Sports Flashcards
(192 cards)
1
Q
In a patient with swelling and ecchymosis over the chest wall after bench pressing what is the expected injury? What is the recommended treatment?
A
Mid-substance pectorals major tear. These injuries typically do not benefit from surgery. Period of immobilization followed by PT.
2
Q
What is the most common complication after a lateral closing wedge high tibial osteotomy?
A
Anterior knee pain.
3
Q
What does the dial test look for? How do you perform it?
A
posterolateral rotary instability of the knee . > 10 degrees of external rotation asymmetry at 30 and 90 degrees consistent with PLC and PCL injury. >10 degrees of external rotation asymmetry at 30 degrees only consistent with isolated PLC injury.
4
Q
How do you test for anteromedial rotatory instability?
A
anterior drawer test with tibia in external rotation. Will expect greater laxity here with combined ACL and MCL injury than in neutral or internal rotation.
5
Q
How do you measure Insall-Salvati Index? What is a normal value?
A
Ratio of patellar tendon length to patellar height. Normal values range from .8 to 1.2
6
Q
What nerve plasy is most common with traction during hip arthroscopy?
A
pudendal nerve palsy.
7
Q
What nerve is at risk with placement of the anterolateral portal for hip arthroscopy?
A
superior gluteal nerve.
8
Q
What is the interval for an inside out medial meniscus repair?
A
Between the joint capsule and the medial head of the gastrocnemius.
Saphenous nerve is at risk.
Capsule is exposed by incising the sartorius fascia and retracting the pes tendons/semimembranosus posteriorly.
9
Q
What is the interval for a inside out repair of the lateral meniscus?
A
between the lateral head of the gastrocnemius and the joint capsule.
10
Q
What does a double PCL sign signify?
A
Medial mensicus bucket handle tear.
11
Q
What is the leading cause of death in college football?
A
Exertional sickling collaps
Treat with rest, oxygen, and hydration.
12
Q
good prognostic indicators for successful meniscus repair are:
A
Vertical and longitudinal tears
Peripheral tears
Tears in the red-red zone
Smaller rim width (rim width is the distance from the meniscocapsular junction and the tear). Smaller rim widths = better blood supply.
13
Q
Describe the consequences of a malpositioned femoral tunnel that is too anterior, posterior, and centra/vertical.
Tibia tunnel malpositioned too anterior, posterior, medial, and lateral.
A
14
Q
What is demonstrated in the radiograph and what injury is it associated with?
A
Segond fracture. Avulsion fracture of the anterolateral ligament.
Associated with ACL tear 75% of the time.
It is caused by internal rotation and varus load unlike the more common cause of ACL tears which is valgus stress.
15
Q
What is demonstrated on the radiograph?
A
avulsion fracture of the arcuate complex where it inserts on the proximal fibula.
Fracture fragment is attached to the LCL or biceps femoris tendon.
Associated with curciate ligament injuries 90% of cases.
16
Q
What are the three forms of snapping hip?
A
- External snapping hip, which is caused by the iliotibial band sliding over the greater trochanter.
- Internal snapping hip.
- Intraarticular snapping hip which is caused by loose bodies.
17
Q
What condition is most likley if this image is from an otherwise healthy 20 football player?
A
Osteitis pubis. Will show bony erosion and irregularity and widening of the pubic symphysis.
From exissive physicla strain and is msot common in young football players.
Symptoms include loss of flexibility in the groin with dull aching pain. Can occassionally hav emore severe sharp pain when running, kicking, or chaning directions.
NSAIDs, physical therapy, an rest from sports.
18
Q
What is Athletica pubalgia?
A
Sports hernia.
Overuse syndrome typically seen in high level athletes.
Extension-abduction of the leg with eccentric contraction of the adductors leads to high shear stress on the rectus and may lead to tears of the transverslais fascia, rectus muscle, and/or adductor magnus origin.
19
Q
Describe the two bundles of the ACL and PCL with regards to which one is tight in flexion and extension?
A
20
Q
What is the size of the ACL?
A
33mmx11mm
21
Q
Describe the two bundles of the ACL?
A
Anteromedial: tight in flexion and loose in extension. fibers are parallel in extension and are externally rotated in flexion.
Posterolateral: prevents pivot shift. prevents internal tibial rotation with knee near extension. tight in extension and loose in flexion.
22
Q
What is the most sensitive exam test for an ACL injury?
How is it graded?
A
Lachman’s test
A= firm endpint B= no endpoint
Grade 1: <5mm translation
Grade 2 A/B: 5-10mm translation
Grade 3 A/B: >10mm translation
23
Q
In a normal knee at 90 degrees where is the medial tibial plateau relative to the femur?
A
1cm anterior to the medial femoral condyle.
If it is not should suspect a PCL injury.
May reduce with a quadriceps active test.
24
Q
What are the grades of MCL injuries?
