Sports Medicine 2014

Question 1

Question 11

A left-handed 24-year-old minor league pitcher has progressive medial elbow pain that occurs duringpitching. He also reports pain with lifting when using his left arm. Examination reveals he has pain anterior to the medial epicondyle. He also has pain with power grip and with resisted wrist flexion. A standard dynamic valgus stress test does not provoke pain, but there is pain if the test is performed with his fist clench and pronated. With is the most likely diagnosis?

1- Cubital tunnel syndrome

2- Snapping medial triceps tendon

3- Common flexor-pronator tendonitis

4- A tear of the ulnar collateral ligament

5- Posteromedial impingement from an olecranon osteophyte

Answer 1

3- Common flexor-pronator tendonitis

RECOMMENDED READINGS

Levine W. The Athlete’s Elbow. In: Levine W, ed. AAOS Monograph Vol. 39. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:71-83.

Cain EL Jr, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 2003 Jul-Aug;31(4):621-35. Review. PubMed PMID: 12860556.

Question 2

Question 23

An 8-year-old boy fell and has a painful left knee and a 15-degree block to extension (Figure 23a). MR imaging findings are shown in Figure 23b, and arthroscopic findings are shown in Figure 23c. What is the best next step?

1. Observation
2. Mosaicplasty
3. Total menisectomy
4. Meniscal allograft
5. Arthroscopic saucerization and repair

Answer 2

5. Arthroscopic saucerization and repair

RECOMMENDED READINGS

Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and treatment. J Am Acad Orthop Surg. 2009 Nov;17(11):698-707. Review. PubMed PMID: 19880680.

Question 3

Question 51

Figures 51a through 51d are the radiographs and sagittal MR knee images of a healthy, active 23-yearold man who had the acute onset of right knee pain and an inability to fully extend his knee after trying to stand from a seated position yesterday. He sustained a noncontact injury to his right knee 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction with bone-patella tendon-bone autograft and medial meniscus repair. He sustained a noncontact injury to his right knee 8 months later and underwent a revision ACL reconstruction using soft-tissue allograft and a revision medial meniscus repair. He reported multiple episodes of “giving way” of the knee but no pain before yesterday’s acute injury. He has positive Lachman and pivot shift findings and a negative dial test result. What is the best next step?

1. Arthroscopic partial medial menisectomy
2. Arthroscopic revision medial meniscus repair
3. Arthroscopic-assisted revision ACL reconstruction and meniscal surgery as necessary
4. Arthroscopic-assisted revision ACL reconstruction with posterolateral corner augmentation
5. Injection, physical therapy, and functional bracing

Answer 3

3. Arthroscopic-assisted revision ACL reconstruction and meniscal surgery as necessary

RECOMMENDED READINGS

Noyes FR, Barber-Westin SD. Anterior cruciate ligament graft placement recommendations and bonepatellar tendon-bone graft indications to restore knee stability. Instr Course Lect. 2011;60:499-521. Review. PubMed PMID: 21553794.

Driscoll MD, Isabell GP Jr, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR. Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy. 2012 Oct;28(10):1481-9. PMID: 22796141.

Question 4

Question 62

Figures 62a through 62c are the radiographs of a 27-year-old woman who is experiencing lack of motion and decreased functional use of her left elbow. She has no pain and reports that although her functional use recently decreased, she has never had full motion in that elbow. Examination reveals her left elbow has full and equivalent flexion and extension with fixed 20 degrees of pronation. No further pronation or supination is present actively or passively. No pain is elicited during the examination. Her right elbow has full motion. She is unhappy with her range of motion and is requesting treatment. What is the best next step?

1. Observation
2. Excision of the synostosis
3. Derotational osteotomy to position the forearm in neutral
4. Excision of the synostosis and a vascularized interposition fat patch
5. Derotational osteotomy to position the forearm in 20 degrees of pronation

Answer 4

4. Excision of the synostosis and a vascularized interposition fat patch

RECOMMENDED READINGS

Cleary JE, Omer GE, Jr. Congenital proximal radio-ulnar synostosis. Natural history and functional assessment. J Bone Joint Surg -Am Volume 1985; 67(4): 539-45. PMID: 3980498.

Kanaya F, Ibaraki K. Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fascio-fat graft. J Bone Joint Surg Am Volume 1998; 80( 8): 1186-92. PMID: 9730128.

Question 5

Question 83

A patient returns for a first postsurgical visit 6 weeks after undergoing arthroscopic rotator cuff repair. This patient has not been attending formal physical therapy and has remained in a sling. When compared to control patients who immediately began formal physical therapy, what is the expected outcome 1 year after surgery?

