the
arm in external rotation and abduction describes the apprehension sign. Pain
or instability with the arm in flexion and abduction is a nonspecific finding.
Correct answer : C
50
63- Figures 1 and 2 are the radiographs of a 55-year-old man who has a
3-year history of right shoulder pain. He has maximized nonoperative
management and is interested in operative treatment. He had an open
Bankart repair 20 years ago and did well until a few years ago. What is
most important to know when deciding on the best surgical treatment for
this patient?

A. Range of motion
B. Infraspinatus strength
C. Activity level
D. Quality of the subscapularis

The radiographs show severe osteoarthritis of the shoulder. The best

surgical option would be an arthroplasty. The major determining factor for
which type of arthroplasty to choose is the integrity of the rotator cuff
tendons. Although the radiographs do not reveal any obvious signs of rotator
cuff failure, the patient had had an open Bankart 20 years ago. The integrity
of the subscapularis tendon following a previous open shoulder procedure is
crucial in deciding which type of arthroplasty to consider. Range of motion
and infraspinatus strength do not affect the decision-making process,
assuming the rotator cuff is intact. Activity level can be important when
deciding whether to proceed with an arthroplasty, but it is not as important as
the rotator cuff integrity when choosing which arthroplasty to use.
Correct answer : D

51
65- Which group experiences the highest rate of anterior cruciate
ligament (ACL) tears?

A. Female athletes with valgus knee alignment and small femoral notch
width
B. Female athletes with valgus knee alignment and large ACL width
C. Male athletes with valgus knee alignment and small ACL width
D. Male athletes with varus knee alignment and small femoral notch width

ACL tears are several times more common among women than men. Women
who land from jumps in increased valgus and external rotation are at
particularly increased risk for ACL tears. Women have smaller notch widths
and a smaller ACL cross-sectional area than men, but these factors have not
been definitively proven to increase risk for ACL tears.
Correct answer : A

65- Figure 1 is the MRI scan of a 20-year-old Division I baseball pitcher

who has a 1-month history of medial elbow pain in his throwing arm. He
also notes a decrease in both control and pitching velocity. An
examination reveals tenderness at the medial epicondyle that is
exacerbated with valgus elbow stress. The strongest indication for ulnar
collateral ligament (UCL) reconstruction is

A. progressive ulnar neuropathy.

B. a decision to enter the Major League
Baseball (MLB) draft.
C. pain with resisted wrist flexion.
D. failure to improve after prolonged
nonsurgical treatment.
All responses represent findings that may be
associated with chronic UCL insufficiency.
Responses A and C reflect injury to the UCL
itself. In most patients, particularly young
patients, UCL reconstruction should not be
considered until an appropriate trial of
nonsurgical measures has failed. This trial
should include, at a minimum, 6 weeks of
throwing abstinence followed by rehabilitation
to address pitching mechanics and shoulder
52
 motion deficits and core strengthening. Although the decision to enter the MLB
draft may influence surgical decision making, a pitcher with a 1-month history
of elbow symptoms should attempt nonsurgical therapy before making a
surgical decision that is not based on clinical data.
Correct answer : D

66- Figure 1 is the MRI scan of a patient with recurrent knee instability,
which persists after a period of nonsurgical treatment. Anatomic
reconstruction of the torn ligament is recommended. What radiographic
finding is the most important independent predictor of recurrent
instability following surgery?

A. Tibial tubercle to trochlear

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

67- An otherwise healthy 31-year-old man has had right knee pain for the
past 9 months. His former physician administered a cortisone injection
and ordered 6 months of physical therapy. The patient later had an
arthroscopy with debridement of the right knee by another physician and
completed another course of physical therapy. He had minimal relief from
these treatments and still is not able to walk longer distances or go on
hikes. On examination, he is a healthy appearing male with a body mass
index of 24 kg/m2. He has a small effusion, minimal quadriceps atrophy, no 53
tenderness about the knee, full range of motion, stable to varus and
valgus stress at 30° of flexion, a grade 1 Lachman test, and a normal
posterior drawer. Figures 1 through 4 are his arthroscopic views,
radiograph and MRI scan from his prior surgical procedure. What is the
next most appropriate step in treatment?