A
Grade I: 0-5mm opening
Grade II: 6-10mm opening
Grade III: 11-15mm opening
Medial opening at 30 degrees only -> isolated MCL injury
Medial opening at 0 and 30 degrees -> combined MCL and ACL and/or PCL. Same thought process for LCL.
25
What is a J sign about the knee?
Excessive lateral translation in extension which pops into groove as the patella engages the trochlea early in flexion.
Associated with patella alta.
26
What is a normal amount of passive patellar translation?
Normal motion is \< 2 quadrants of patellar translation.
Midline of patella is considered 0
Lateral translation of medial border of patella to lateral edge of trochlear groove is considered 2 quadransts and is an abnormal amount of translation.
27
What kind of gait will you see in a patient with a PLC injury?
Varus thrust or hyperextension thrust.
28
What tests other than dial test are there to diagnose PLC injury?
**Posterolateral drawer test-** Performed with the hip flexed 45 deg, knee flexed 80 deg, and foor ER 15 deg. A combined posterior drawer and ER force is paplied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to later femoral condyle).
**Reverse pivot shift test-** With the knee positioned at 90 deg, ER and valgus forces are applied to tibia. Tibia reduces from a posterior subluxed position at 20 deg of flexion to a reduced position in full extension. Reduction force is from IT band transitioning from a flexor to an extensor of the knee.
**External rotation recurvatum test-** Positive when the leg falls into ER and recurvatum when the lower extremity is suspended by the toes in a supine patient.
29
How much force is transmited by the meniscus?
transmits 50% weight bearing load in extension and 85% in flexion.
The meniscus is more elastic than articular cartilage.
90% Type I collagen
67-75% water
30
What is the shape of the medial and lateral meniscus?
**Medial:** C-shaped with triangular cross section. Average width of 9-10mm. Average thickness of 3-5mm.
**Lateral:** Is more circular (the horns are closer together and approximate the ACL). Covers a large portion of the articular surface. AVerage width is 10-12mm. AVerage thickness is 4-5mm.
31
What are the attachments of the menisci?
**transverses (intermeniscal) ligament-** connects the medial and lateral meniscus anteriorly
**coronary ligaments-** connects the meniscus periperhally. Medial meniscus has less mobility with more rigid peripheral dixation than the lateral meniscus
**Meniscofemoral ligament-** connects the meniscus into the substance of the PCL. Originate from the posterior horn of the lateral meniscus and has two components:
Humphrey ligament (anterior)
Ligament of Wrisberg (posterior)
32
What is the blood supply of the menisci?
**Middle genicular artery-** supply to posterior horns
**Medial inferior genicular artery-** supplies peripheral 20-30% of medial meniscus
**Lateral inferior genicular artery-** supplies peripheral 10-25% of lateral meniscus
**Central 75% receive nutrition through diffusion.**
33
What are more common medial or lateral meniscal tears?
Medial are more common.
The exception is in the setting of an acute ACL tear where lateral tears are more common.
34
What is the most sensitive physical exam finding of a meniscal tear?
Joint line tenderness
35
What is a Thessaly test?
Provocative test for a meniscal tear.
Standing at 20 degrees of knee flexion on the affected limb the patient twists the knee with external and internal rotation. A positive test is discomfort and clicking.
36
What is another sign other than double PCL that indicates a meniscal tear?
Double anterior horn sing
37
What is the success rates after a partial meniscectomy?
What are predictors for success?
How many patients will have radiographic degenerative changes at final follow-up?
\>80% satisfactory function at minimum follow-up.
Age\<40 years, normal alignment, minimal or no arthritis, and a single tear.
50% will have osteophytes, flattening, joint space narrowing.
38
The best candidate for a meniscal repair has what characteristics?
red-red zone
low rim width
vertical or longitudinal tear
1-4mm in length
root tear
Acute repair combined with ACL reconstruction.
39
What are the indications for a meniscal transplantation?
What are the contraindications?
Outcomes?
Young patient with near total meniscectomy, especially lateral.
Inflammatory arthritis, instability, marked obesity, grade IV chondrosis (if not concurrently addressed), malaignment (if not concurrently addressed), and diffuse arthritis.
Requires 8-12 month s for graft to fully heal. Return to sports by 6-9 months.
10 year follow-up showed persistent improvement in subjective pain and function scores.
Most had radiographic progression of degenerative changes.
Re-tears or extrusion are common
40
What technique is considered the gold standard for meniscal repairs?
Inside-out technique
**Medial Approach:** Expose capsule by incising the sartorius fascia, retract pes tendons/semimembranosus posteriorly, develop plane between the medial gastrocnemius and capsule.
**Lateral Approach:** Develop plane between IT band and biceps tendon, then retract lateral head of gastrocnemius posteriorly.
41
When might an outside in repair technique be used for a meniscal tear?