1. Increased pain levels
2. Decreased range of motion
3. Decreased likelihood of returning to work
4. Improved functional outcome scores
5. No difference in range-of-motion or outcome scores

Answer 5

5. No difference in range-of-motion or outcome scores

RECOMMENDED READINGS

Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med. 2012 Apr;40(4):815-21. doi: 10.1177/0363546511434287. Epub 2012 Jan 27. PubMed PMID: 22287641.

Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg. 2012 Nov;21(11):1450-5. doi: 10.1016/j.jse.2012.01.025. Epub 2012 May 2. PubMed PMID: 22554876.

Question 6

Question 99

A 19-year-old collegiate field hockey player is struck in the head bya stick while challenging for a loose ball. She is seen by the athletic training staff on the sideline and is determined to be alert and conversing appropriately. She denies any loss of consciousness but cannot recall the events immediately preceding the injury. Her motor and sensory examination is unremarkable, with mild tenderness but no laceration over the posterior aspect of her occiput (the location at which she was struck). She is eager to return to play. According to an NCAA protocol, when may this athlete safely return to play?

1. 15 minutes after sustaining the injury as long as she has no symptoms
2. During the second half as long as she remains without symptoms and can perform

cardiovascular exercise without experiencing symptoms

3. 2 to 3 days after sustaining the injury as long as she can progress through the stepwise rehabilitation protocol without experiencing symptoms
4. 7 to 10 days after sustaining the injury as long as she can progress through the stepwise rehabilitation protocol without experiencing symptoms
5. This athlete is not to return to athletics until the following season, and only if symptoms do not arise.

Answer 6

4. 7 to 10 days after sustaining the injury as long as she can progress through the stepwise rehabilitation protocol without experiencing symptoms

RECOMMENDED READINGS

http://www.ncaa.org/health-and-safety/concussion-guidelines Last accessed 8/23/2014. Ma R, Miller CD, Hogan MV, Diduch BK, Carson EW, Miller MD. Sports-related concussion: assessment and management. J Bone Joint Surg Am. 2012 Sep5;94(17):1618-27. Review. PubMed PMID: 22992853.

McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8. PMID: 23479479.

Question 7

Question 112

A 17-year-old cross-country runner has leg pain that initially occurred with running but now occurs with any weight-bearing activity. An initial evaluation of her problem should include

1. a whole-body bone scan.
2. a menstrual and dietary history.
3. postexercise compartment pressure measurements.
4. a skeletal survey to evaluate for additional areas of stress injury.
5. a functional movement evaluation to detect predisposing factors.

Answer 7

2. a menstrual and dietary history.

RECOMMENDED READINGS

Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987 Jan-Feb;15(1):46-58. PubMed PMID: 3812860.

Question 8

Question 125

A revision anterior cruciate ligament reconstruction was performed with a soft-tissue allograft, and postoperative radiographs are seen in Figures 125a and 125b. As opposed to a presurgical knee examination, the revision reconstruction is expected to improve findings for which test

1. Dial
2. Pivot shift
3. Anterior drawer
4. Posterior drawer
5. Reverse pivot shift

Answer 8

2. Pivot shift

RECOMMENDED READINGS

Noyes FR, Barber-Westin SD. Anterior cruciate ligament graft placement recommendations and bonepatellar tendon-bone graft indications to restore knee stability. Instr Course Lect. 2011;60:499-521. PMID: 21553794.

Driscoll MD, Isabell GP Jr, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR. Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a

biomechanical study. Arthroscopy. 2012 Oct;28(10):1481-9. PMID: 22796141.

Question 9

Question 146

Figures 146a and 146b are the radiographs of a 17-year-old football player who is seen after the season ends. He has anterior knee pain that is exacerbated by kneeling and squatting. He also has had knee pain on and off for 3 years and has used a knee pad, non steroidal anti-inflammatory durgs, and ice, but has experienced no relief. Recommended treatment should consist of

1. hamstring lengthening.
2. injection with prednisolone.
3. a night knee extension brace.
4. ossicle resection and tibial tubercleplasty.
5. continued nonsurgical treatment because his growth plates remain open.

Answer 9

4. ossicle resection and tibial tubercleplasty.

RECOMMENDED READINGS

Pihlajamäki HK, Visuri TI. Long-term outcome after surgical treatment of unresolved osgood-schlatter disease in young men: surgical technique. J Bone Joint Surg Am. 2010 Sep;92 Suppl 1 Pt 2:258-64. doi: 10.2106/JBJS.J.00450. PubMed PMID: 20844181.

Weiss JM, Jordan SS, Andersen JS, Lee BM, Kocher M. Surgical treatment of unresolved Osgood- Schlatter disease: ossicle resection with tibial tubercleplasty. J Pediatr Orthop. 2007 Oct-Nov;27(7):844-7. PubMed PMID: 17878797.