A. Bracing with physical therapy focusing on quadriceps/vastus medialis

obliquus (VMO) and hamstring strengthening
B. Osteotomy
C. Osteochondral allograft transplant
D. Arthroscopy with femoral condyle microfracture
54
 the patient has a symptomatic cartilage lesion of his medial femoral condyle,
which has not responded to nonsurgical measures, and he failed a prior
arthroscopy with debridement. Based on his examination and imaging, he is
ligamentously stable, has normal mechanical alignment, and has intact
menisci, making him a candidate for a cartilage restoration procedure. The
accompanying MRI also indicates subchondral bone involvement with
increased T2 signal underlying the cartilage defect. Osteochondral allograft is
the only choice that addresses both the cartilage defect, as well as
compromised subchondral bone. Depending on lesion size, osteochondral
autograft transfer may also be considered, but this is not presented as an
answer choice.
Given the radiographic finding of neutral mechanical alignment, bracing would
be less effective, and the patient has already tried extensive physical therapy.
Lack of malalignment also excludes tibial osteotomy as a preferred answer
choice. Microfracture is best for small cartilage lesions without significant bone
marrow involvement.
Correct answer : C

68- The lesion noted on the MRI scans in Figures 1 through 3 leads to
what effect on tibiofemoral contact pressure?

A. Increased medial compartment contact

pressures worsening in extension
B. Increased medial compartment contact
pressures worsening in flexion
C. Increased lateral compartment contact
pressures worsening in extension
D. Increased lateral compartment contact
pressures worsening in flexion
55
The MRI scans reveal a root tear of the medial meniscus. Studies demonstrate
that this tear pattern greatly increases the tibiofemoral contact forces. These
forces, and meniscal extrusion, worsen with increasing flexion. Correct
answer : B

69- A 45-year-old postmenopausal smoker with a body mass index (BMI)

of 22 has had severe knee pain for the past year. The pain has been
progressing and the patient is now only able to perform activities of daily
living. Knee radiographs reveal medial compartment osteoarthritis
without any involvement of the patellofemoral joint or the lateral
compartment. What is the contraindication for a high tibial osteotomy
(HTO) in this patient?

A. Smoking status
B. Postmenopausal status
C. BMI
D. Radiographic findings

The principal contraindications to valgus-producing HTO include (1) lateral

compartment degenerative joint disease, (2) loss of a significant portion of the
lateral meniscus, (3) symptomatic patellofemoral degenerative joint disease,
(4) nonconcordant pain (ie, patellofemoral pain with medial compartment
osteoarthritis), (5) smoking, (6) patient unwillingness to accept the anticipated
cosmetic appearance of the desired amount of angular correction, and (7)
inflammatory arthritis.
Correct answer : A

70- In an asymptomatic athlete, what condition represents an absolute

contraindication to returning to contact or collision sports?

A. Healed one-level anterior cervical fusion

B. Congenital atlanto-occipital fusion
C. Cervical disk herniation previously
treated nonoperatively
D. Spina bifida occulta

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

71- Based on the injury shown on the axial MRI scan of the shoulder in
Figure 1, what other pathology should be closely examined for during
surgery?

A. Subscapularis tear
B. Supraspinatus tear
C. Superior labral anterior-
posterior (SLAP) tear
D. Bankart tear

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh
and associates, 85% of patients with a biceps subluxation on MRI were
found to have a subscapularis tear at the time of arthroscopy. These are not
always obvious on the MRI, and close inspection of the leading edge/upper
border of the subscapularis tendon at the time of arthroscopy is necessary.
Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in
conjunction with a biceps subluxation, none have been shown to be strongly
correlated with this pathology, nor as specific to this pathology.
Correct answer : A 57
73- Figures 1 through 4 are the MRI scans of a 24-year-old former
collegiate basketball player who injured his left knee while playing
recreational basketball 10 days prior to presentation. He landed from a
jump awkwardly and reported that his knee gave out. He heard a pop at
the time of injury and was unable to continue playing. He complains of
medial and lateral knee pain and difficulty with weight bearing. On
physical examination, he has a moderate effusion and his range of
motion is from 10° to 80°. Ligament examination reveals a 2B Lachman,
negative posterior drawer as well as negative varus and valgus stress
testing. What is the diagnosis?

A. Meniscus tear
B. Anterior cruciate ligament (ACL) tear
C. ACL tear and posterior cruciate ligament
(PCL) tear
D. ACL tear and medial meniscus tear

58
The MRI scans reveal an acute ACL rupture with pivot shift contusions in the
lateral tibiofemoral compartment and a bucket handle tear of the medial
meniscus. Additionally, there is likely a radial tear of the lateral meniscus at the
anterior horn/body junction (Figure 4). Figure 1 shows a bucket handle tear of
the medial meniscus with the posterior horn displaced anteriorly. Figure 3
shows a double posterior cruciate ligament sign. Figure 2 shows the ACL tear
and Figure 4 shows the pivot shift contusions. There is no evidence of PCL
injury on examination or imaging.
Correct answer : D

73- A 49-year-old marathon runner is unable to continue running at the

18-mile marker. The ambient temperature is 28°C (82°F) with a relative
humidity of 80%. Concern for heat-related illness prompts immediate
recooling efforts, including ice, fans and oral rehydration. What symptom
should most strongly urge transfer to a hospital or other definitive
treatment facility?