Anterior horn tears.
42
Which suture technique provides the strongest fixation?
vertical mattress sutures
43
Which meniscus is usally involved in a discoid meniscus?
How often is the condition bilateral?
Lateral meniscus
25% bilateral
44
What are the radiographic findings that indicate a possible disocid meniscus?
Widening joint space up to 11mm.
Squaring of lateral condyle with cupping of lateral tibial plateau.
Hypoplastic lateral intercondylar spine.
Diagnosis with MRI can be made with 3 or more 5mm sagittal images with meniscal continuity. "Bow-Tie Sign"
45
What are the sex related differences in ACL injuries?
More common in female athletes 4.5:1 ratio
Younger age than males
Females get ACL injuries on the supporting leg while males get more ACL injuries on the kicking leg.
**Landing biomechanics and neuromuscular activatin patterns (quadriceps dominant) play the biggest role.**
46
What is the innervation to the ACL?
posterior articular nerve (a branch of tibial nerve)
47
What is depcited in the radiograph?
Deep sulcus (terminalis) sign
Depression on the lateral femoral condyle at the terminal sulcus, a junction between the weight bearing tibial articular surface and the patellar articular surface of the femoral condyle.
48
What bone bruising on MRI is consistent with an ACL tear?
Middle 1/3 of LFC (sulcus terninalis)
Posterior 1/3 of the lateral tibial plateau
49
Describe proper Femoral and Tibial tunnel placement for an ACL reconstruction.
**Femoral Tunnel Placement:** Sagittal plane 1-2mm rim of bone between the tunnel and posterior cortex of the femur. Coronal plane the tunnel should be placed on the lateral wall at 2 for a left knee and at 10 for a right knee. This creates a more horizontal graft.
**Tibial tunnel placement:** Sagittal plane the center of the tunnel entrance into the joint should be 10-11mm in front of the anterior border of the PCL insertion. 6mm anterior ro the median eminence and 9mm posterior to the inter-meniscal ligament. Coronal plane tunnel trajetory of \<75 defrees from the horizontal Can be obtained by moving tibial starting point halfway between tibial tubercle and posterior medial edge of the tibia.
50
What does graft preconditioning due for ACL reconstructioning?
Can reduce stress relaxation up to 50%.
Graft tensioning in 20-30 degrees of flexion.
51
What are complications associated with bone-patellar-bone autograft?
Patella fractures, these usually occur post-op during rehab.
Patellar tendon rupture.
Re-rupture. This is associated \<20 years and graft size \< 8mm
52
Which graft has better peak flexion strength at 3 years? BTB or Quadruple hamstring?
Bone-PT-Bone
53
What are the different ways allograft is processed before use for ACL grafts?
What are the effects on pathogen transmission?
What are the effects on the grafts mechanical properties?
**Supercritical CO2:** decreases the structural and mechanical properties.
**Radiation:** \> 3 is required to kill HIV however this decreased the structural and mechanical properties. 2-2.8 Mrad decreases stiffness by 30%. 1-1.2 Mrad decreases stiffness by 20%
**Deep freeing:** destroys cells but does not affect the strength of the graft.
**4% chlorhexidine gluconate:** destroys cells but does not affect the strength of the graft.
54
What immediate rehab is recommended after ACL reconstruction?
aggressive cryotherapy.
immediate weight bearing shown to reduce to patellofemoral pain.
emphasize early full passive extension. Especially if associated with MCL injury of patella dislocation.
55
What early rehab is recommended after an ACL reconstruction?
What rehab exercises should be avoided?
eccentric strengthening at 3 weeks has been shown to result in increased quadriceps volume and strength.
Isometric hamstring contractions at any angle
isometric quadriceps or simultaneous quadriceps and hamstrings contraction
Active knee motion between 35 degrees and 90 degrees of flexion.
Emphasize closed chain (planted foot) exercises.
**Avoid:** isokinetic quadriceps strengthening (15-30 deg ) during early rehab. Open chain quadriceps strengthening.
56
What is the most common infection after ACL reconstruction?
Staph epidermidis
Staph Aureus is 2nd most common
Can treat with arthroscopic I&D and retention of graft with staph epi. Less likely to be successful with S. aureus.
57
What treatment should be recommended for arthrofibrosis and loss of motion after an ACL reconstruction?
\< 12 weeks, then treat with appressive PT and serial splinting.
\> 12 weeks, then treat with lysis of adhesions/manipulation under anesthesia
58
Patella infera is another name for what?
Patella baja.
59
How will a cyclops lesion present after ACL reconstruction?
block to extension
Click heard at terminal extension
60
What three mechanisms most commmonly lead to PCL injury?
Direct blow to proximal tibia with a flexed knee. (dashboard injury)
Noncontact hyperflexion with a plantar-flexed foot
Hyperextension injury
61
Chronic PCL injuries are most likely to have degenerative changes in what knee compartments?