Question 10

Question 151

In the course of closing after an anterior cruciate ligament reconstruction, the junior resident realizes that a sponge was left deep in the wound. When he mentions this to the attending surgeon as the skin is being closed, he is told, “You don’t know what you’re talking about–the count was correct.” The appropriate course of action for the resident is to

1. assume that he was incorrect and allow the closure to proceed.
2. begin removing sutures to prove that a sponge has been left in the patient.
3. perform his own sponge count to address his suspicion that the count was incorrect.
4. repeat his concern and insist that the procedure stop until the issue is resolved.
5. leave the operating room and report the attending surgeon to the cheif medical officer

Answer 10

4. repeat his concern and insist that the procedure stop until the issue is resolved.

RECOMMENDED READINGS

US Department of Health & Human Services Agency for Healthcare Research and Quality TeamSTEPPS website: http://teamstepps.ahrq.gov. Last accessed 8/23/14.

Wiener EL, Kanki BG, Helmreich RL. Cockpit Resource Management. San Diego, CA:Harcourt Brace;1993.

Question 11

Question 159

Figures 159a through 159h are the MR images of a 21-year-old collegiate wrestler who has activityrelated left knee pain and an inability to participate in practice after injuring his knee in a match 7 days ago. Which examination finding is most sensative for the pathology.

1. Lateral joint line tenderness
2. Medial joint line tenderness
3. Positive anterior drawer test result
4. Positive McMurray test result (localized medially)
5. Positive McMurray test result (localized laterally)

Answer 11

1. Lateral joint line tenderness

RECOMMENDED READINGS

Abdon P, Lindstrand A, Thorngren KG: Statistical evaluation of the diagnostic criteria for meniscal tears. Int Orthop. 1990;14(4):341-5. PMID: 2076915.

Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res. 2007 Feb;455:123-33. PMID: 17279041.

Question 12

Question 171

Figures 171a and 171b are the anteroposterior and lateral radiograph of a 10-year-old boy who hyperextended his knee while skiing. He has a swollen knee and cannot bear weight. Initial treatment should consist of

1. open fixation with a screw
2. arthroscopic microfracture.
3. arthroscopic fixation with a suture
4. aspiration of the knee, closed reduction with fluroscopy, and a cast in extension.
5. injection of the knee with a marcaine, a range of motion brace locked at 3 degrees of flexion and therapy

Answer 12

4. aspiration of the knee, closed reduction with fluroscopy, and a cast in extension.

RECOMMENDED READINGS

Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: a review of 35 patients. J Bone Joint Surg Br. 1981 Feb;63-B(1):89-91. PubMed PMID: 7225187.

Question 13

Question 181

Figures 181a and 181b are the immediate postsurgery and new radiographs of a 57-year-old man who had increasing left shoulder pain after sustaining an acute fall. Two weeks have passed since he underwent an uncomplicated linked (transosseous equivalent) double-row supraspinatus and infraspinatus tendon repair. He has limited active motion of his shoulder secondary to pain and his passive forward elevation is to 90 degrees, again limited by pain. The wounds are healed with no evidence of erythema or drainage and he is afebrile. What is the best next treatment step?

1. Continued rehabilitation
2. Shoulder aspiration and culture
3. MR image to determine the integrity of the repair
4. Return to the operating room for revision rotator cuff repair.
5. Return to the operating room for implant removal and rehabilitation.

Answer 13

4. Return to the operating room for revision rotator cuff repair.

RECOMMENDED READINGS

Diduch DR, Scanelli J, Tompkins M, Milewski MD, Carson E, Ma SY. Tissue anchor use in arthroscopic glenohumeral surgery. J Am Acad Orthop Surg. 2012 Jul;20(7):459-71. PMID: 22751165.

George MS, Khazzam M. Current concepts review: revision rotator cuff repair. J Shoulder Elbow Surg. 2012 Apr;21(4):431-40. doi: 10.1016/j.jse.2011.11.029. Epub 2012 Jan 9. PubMed PMID: 22226536.

Question 14

Question 188

After recovering from an uncomplicated ankle sprain, a 12-year-old boy wants to lift weights for football training. In this age group, weight training leads to

1. increased injury risk.
2. growth disturbances.
3. decreased flexibility
4. strength gains that are temporary if training ceases.
5. no benefit because of low circulating levels of androgens

Answer 14

4. strength gains that are temporary if training ceases.

RECOMMENDED READINGS

Guy JA, Micheli LJ. Strength training for children and adolescents. J Am Acad Orthop Surg. 2001 Jan- Feb;9(1):29-36. Review. PubMed PMID: 11174161.

Malina RM. Weight training in youth-growth, maturation, and safety: an evidence-based review. Clin J Sport Med. 2006 Nov;16(6):478-87. Review. PubMed PMID: 17119361.