A. Core body temperature of 39ºC (102ºF)

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

74- A 16-year-old female basketball player sustains a re-tear of her

anterior cruciate ligament (ACL) reconstruction. Her physical
examination reveals a 3+ Lachman and 2+ pivot shift. Her range of
motion is 10° of hyperextension to 130° of flexion. Radiographs reveal
her ACL inclination angle to be 50°, tibial slope, 7°, and her physes are
closed. What finding has been associated with an increased risk graft
failure?
59
 A. Hyperextension
B. Flexion
C. Tibial slope
D. ACL inclination angle

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

75- A 20-year-old collegiate running back lowers his head to absorb a hit
and is tackled to the ground. He is able to get up immediately and return
to the sidelines on his own power but reports to the medical staff that he
felt a burning sensation in his left shoulder, arm, and hand for 15
seconds following the hit. The feeling has since resolved. This is the first
time this sensation has occurred. Examination on the sidelines reveals
full and painless neck range of motion and normal and symmetric
strength throughout the upper and lower extremity. What is the best next
course of action?

A. Removal from the game with additional physical examination and

continued monitoring of symptoms
B. Removal from the game with placement of cervical immobilization
C. Urgent MRI scan
D. Return to play without restrictions

This player has experienced a “stinger” or “burner”, which results from a

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

60
76- Figure 1 is the radiograph of a 14-year-old girl with increasing
posterior ankle pain, especially during pointe technique exercises.
Nonsurgical measures such as modification, stretching, and injection
have been unsuccessful. Which nerve is most vulnerable to injury during
endoscopic excision of this lesion?

A. Sural
B. Deep peroneal
C. Medial plantar
D. Posterior tibial

The pathology is that of posterior

ankle impingement, which is
secondary to a symptomatic os
trigonum. Endoscopic excision
necessitates posteromedial and
posterolateral ankle portals. Although
plantar numbness has been
described as a relatively common
postsurgical complication, the
neurovascular structure most
commonly injured is the sural nerve.
Correct answer : A

77- A 65-year-old man presents with chronic shoulder pain and

weakness after failing extensive nonoperative treatment. Physical
examination shows full passive range of motion, weakness with
shoulder abduction, pain on palpation of the acromioclavicular (AC)
joint and with cross-body adduction. Radiographs of the affected
shoulder show evidence of AC joint osteoarthritis and an MRI scan
reveals a full-thickness, reparable supraspinatus tear. A preoperative
diagnostic lidocaine injection transiently improves the patient’s pain in
the AC joint. In comparison with rotator cuff repair alone, at 2-year
follow-up, distal clavicle excision for this patient’s condition has been
shown to

A. decrease AC joint pain.

B. improve range of motion in forward elevation.
C. have no difference in patient-oriented outcome scores.
D. decrease the need for repeat surgery.
61
In patients with painful AC joint osteoarthritis undergoing surgery for
concomitant rotator cuff tear, several well-designed studies and meta-
analyses have shown that distal clavicle excision does not improve pain,
function, shoulder range of motion or decrease need for revision surgery
compared with rotator cuff repair alone.
Correct answer: C

78- A 68-year-old man with a history of degenerative joint disease is

taken to the operating room for a right total shoulder arthroplasty.
Figure 1 is the clinical photograph of the deltopectoral incision.
Excessive retraction using the Kolbel self-retaining retractor would
most likely result in what functional deficit?

A. Shoulder abduction weakness

B. Shoulder external rotation weakness
C. Elbow flexion weakness
D. Wrist extension weakness

The musculocutaneous nerve

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

78- Figure 1 is an arthroscopic view of the intercondylar notch of a right

knee from an anterolateral portal. What is the main function of the
structure delineated by the black asterisks?

62
A. Resist anterior translation during knee
flexion
B. Resist posterior translation during
knee flexion
C. Resist rotatory loads during knee
flexion
D. Resist rotatory loads during knee
extension

The structure shown is the posterolateral bundle of the anterior cruciate

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

80- A 58-year-old woman returns for an evaluation of right knee pain after
a twisting injury. A small pop was felt at the time of injury. Her pain is
medial and she is unable to bear weight. A complete physical
examination demonstrated range of motion is 0°to 125°; significant
medial joint line tenderness; negative flexion McMurray; negative
Lachman; stable to varus and valgus stress at 0° and 30° and negative
posterior drawer. Based on her history, physical examination, and the
MRI scan shown in Figure 1, what is the diagnosis?