Patellofemoral and medial compartments.
This is due to increased contact pressures and varus alignment.
62
What radiograph can be obtained to diagnose and quantify a PCL injury?
Lateral stress view
Apply stress to anterior tibia with the knee flexed to 70 degrees.
10-12 mm more likely isolated PCL
\>12 mm suggests a combined injury
63
What treatment is recommended for a Grade II PCL injury?
Grade I partial (1-5mm posterior tanslation posterior drawer), Grade II complete (6-10mm), Grade III (\>10mm) combined.
PWB and rehab.
Quadriceps rehabilitation with a focus on knee extensor strengthening.
Return to sport in 2-4 weeks
64
When may non-operative treatment be an option for Grade III PCL injuries?
Older lower demand patient and must be isolated.
Less likely for bony avulsions or a young athlete.
4 weeks Extension bracing with limited daily ROM excercises.
Period of immobilization is followed by quadriceps strengthening.
65
What are the results of PCL reconstruction?
Typically are less successful than ACL reconstruction.
Often have residual posterior laxity.
Reconstruction options include tibal inlay vs transtibial methods. Single bundle bs double bundle.
No studies have clearly supported one reconstruction technique over another.
66
What are the indication sfor PCL repair or reconstruction?
Repairs are unsuccesful unless ORIF of bony avulsions.
Combined ligamentous injuries.
Isolated chronic PCL injuries with a functionally unstable knee.
67
The image is from an 18 year old with a remote history of a PCL injury. He has medial knee pain that has failed conservative measures. What treatment whould you recommend.
High tibial osteotomy.
Medial opening wedge osteotomy is a better choice than a lateral closing wedge osteotomy as the opening wedge more effectively increases posterior tibial slope which is helpful in PCL deficient knees.
Increasing tibial slope reduces the posterior sag of the tibia.
68
What is the theoretic advantage of a double bundle PCL reconstruction?
Biomechanically show to improve function in both flexion and extension.
Anterolateral bundle tensioned in 90 degrees of flexion
Posteromedial bundle tensioned in extension
Clinical advantage has yet to be determined.
69
Briefly describe the arthroscopic transtibial technique for PCL reconstruction?
Standard arthroscopic portals with **an accessory posteromedial portal**. This portal is placed 1 cm proximal to the joint line posterio to the MCL. Avoid injury to branches of the saphenous nerve during placement.
Posteromedial corner of the knee is best visualized with a 70 degrees arthroscope either through the notch (**modified Gillquist view**) or using a posteromedial portal.
Transtibial drilling anterior to posterior
Fix graft in 90 degrees of flexion with an anterior drawer.
70
Briefly describe an Open tibial inlay technique for PCL reconstruction.
Uses a posteromedial incision between medial head of gastrocnemius and semimembranosus.
Also used for ORIF of bony avulsion
Biomechanical advantage with a decrease in the **killer turn** with less fraft attenuation and failure.
screw fixation of the graft bone block is within 20mm of the popliteal artery
71
Rehabilitation after PCL reconstruction?
Immobilize in extension early and protect against gravity.
Early motion should be in prone position
Focus on quadriceps rehabilitation
Avoid resisted hamstring strengthening exercises (ex. hamstring curls) in early rehab. They create a posterior pull on the tibia which increases stress on the graft.
72
What is the most common ligamentous injury in the knee?
MCL injury
Males \> females
valgus stress is the most common mechanism
usually with the knee held in slight flexion and external rotation
73
Where does MCL rupture more commonly occur?
Rupture usually occurs at the femoral insertion of the MCL
Proximal MCL tears have greater healing rates.
Distal MCL tears have inferior healing and residual valgus laxity.
74
What is the most common multiligamentous knee injury?
ACL-MCL
95% of associated MCL injuries are with an ACL injury
Often associated with high grade MCL injuries.
75
What mensicus tear is most common with MCL injury?
Medial \> Lateral
Only about 5% of isolated MCL injuries are associated with meniscus tears.
76
What is Pellegrini-Stieda Syndrome?
Calcification at the medial femoral insertion site.
Results from chronic MCL deficiency.
77
What are the dynamic stabilizers of the medial knee?
semimembranosus complex
Consists of 5 attachments: vastus medialis, medial retinaculum, pes anserine muscle group (sartorius, semitendinosus, and gracilis).
78
What are general return to play recommendation for isolated MCL injuries on the femoral side?
All can be treated non-operatively.
Grade I -\> 5-7 days
Grade II -\> 2-4 weeks
Grade III -\> 4-8 weeks
79
What are the relative indications for MCL repair/reconstruction?
Acute repair in grade III injuries that are part of a multi-ligament knee injury or displaced distla avulsions with "stener-type" lesion or entrapment of the torn end in the medial compartment.