Faigenbaum AD, Kraemer WJ, Blimkie CJ, Jeffreys I, Micheli LJ, Nitka M, Rowland TW. Youth resistance training: updated position statement paper from the national strength and conditioning association. J Strength Cond Res. 2009 Aug;23(5 Suppl):S60-79. doi: 10.1519/JSC.0b013e31819df407. Review. PubMed PMID: 19620931.

Question 15

Question 201

Which factor can help surgeons predict motion deficit following anterior cruciate ligament reconstruction?

1. Male gender
2. Presence of a radial lateral meniscal tear
3. Inability to access formal physical therapy
4. Typical bone bruises on MR images
5. Reconstruction delay lasting longer than 6 weeks

Answer 15

4. Typical bone bruises on MR images

Question 16

Question 209

Figures 209a and 209b are the clinical photographs of a 13-year-old overweight freshman basketball player who has had a 3-month history of left anterior knee pain that is refractory to nonsurgical treatment that has included rest, therapy, nonsteroidal anti-inflammatory drugs, and a patella sleeve brae. Her knee radiographic findings are normal. What is the best next step?

1. An MR image of the left knee
2. Hip examination and a frog pelvis radiograph
3. Knee aspiration and laboratory tests for Lyme arthritis
4. Arthroscopic examination of the knee and a lateral release
5. A plyometric program and a detailed menstrual and dietary history

Answer 16

2. Hip examination and a frog pelvis radiograph

RECOMMENDED READINGS

Matava MJ, Patton CM, Luhmann S, Gordon JE, Schoenecker PL. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop. 1999 Jul-Aug;19(4):455-60. PubMed PMID: 10412993.

Kocher MS, Bishop JA, Weed B, Hresko MT, Millis MB, Kim YJ, Kasser JR. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics. 2004 Apr;113(4):e322-5. PubMed PMID: 15060261.

Question 17

Question 231

A 26-year-old elite sprinter is evaluated for an injury to the biceps femoris, semimembranosis, and semitendinosis, and an avulsion of the tendinous origins is present. What is best next step?

1. Ultrasound-guided injection of platelet-rich plasma to the injury site
2. Surgical repair of all tendons to their origin at the ischial tuberosity
3. Surgical repair of the semimembranosis with tenodesis of the remaining tendons
4. Initial rest and icing with a progressive strengthening program after pain subsides
5. Stretching and progressive mobilization with strengthening after this athlete begins running

Answer 17

2. Surgical repair of all tendons to their origin at the ischial tuberosity

RECOMMENDED READINGS

Cohen S, Bradley J. Acute proximal hamstring rupture. J Am Acad Orthop Surg. 2007 Jun;15(6):350-5. Review. PubMed PMID: 17548884.

Lefevre N, Bohu Y, Naouri JF, Klouche S, Herman S. Returning to sports after surgical repair of acute proximal hamstring ruptures. Knee Surg Sports Traumatol Arthrosc. 2013 Mar;21(3):534-9. doi: 10.1007/ s00167-012-2204-2. Epub 2012 Sep 13. PubMed PMID: 22972314.

Question 18

Question 244

Figures 244a through 244c are the radiographs of a 20-year-old college football offensive lineman who feels a pop in his foot. He is unable to bear weight after his injury. He had foot pain earlier in the season. What is the best treatment option?

1. Intramedullary screw fixation of the fracture
2. Short-leg cast with weight bearing as tolerated
3. Short-leg cast with nonweight bearing activity for 6 weeks
4. Use of a hard-sole shoe with weight bearing as tolerated
5. Open reduction and internal fixation using a lateral plate and bone grafting

Answer 18

1. Intramedullary screw fixation of the fracture

Question 19

Question 252

Figure 252 is an oblique foot radiograph of a 15-year-old Amateur Athletic Union basketball star who has a 1-year history of left ankle sprains, a stiff left flat foo,and a heel in mild valgus. Toe walking does not correct the valgus.Multiple nonsurgical treatments including a cam walker boot and physical therapy have failed to relieve his symptoms. Treatment should now involve

1. custom orthotics.
2. a triple arthrodesis.
3. high-top basketball shoes and a lace-up ankle sleeve.
4. resection of the calcaneal navicular coalition and interposition of fat.
5. resection of the subtalar coalition and interposition of the extensor brevis muscle.

Answer 19

4. resection of the calcaneal navicular coalition and interposition of fat.

RECOMMENDED READINGS

Khoshbin A, Law PW, Caspi L, Wright JG. Long-term functional outcomes of resected tarsal coalitions. Foot Ankle Int. 2013 Oct;34(10):1370-5. doi: 10.1177/1071100713489122. Epub 2013 May 12. PubMed PMID: 23667048.

Mubarak SJ, Patel PN, Upasani VV, Moor MA, Wenger DR. Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. 2009 Jul-Aug;29(5):418-26. doi: 10.1097/ BPO.0b013e3181aa24c0. PubMed PMID: 19568010.