A. Posterior cruciate ligament

(PCL) tear
B. Horizontal tear of posterior horn
of medial meniscus
C. Posterior root tear of medial
meniscus
D. Anterior root tear of medial
meniscus

63
The low likelihood that common symptoms associated with meniscal body
injury will manifest in patients with root tears makes clinical diagnoses
challenging. For instance, patients with a posterior root tear injury may
experience joint line pain, but the absence of mechanical symptoms such as
locking or catching is probable. Meniscal root tears are also not typically
associated with an inciting traumatic event. MRI has become increasingly used
in the diagnosis of meniscal root tears. Telltale signs of a root tear include the
presence or absence of a ghost sign, which is the absence of an identifiable
meniscus in the sagittal plane or high signal replacing the normal dark
meniscal signal. The posterior meniscus is seen in sagittal MRI view in all
images up to the one that shows the PCL. The posterior root of the medial
meniscus attaches anterior to the posterior cruciate ligament (PCL).
Correct answer: C

81- A 30-year-old woman complains of medial knee pain 15 years after a

meniscectomy. Radiographs show her affected knee to be 8° varus while
her contralateral knee shows 3° varus. What is the goal of performing a
high tibial osteotomy (HTO) on this patient?

A. Increase tibial slope

B. Decrease tibial slope
C. Decrease compartment pressure in
medial compartment
D. Increase varus thrust moment arm

Varus and valgus deformities are contributing factors for unilateral

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

82- Figures 1 through 3 are the radiographs of a 65-year-old man with

long-standing shoulder pain who has had acute worsening shoulder pain
over the past three months following a fall. He is unable to raise his arm
in forward elevation >90° and has failed nonsurgical treatments including
physical therapy. What is the most predictable way to reverse
pseudoparalysis?

64
A. Reverse shoulder arthroplasty (RSA)
B. Superior capsular reconstruction
C. Rotator cuff repair
D. Lower trapezius muscle transfer

The radiographs reveal a high-riding

humeral head with an acromiohumeral
interval of 1 mm. This indicates a chronic
long-standing rotator cuff tear. There is
further evidence of arthritic change with
grade 4 Hamada findings. The only
surgery with predictable outcomes for
massive tear, high-riding humeral head
and severe arthritis is RSA.
Correct answer : A

65
83- A 13-year-old football player sustains the injury shown in the AP and
axillary radiographs in Figures 1 and 2. When deciding between
operative and nonoperative treatment, what risk factor is most
associated with poorer outcomes with nonoperative treatment?

A. Displacement
B. Angulation
C. Skeletal age of the patient
D. Playing contact sports

The radiographs reveal a displaced proximal humerus fracture in a skeletally

immature patient. There is tremendous remodeling potential, and similar
outcomes are seen in both operative and nonoperative treatment. Worse
outcomes are seen with older patients, as the remodeling potential decreases.
In a study of 32 pediatric proximal humeral fractures, subgroup analysis of the
nonoperative cases showed that, for every 1-year increase in age at initial
injury, the odds of a less than desirable outcome increased by a factor of 3.81.
Correct answer : C

84- A patient is considering treatment of knee pain with bone marrow

aspirate versus platelet-rich plasma. Which factor has been shown to be
higher in bone marrow aspirate in comparison with platelet-rich plasma?

A. Interleukin-1 receptor antagonist (IL-1ra)

B. Platelet-derived growth factor
C. CD-40 cell surface marker
D. Matrix metalloprotease

66
Bone marrow aspirate has been shown to have higher concentrations of IL-1ra
versus both leukocyte-rich and leukocyte-poor platelet-rich plasma. IL-1 is a
potent proinflammatory cytokine. IL-1ra blocks binding of IL-1 to its receptor
and therefore, serves an anti-inflammatory role.
Correct answer : A

85- A 65-year-old woman complains of right shoulder pain. She has been
diagnosed with a full-thickness rotator cuff tear. She has failed
nonsurgical measures including physical therapy, corticosteroid
injections, and oral pain medication. She is considering platelet-rich
plasma (PRP) injections to the shoulder in conjunction with rotator cuff
repair. What should the patient be informed of regarding PRP injections
in this setting?