Sub-acute repair in Grade II injuries with continued instability despite non-op treatment.
Reconstruction for chornic injuries that are not repairable.
**All should have diagnostic arthroscopy to rule out associated injuries.**
80
How should a MCL avulsion be surgically fixed?
Should be reattached with suture anchors in 30 degrees of flexion.
81
What is the origin and insertion of the LCL?
Where is the origin relative to the popliteus?
**Origin:** lateral femoral epicondyle. **Posterior and proximal to popliteus.**
**Insertion:** anterolateral fibula head. most anterior structure on the proximal fibula (LCL -\> popliteofibular ligament, biceps femoris).
82
When and what nonoperative treatment is recommended for LCL injuries?
For isolated grade I or II LCL injuries
Limited immobilization, progressive ROM, and functional rehabilitation.
return to sport expected in 6-8 weeks.
83
What approach is used for LCL repair?
Lateral approach to the knee
Use interval between iliotibial band (superior gluteal nerve) and bicpes femoris (sciatic nerve).
This xposes the LCL insertion on the fibular head
Develop a second internal proximally within ITB to identify the lateral femoral epicondyle.
84
What reconstruction technique should be utilized when multiple PLC structures are injured in addition to LCL?
Should not do a single stranded graft.
Need to reconstruct LCL and popliteofibular ligament.
Three options:
**Fibular-based reconstruction (Larson technique).**
**Transtibial double-bundle reconstruction.**
**Anatomic reconstruction.**
85
What is the epidemiology, pathophysiology, and associated conditions Proximal Tib-Fib Dislocation?
Rare injury, very uncommon as an isolated injury. Most common in 2nd to 4th decades of life.
High-energy trauma. Fall onto a flexed and adducted knee. More common with horseback riding and parachuting.
Associated conditions: Posterior hip dislocation, open tib-fib fractures, and other fractures about the knee and ankle.
86
What proximal tib-fib dislocation is most common?
Anterolateral- Most common
Also Posteromedial and superior dislocations.
87
How are proximal tib-fib dislocations treated?
Closed reductions for acute dislocations. Operative intervention for chronic dislocations with chronic pain and symptomatic instability.
Closed redcution: flex knee 80-110 degrees and apply pressure over the fibular head opposite to the direction of the dislocation. Post-reduction immobilization in extension with early range of motion. **Commonly succesful with minimal disadvantages.**
88
PLC injuries is most commonly combined with what other ligament injury?
PCL more common than ACL
Missed PLC injury diagnosis is common cause of ACL reconstruction failure.
Only 28% of all PLC injuries are isolated.
Also commonly associated with common peroneal nerve injury (15-29%) and vascular injury.
89
What makes up the Arcuate complex?
LCL, arcuate ligament, and popliteus tendon.
90
Describe the different grades of PLC injury?
91
How do you perform a reverse pivot shift test?
What is a positive test indicative of?
Knee positioned at 90 degrees. External rotation and valgus force applied to tibia.
As the knee is extended the tibia reduces with a palpable clunk.
Tibia reduces from a posterior subluxed position at 20 degrees of flexion to a reduced position in full extention. Reduction force from IT band transitioning from a flexor to an extensor of the knee.
92
How are stress radiographs used to identify a PLC knee injury?
Obtain bilateral varus stress radiographs of the knees in 20 degrees of flexion.
Side to side difference 2.7-4mm = isolated LCL tear
Side to side difference \> 4mm = PLC injury.
93
What is triple varus alignement of the knee?
Seen in cases of chronic PLC injury.
Need long-leg standing radiographs to evaluate.
**Primary varus = tibiofemoral malalignment**
**Secondary varus =** LCL deficiency with increased lateral opening.
**Triple varus =** remaining PLC deficient, overall varus recurvatum alignment.
Necessary to determine mechanical axis and if a proximal tibial osteotomy is necessary for correction.
94
What bone bruising may be seen on MRI with PLC injuries to the knee?
Bruising of medial femoral condyle and medial tibial plateau
95
What PCL injuries can be treated non-operatively?
Grade II and isolated midsubstance grade II injury.
Midsubstance repair have a 40% failure rate following repair.
Hinged knee brace locked in extension 4 weeks. Followed by progressive functional rehabilitation. Quad strengthening, and return to sports in 8 weeks.
96
What PLC injuries can undergo a repair instead of a reconstruction?
Grade II avulsion injries.
Repari of LCL, popliteus tendon, and/or popliteofibular ligament should be performed if structures can be anatomically reduced to their attachement site.
Avulsion fracture of fibular head can be treated with screws or suture anchors.
97
What is the rehabilitation after a PLC injury that undergos reconstruction?
HKB and NWB for 6 weeks.
ROM either early or after 2 weeks of immobilization.
6 weeks begin weight bearing and closed-chain strengthening.
Avoid active hamstring exercised as they will stress the PLC.
Full active extension is allowed.
Return to activities and sports at 6-9 months.
98
What are risk factors for patellar tendonitis?
Males \> females
volleyball most common, but in general jumping athletes
adolescents/young adults. **quadriceps tendinopathy is more common in older adults.**
Poor quadriceps and hamstring flexibility.
99
What does the histology of patellar tendonitis show?
mircro tears of the tendinous tissue
## Footnote
**actually more of a degenerative process rather than an inflammatory one.**
100
What is Basset's sign and "movie theater sign" with regards to jumpers knee?
Basset's sign is a provocative test where there is tenderness to plapation at the distal pole of the patella in full extension, but no tenderness to palpation at distal pole of patella in full flexion.
The movie theater sign is when there is pain with prolonged flexion. It is a late phase finding.
101
On an MRI of the knee what can be more diagnostic than edema for patellar tendonitis?
tendon thickening
102
When might surgical excision and sture repair be considered for patellar tendonitis?
What is the process?
Chronic pain and dysfunction not amendable to conservative treatment. Partial tears. Blazina stage III disease( pain with and without activity. Deteriation in performance)
Resect diseases area. Bony abrasion at tendon insertion. Suture anchors.
Initial immobilization in extension with progressive ROM and WBAT.
return to sport in 80-90% of athletes. Activity related aching for 4-6 months after surgery.
103
What is miserable malalignment syndrome?
A term named for 3 anatomic characteristics that lead to an increased Q angle:
Femoral anteversion
Genu valgum
External tibial torsion/pronated feet
104
Medial patellar dislocation and medial patellofemoral arthritis is almost exclusively caused by?
Prior patellar stabilization surgery.
105
What are the risk factors for patellar instability in the native knee?
**General:** Ligamentous laxity (Ehlers-Danlos syndrome), previous patellar instability event
**Anatomical Factors:** Miserable malalignment syndrome
OSSEOUS- Patella alta (causes patella to not articulate with sulcus, losing its constraint effects. Trochlear dysplasia. Excessive lateral patellar tilt (measured in extension). Lateral femoral condyle hypoplasia.
MUSCLE- Dysplastic VMO. Overpulls of lateral structures from iliotibial band and vastus lateralis.
106
What structure attaches to MPFL and provides dynamic stability to the Patella?
Vastus Medialis
107
Where is the most common site of avulsion of the MPFL?
Femoral side between medial epicondyle and adductor tubercle.
108
What are the primary restraints to the patellar-femoral joint.
0-20 degrees MPFL
20 degrees and beyond patellar-femoral bony structures.
109
What is a J sign?
Excessive lateral translation in extension which pops into groove as the patella engages the trochlea early in flexion.
110
What is the most common fracture in a patella dislocation?
Medial patellar facet followed by lateral femoral condyle.
111
What is the best way to assess for trochlear dysplasia?
Lateral Radiograph
May see:
Crossing sign- trochlear groove lies in same plane as anterior border of lateral condyle. Represents flattened trochlear groove.
Double contour sing- Anterior border of lateral condyle lies naterior to anterior border of medial condyle. Represents convex trochlear groove/hypoplastic medial condyle.
Supratrochlear spur- arises in proximal aspect of trochlea.
112
What is the insall-Salvati method?
What is a normal value?
Normal between .8 and 1.2
113
How do you measure the Blackburn-Peel Index?
What is a normal value?
Normal .5 to 1.
114
What radiographic measurement is used to determine if a lateral retinacular release may be helpful?
Lateral Patello-femoral angle.
Angle formed by lateral patellar facet and a line drawn across most prominent aspects of anterior portion of the trochlea on a CT scan or Sunrise view radiograph.
If there is a negative patellar tilt on this measurement the patient may benefit from a lateral release for pain relief.
115
How do you measure the TT-TG distance?
What is considered an abnormal valued?
Measures the distance between 2 perpendicular lines from the posterior cortex to the tibial tubercle and the trochlear groove.
\>20mm usually considered abnormal
116
What rehab techniques should be used for first time patellar dislocation?
Short-term immobilization for comfort followed by 6 weeks of controlled motion.
Emphasis on the following strengthening: Cosed chain short arc quadriceps exercises. Quad strengthening. Core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals).
117
When is trochleoplasty used for patellar instability?
Rarely even if torchlear dysplasia is present.
May consider in severe or revision cases.
118
Describe the Outerbridge classification of Chondromalacia?
119
What is the best MRI sequence to evaluate articular cartilage?
T2 sequence
Abnormal cartilage is usually of high signal compared to normal cartilage.
120
What treatment is recommended for patellar-femoral pain or idiopathic chondromalacia of the patella?
Rest, rehab, NSAIDs
Should be done for up to a year before considereing operative intervention.