A. There is good evidence to suggest that PRP injections help heal

full-thickness rotator cuff tears nonoperatively.
B. The use of PRP injections during rotator cuff repair is associated
with decreased pain scores.
C. There remains a lack of evidence to support the use of PRP in
rotator cuff repair.
D. Leukocyte-depleted PRP is more efficacious in healing rotator cuff
tears than leuckocyte-enhanced PRP.
Recently, there has been much excitement and interest in the use of biologic
injections for orthopaedic injuries including tendinopathies, rotator cuff tears,
muscle injuries, articular cartilage lesions, sprains and osteoarthritis. PRP is a
preparation of human plasma taken from a blood sample of a patient. Through
centrifugation, the platelets and plasma are separated from other blood
components, and the concentration of platelets is increased. It is not
completely clear how PRP works; however, these platelets contain a variety of
growth factors, which many believe will aid in the healing of ailments. Though
various studies may show limited evidence of their efficacy, there certainly is
no conclusive evidence. In particular, clinical trials on the efficacy of PRP in
the setting of rotator cuff tears have shown equivocal results.
Correct answer : C

86- An 18-year-old male wrestler is injured while picking up an opponent

over his head. Witnesses observed his knee buckle out from under him.
He is immediately taken to the hospital. On physical examination, his
knee is swollen and grossly unstable in multiple planes. Radiographs
reveal a located joint without fracture. Distal pulses are palpable. What is
the best next step?
67
 A. Measure compartment pressures.
B. Order a knee MRI scan.
C. Perform ankle-brachial index (ABI).
D. Go to surgery for urgent stabilization of the knee.

Multiple factors need to be considered in the setting of the acutely dislocated

knee, but beyond the joint being located, the vascular status of the knee needs
to be established to avoid an ischemic limb and possibility of amputation.
While palpation for pulses certainly can be performed, an ABI should be
performed first in this setting. The patient should be supine and ideally Doppler
ultrasonography should be used to detect the pulse. ABI <0.9 has been
demonstrated to be 100% sensitive and 100% specific for vascular injury (Mills
and associates). Selective angiography can be employed if ABI measures
indicate a possible injury. ABI measurements can be affected by existing distal
arterial sclerosis or calcification, which would not be expected in this young
patient. If pulses are absent or other hard ischemic signs are present, ABI can
be foregone for operating room (OR) angiography or an equivalent study to
determine the exact location of the vascular injury.
A missed compartment syndrome in the setting of a knee dislocation can be a
devastating event leading to ischemia and limb dysfunction or tissue death
leading to need for amputation. If a suspected compartment syndrome exists,
compartment pressures can be measured directly after ABI, and if needed,
compartments can be released in the OR in conjunction with vascular repair (if
required). Urgent stabilization can also be done in the OR at the time of
vascular repair but is not the most important priority in this setting. Angiograms
can be performed in the OR to reduce warm ischemia time if ABI measures
are concerning, with vascular repair if indicated. This has been superseded by
CT-arteriogram in many trauma centers, which can be performed just prior to
OR if indicated.
Correct answer : C

68
87- Figure 1 is the clinical photograph and Video 1 is the
nonarthrographic sagittal plane MRI scan of a 23-year-old male active
duty Marine who presents with 3 months of pain and weakness in his
nondominant arm. He states that he had rapid onset of “severe” left
shoulder pain, which has recently subsided followed closely by
weakness in that arm. There was no antecedent trauma that he can
recall. Upon further questioning, he states he had one episode of a brief
cold sometime prior to the development of symptoms, but he is
uncertain. On examination, he is weak in forward flexion and external
rotation at 0° of abduction, but otherwise he is neurologically intact. The
EMG result is abnormal. What is the best next step?

A. Physical therapy for range-of-motion and periscapular muscle treatment

B. Arthroscopic labrum repair and paralabral cyst decompression
C. Radiographs and MRI scan of the cervical spine
D. Arthroscopic transverse scapular ligament release