NSAIDs better than steroids
Rehabilitation with emphasis on: VMO strengthening, core strengthening, closed chain short arc quadriceps exercises, and strengthening of hip external rotators.
121
Regarding Quadriceps ruptures:
Demographics?
Location of rupture?
Risk factors?
More common than patellar tendon ruptures. Patients usually \> 40 years of age. Males \> Females (8:1). Occurs in nondominant limb more than twice as often.
usually at insertion of tendon to the patella
Renal failure, diabetes, rheumatoid, hyperparathyroidism, connective tissue disorders, steroid use, and intraarticular injections (history of in 20-33%)
122
Which method of fixation for quadriceps repairs has been shown to have the highest ultimate load to failure and less gap formation?
Repair with suture anchors.
123
What is the prognosis regarding strength after a quadriceps rupture?
What percent of patients are able to return to prior level of activities and sports?
33-50% of patients will have some sort of strength deficit.
50% of patients are unable to return to prior level of activity/sports.
124
Failure of the patellar tendon most commonly occurs where?
Avulsion with or without bone from the inferior pole of the patella.
125
What are general post-operative rehab goals after a acute patellar tednon primary repair with suture?
Immediate immobilization in extension with full WBAT
Controlled initiation of knee ROM at 7-10 days.
Goal of brace free ambulation, full extension and 120 dgrees of knee flexion by 6 weeks.
Return to sport by 6 months.
126
What percentage of people \> 40 years old have high grade chondral lesions?
5-10%
127
Where are the majority of osteochondritis dessecan lesions of the knee found?
70% of lesions found in posterolateral aspect of medial femoral condyle.
128
Chronic ACL tears lead to articular cartilage defects where in the knee?
Anterior aspect of lateral femoral condyle adn posterolateral tibial plateau.
129
Describe a basic algorithm for dealing with cartilage defects?
130
What is the general post-op protocol after mircrofacture of a cartilage defect in the knee?
NWB for 6-8 weeks.
Early ROM.
131
What is weight bearing status and for how long after Osteochondral autograft or Mosaicplasty?
3 months NWB.
132
What are the limitations of autologous chondrocyte implantation?
Must have full-thickness cartilage margins around the defect.
Open surgery
2-stage procedure
prolonged protection necessary to allow for maturation
133
What is the difference between ACI and MACI cartilage procedures?
ACI-chondrocytes are injected under a periosteal patch that is sewn over the defect.
MACI-cells are cultured and embedded in a matrix or scaffold. That matrix is then secured with fibrin glue or sutures.
MACI can be performed without suturing so it can be done arthroscopically. **Only FDA approved cell therapy for cartilage in the USA.**
limitations are its a two stage procedure and is very expensive.
134
What should be on your differential for Osteonecrosis of the knee?
**Secondary Osteonecrosis of the knee-** Most commonly wedge shaped on imaging.
**Spontaneous osteonecrosis of the knee-** Most commonly crescent shaped
**Osteochondritis dissecans-** More commonly found at lateral aspect of medial femoral condyle of 15 to 20 year old males.
**Transiet Osteoporosis-** More common in young to middle-aged men. Multiple joint involvement found in 40% of patients
**Occult fractures and bone bruises-** Associated with trauma, weak bones, or overuse.
135
Describe the demographics, location, risk factors, and prognosis of secondary osteonecrosis of the knee?
**Demographics-** Women:men 3:1. More commonly in women \< 55. Found after knee arthroscopy.
**Location-** Usually involves more than one compartment of the knee. 80% are bilateral. Multifocal lesions are not uncommon.
**Risk Factors-** alcoholism, dysbaric disorders, marro-replacing diseases (Gaucher's disease), sickle cell, hypercoagulable states, steroids, SLE, IBS, transplant patients, Virus, Protease inhibitors (HIV meds).
**Prongnois-** Self-limiting condition.
136
Describe the demographics, location, and presentation of SONK (spontaneous osteonecrosis of the knee)?
**Demographics-** Most common in middle age and elderly. Females more than males.
**Location-** 99% of patients only have one joint involved (as opposed to secondary osteonecrosis of the knee that is bilateral 80% of the time). Usually epiphysis and medial femoral condyle (secondary osteonecrosis of the knee commonly includes metaphysis).
**Presentation-** Less insidious than secondary. Usually presents with sudden onset of severe pain. Effusion, Limited ROM.
**Mainstay of treatment is NSAIDs, narcotics for pain, and protected weight bearing. Most cases will resolve.**
137
What joint is most commonly involved with osteochondritis dissecans? Where are the lesions within the joint most commonly found?
Knee, capitellum of humerus, and talus in descending order.
Posterolateral aspect of medial femoral condyle 70% of the time in the knee.
Cause of adult form is thought to be vascular.
138
What on imaging correlates with a poor prognosis for juvenile osteochondritis dissecans?
Sclerosis on xrays correlates with poor prognosis.