The patient is exhibiting a motor mononeuropathy that does not follow a

radicular pattern. In the absence of a space-filling lesion, e.g., a paralabral
cyst at the suprascapular notch or, more commonly, at the spinoglenoid
notch (which this patient does not have on MRI), at this time, the patient’s
diagnosis is most consistent with neuralgic amyotrophy (NA) - i.e
Parsonage-Turner syndrome. NA is reported to be quite rare, with a range of
about 20 to 30 cases in 100,000 individuals. Although a hereditary form
exists, it is much rarer (and severe), with most cases being idiopathic.
Causes are unknown but generally it is thought to be autoimmune in nature
and can be triggered by viral illness, as well as other noninfectious triggers..
69
Presentation is variable but most commonly affects males and nerves
emanating from the upper trunk of the brachial plexus. Typically, the nerves
affected are motor and usually, it is a unilateral presentation. The process is
usually self-limiting within a 6-month period, but residual deficits can be seen
as far out as 3 years from initial presentation. MRI is very sensitive to
inflammation in the affected muscles and EMG is typically abnormal along the
specific nerve affected. Typically, the best treatment in this time frame is
benign neglect, with physical therapy helpful in maintaining range of motion of
the affected joint (usually the shoulder) and treatment of the periscapular
muscles that are usually being overused to establish function in the affected
limb.

Physical examination and these supporting studies differentiate this condition

from cervical radiculopathies. An arthroscopic or open decompression of the
suprascapular notch may be indicated if no improvement is seen within 6
months of onset of symptoms
Correct answer : A

88- When performing an arthroscopic Bankart repair in the lateral

decubitus position, a surgeon notes a patulous capsule and a very lax
anterior band of the inferior glenohumeral ligament. The surgeon decides
that in addition to simply repairing the torn labrum, a capsular shift
should be performed. The surgeon instructs the fellow assisting to take a
“nice, big bite” of the capsule in this region to tighten the capsule upon
repair. Which postoperative complication is most likely a result of this
maneuver?
A. Weakness with shoulder abduction
B. Weakness with shoulder external rotation with arm at side
C. Weakness with wrist extension
D. Numbness at the lateral aspect of the forearm

The axillary nerve is at most risk in this area of the glenohumeral joint as it
passes adjacent to and just inferior to the 6 o’clock position. Although
performing capsular shifts within and up to 1 cm from the glenoid rim is
generally considered safe, taking large amounts of capsule (>1 cm) in this
region in an effort to tighten the capsule can inadvertently damage the nerve
as it crosses there.

The musculocutaneous nerve does not cross in this region, although it can be
injured during dissection around the coracoid, such as in arthroscopic Latarjet
procedures. The musculocutaneous nerve branches to the lateral cutaneous
nerve and provides sensory innervation to the lateral aspect of the forearm.

70
 The suprascapular nerve crosses superior and posterior to the glenoid and is
at greatest risk during transglenoid screw placement in the anteroposterior
directions. The suprascapular nerve innervates the supraspinatus and the
infraspinatus. The radial nerve courses behind the humeral shaft and can be
damaged during bicortical fixation in the anterior to posterior direction in this
region. A radial nerve palsy would result in wrist extension weakness.
Correct answer : A

89- Figure 1 is a representative MRI scan of a 45-year-old man who was

lifting a couch 2 days ago when he felt a pop in the elbow and had
immediate pain in this area. He had no problems with the elbow prior to
this injury. Examination reveals full range of motion; however, he has
significant bruising and swelling in the antecubital fossa. A hook test is
positive. If choosing to perform single-incision surgical repair for this
injury, what is the most common complication associated with this
procedure?

A. Injury to the lateral antebrachial

cutaneous nerve
B. Injury to the radial nerve
C. Radioulnar synostosis
D. Tendon re-tear
This patient has a complete distal
biceps rupture, as evidenced by history,
examination and imaging. Surgical
repair is typically recommended in
otherwise healthy patients to restore
supination strength of the forearm.
Surgical repair can be undertaken using
either a single- or dual-incision
approach. The single-incision approach
is associated with injury to the lateral
antebrachial cutaneous nerve, whereas the dual-incision approach carries an
increased risk of radioulnar synostosis. Tendon retear and radial nerve injury,
while possible, are less common.
Correct answer : A

71
90- Figures 1 through 3 are the MRI scans of a 26-year-old man who
injured his knee wrestling one day prior. He has a moderate effusion,
medial knee pain and an inability to extend his knee actively or passively.
What is the most appropriate definitive treatment option?

A. Physical therapy
B. Posterior cruciate ligament (PCL) reconstruction
C. Attempted meniscus repair
D. Knee aspiration and manipulation under anesthesia

The images show a bucket handle medial meniscus tear, which is likely
responsible for the block to motion. Therefore, surgery should be
recommended with a meniscus repair if possible. Physical therapy or knee
aspiration/manipulation under anesthesia is not the best definitive treatment.
Correct answer : C

91- Figures 1 through 3 are the MRI scans of a 15-year-old boy who
sustained an injury to his shoulder after a fall while playing soccer.
Following completion of a month-long rehabilitation program, he is able
to tolerate sports-specific drills without symptoms. The patient is eager
to return to play, as it is mid-season. How should the patient be
counseled?

72
A. Patient should not return to play mid-season and should undergo
arthroscopic stabilization of the Bankart lesion.
B. Patient may return to play: however, he should be counseled on a
moderate risk for recurrence.
C. Patient may not return to play this season, as the patient has evidence of
significant glenoid bone loss on MRI scan.
D. Patient may return to play, however, only after a repeat MRI arthrogram
confirms interval healing of the Bankart lesion.

Controversy exists regarding optimal treatment of an athlete with a shoulder

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

92- Figures 1 and 2 are the MRI scans of a 28-year-old woman who has
left knee pain and instability 10 days after a fall while skiing. The injury
occurred when her ski became stuck in deep snow. Her shoe did not
pop off and she pivoted around her ski. She was unable to continue
skiing. She reports pain with weight bearing and the feeling of
instability. On physical examination, she demonstrates a positive
Lachman, 2+ opening to valgus stress at 0° and 30° of knee flexion
without an end point. Her knee range of motion is 3° to 120°, and she
has a trace effusion. What is the most appropriate treatment plan?

73
A. Immediate anterior cruciate ligament (ACL) reconstruction and medial
collateral ligament (MCL) repair
B. Immediate ACL and MCL reconstruction
C. Immediate MCL reconstruction and delayed ACL reconstruction
D. Nonoperative management of the MCL and delayed ACL reconstruction

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

93- What examination findings are most consistent with the pathology
seen in the radiographs?

A. Pain with resisted hip flexion

B. Pain with a half sit-up, plus tenderness at the pubic ramus
C. Pain with a combination of hip flexion, adduction, and internal
rotation
D. Tenderness to palpation at the greater trochanter

74
This patient has cam-type femoroacetabular impingement. Decreased internal
rotation and a positive impingement test (forced flexion, adduction, and
internal rotation) are classic findings. The lack of pain with resisted hip flexion
makes hip flexor strain unlikely, and the lack of tenderness at the greater
trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can
be a source of long-standing groin pain, he lacks the pain with a resisted sit-up
and tenderness along the pubic ramus that is frequently noted in patients with
pubalgia. His radiographs reveal a focal femoral neck prominence consistent
with cam impingement, although pistol grip deformities and flattening of the
lateral femoral head are often present as well. His MRI scan shows a labral
tear, which is common in cam impingement. Surgical treatment for cam
impingement can be effective for symptomatic patients. Even among high-level
athletes, open surgical dislocation of the hip has been shown to have good
results. Most patients with cam impingement can be treated with arthroscopic
osteoplasty and achieve results comparable to those realized with open
surgical dislocation. The literature describes success in terms of athletes
returning to sports (even professional athletes) to be approximately 90% after
arthroscopic treatment. Byrd and Jones described 5 patients who developed
transient neurapraxias that resolved uneventfully. The patients in his series
who had concomitant microfracture had a 92% return to sports within the
follow-up period. Cam impingement has long been thought to be associated
with a history of a slipped capital femoral epiphysis. The capitis in these
patients is displaced posteriorly, resulting in a prominent anterior femoral neck
and decreased hip internal rotation. Pincer impingement is associated with a
deep acetabulum, such as protrusion acetabula and acetabular retroversion. A
patient who underwent a periacetabular osteotomy can develop a more
retroverted acetabulum as well.
Correct answer : C

94- A 15-year-old football player was diagnosed with infectious

mononucleosis 2 weeks ago. Today he states that he is relatively
asymptomatic and would like to return to play. At what point can the
patient return to full contact practice?
A. Now if splenomegaly has resolved
B. Now if treated with oral valacyclovir
C. In 2 weeks if splenomegaly has resolved
D. After a 4-week course of oral valacyclovir
Infectious mononucleosis presents with fever, pharyngitis, fatigue and lymph
node enlargement. It is common among individuals in their teens and early
twenties. Participation in contact activities during an acute illness with
unresolved splenomegaly increases the risk of splenic rupture. Evidence-
based return to play criteria recommend that a patient may return to full-
contact activities 4 weeks after the onset of their symptoms with resolution of
splenomegaly. An ultrasonography of the spleen can help confirm that the
spleen has returned to normal size. Correct answer : C 75
95- During knee arthroscopy, you discover an irreparable complete radial
tear of the medial meniscus. After partial medial meniscectomy what
should be the primary concern?

A. Lateral meniscal tear

B. Accelerated medial compartment degeneration
C. Anterior cruciate ligament (ACL) tear
D. Posterior cruciate ligament (PCL) tear

Complete radial tears of the meniscus body are analogous to root avulsions
from a biomechanical standpoint. The complete tears significantly decrease
contact area and increase mean contact pressure. This altered weight
distribution is not well handled by subchondral bone. Although meniscal loss
puts more stress on the ACL and PCL, it is still not a likely mechanism for
injury. Although lateral meniscal tear is possible it is not the most likely
outcome.
Correct answer : B

96- A 19-year-old college runner presents complaining of bilateral leg

pain during activity. There is no history of trauma, but symptoms have
occurred in some degree since her sophomore year of high school. She
notes pain after running for 5 to 10 minutes and localizes her discomfort
to anterolateral aspects of both legs. This pain resolves within 30 to 45
minutes after running. She denies any pain, numbness or tingling in
either foot. There is no pain with routine daily activities. Examination at
rest is normal; specifically, there is no tenderness, swelling, masses, or
edema. Plain radiographs are unremarkable. A course of anti-
inflammatory medication and physical therapy is unsuccessful. The next
most appropriate diagnostic study would be

A. three-phase bone scan.

B. compartment pressure measurements.
C. angiography.
D. MRI scan.

The clinical scenario describes an athlete with chronic exertional leg pain.
The differential is large, and there is much overlap in clinical symptoms
between different potential diagnoses. The most common overall cause
would be medial tibial stress syndrome (MTSS), but in this situation, MTSS is
unlikely given the location of her pain and the absence of bony tenderness,
76
which is typically along the posteromedial tibia in MTSS. Persistent MTSS is
usually evaluated with bone scan or MRI to confirm the diagnosis and to
assess for occult stress fracture. Angiography is useful primarily in cases of
suspected popliteal artery entrapment, which is a dynamic exercise-related
vascular phenomenon. Here, the description of pain in the anterior and/or
lateral compartments, the multi-year history, and the predictable time-course
for onset and relief of symptoms all strongly suggest a diagnosis of exercise-
induced compartment syndrome, also called exertional compartment
syndrome. MRI and bone scan are likely to be negative; definitive diagnosis
can only be made through direct measurement of compartment pressures
before, during and after exercise.
Correct answer : B

97- A 25-year-old professional soccer player presents with a chief

complaint of left ankle pain. He has a history of a grade 3 lateral ankle
sprain that was treated nonsurgically with rest and physical therapy
approximately 4 months ago but has yet to return to play. He continues
to report lateral-sided ankle pain and a mechanical snapping sensation.
A current MRI scan is shown in Figure 1. What is the most appropriate
treatment for this patient?

A. Lateral ligament reconstruction

(Brostrom procedure)
B. Superior retinacular
reconstruction with fibular
groove deepening
C. Syndesmosis repair with suture
button fixation
D. Diagnostic arthroscopy,
synovectomy and microfracture

The patient's MRI scan reveals

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

98- The ABER (abducted and externally rotated) position in the shoulder
MRI scan shown in Figure 1 can be helpful in identifying a variety of
subtle pathologies including rotator cuff tears and capsulolabral injury.
While in the ABER position, the humerus and glenoid are seen
predominantly in what planes, respectively?

A. Sagittal and coronal

B. Coronal and axial
C. Axial and sagittal
D. Axial and coronal

While in the ABER position in the MRI

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

99- A 13-year-old football running back is tackled during a game. On

impact with the ground, his chest is compressed between the opposing
player and the turf. He experiences immediate pain, difficulty breathing,
and on physical examination is tender to palpation over the
sternoclavicular joint. What is the best next step?

A. Administer bronchodialator
B. Repeat examination in 15 minutes
C. Referral for radiograph with attempted
closed reduction
D. Start advanced trauma life support
(ATLS) protocol
78
The sternoclavicular joint has a low rate of injury. Usually, it is associated with
motor vehicle collision or contact sports. Traumatic sternoclavicular joint
injuries are classified from grade I to grade III in ascending severity. Posterior
dislocation can be life-threatening, and ATLS protocol and rapid transport to
the emergency department is recommended. This injury can be diagnosed by
listening for upper airway obstruction or a noticeable change in voice quality
as posterior dislocation of the clavicular head obstructs airflow.
Correct answer : D

100- Figures 1 and 2 are drawings of the posterior and medial aspect of
the knee, respectively. What is the structure demarcated by the arrow
on both images?

A. Oblique popliteal
ligament
B. Popliteofibular ligament
C. Deep fibers of the
medial collateral
ligament
D. Posterior oblique
ligament (POL)

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

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