Synovial fluid behind the lesion on MRI correlates with a worse prognosis.
139
Which area of the knee have the highest potential for pain signals?
Anterior fat pad and joint capsule.
140
What is the initial treatment for patellofemoral syndrome or anterior knee pain?
How long should this be done for?
Rest and NSAIDs
Rehab: emphasis on vastus medialis obliqus strengthening. Core strengthening. Closed chain short arc quadriceps exercises. Strengthening of hip external rotators.
141
What is the prognosis for Tibial Tubercle Apophysitis?
Self-limiting but does not resolve until gowth has halted.
Tibial tubercle is a secondary ossification center.
\<11 yrs cartilaginous
11-14 yrs apophysis forms
14-18 yrs apophysis fuses with tibial epiphysis
Age \> 18 years epiphysis (and apophysis) is fused to rest of tibia
142
What is Sinding-Larsen-Johansson syndrome?
Chronic apophysitis or minor avulsion injury of inferior patella pole
Occurs in 10-14 yr old children.
Especially children with cerebral palsy.
143
What has to have taken place before considering ossicle excision for Osgood Schlatter's Disease?
The patient has to be skeletally mature.
144
Trochlear dysplasia is defined as a sulcus angle \> than what?
145 degrees.
A value great than 145 degrees is not an indication for AMZ.
145
When do AIIS avulsion occur most often?
Kicking sports where hip is extended and knee is flexed
During an eccentric contraction.
Males more than females. Ages 14-17.
146
What is recommended treatment for an AIIS avulsion?
Bed-rest, ice, and activity modification.
2 weeks of keeping hip flexed.
Guarded weight bearing for 4 weeks.
147
What is a provocative test for athletica pubalgia?
Pain with valsalva and sit-ups.
148
What is the operative treatment for a sports hernia after rest and months of PT fail?
Pelvic floor repair vs adductor/ rectus recession.
Another option is decompression of the genital branch of the genitofemoral nerve.
149
What is the most common form of snapping hip?
Internal snapping hip.
Iliopsoas tendon sliding over: femoral head, prominent iliopectineal ridge, exostoses of lesser trochanter, and iliopsoas bursa.
**Internal snapping hip you can hear across the room. External snapping hip you can see across the room.**
150
What is the provocative test for an anterior labral tear?
Posterior labral tear?
ANTERIOR- pain if the hip is brought from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction.
POSTERIOR- pain if hip is brought from a flexed, adducted, and internally rotated position to one of abduction, external rotation, and extension.
151
Cam impingement of the hip is seen more in what patient population?
What injuries are more commonly seen?
Young athletic males.
Occurs if the femoral head/neck bone is too broad. Mostly anterolateral neck.
Shearing at the chondro-labral junction leading to cartilage delamination and labrla separation.
152
Pincer impingement is seen more in what patient population?
What injury to the hip joint is more commonly seen?
Active middle-aged women
Femoral neck impinges and crushes the labrum creating intra-substance tearing.
This levers the femorla head into the postero-inferior acetabulum leading to a contrecoup cartilaginous injury.
153
How do you perform the anterior impingement test for patients you are concerned have FAI?
Flexion, adduction, and internal rotation.
154
How do you measure the head-neck offset ratio to evaluate for femoroacetabular impingement?
What is a normal value?
See photo for method of obtaining.
Use a lateral radiograph.
If value is \<.17 then a cam deformity is likely present.
155
A lateral center-edge angle (also known as angle of Wiberg) is consistent with FAI when the value is \> than what?
What are other measurement and their abnormal values?
Greater than 40 degrees.
Anterior center edge angle of 25-50 are considered normal
Tonnis angles of 0-10 degrees are considered normal. Greater angle is considered over coverage.
Femoral head position more than 10mm lateral to the ilioischial line is considered dysplastic. Less than 10mm is considered normal.
156
What should be done to limit risk of femoral neck fracture with head-neck osteoplasty?
limit osteoplasty depth to \<30% of femoral neck diameter
157
What is the most common cause of persistent pain after hip arthroscopy?
Residual deformity from incomplete osteoplasty.
158
What provides a landmark for the iliopsoas tendon during hip arthroscopy?
Zona orbicularis
Need to use the distal anterolateral portal in order to visualize the peripheral compartment of the femoral neck.
3-5cm distal to the anterolateral portal.
159
What nerve is at risk with a posterolateral hip portal?
What movement of the limb increases this risk?
Sciatic nerve
External rotation of the hip.
160
When is it appropriate to return to play after a hamstring injury that has been treated non-operatively?
When strength is 90% of contralateral side.
161
When is surgical repair of a hamstring injury indicated?
Proximal avulsions
Partial avulsion that has failed nonoperative management for 6 months
2 tendons and \> 2cm retraction in young active patients.
162
What treatment is recommended for a quadriceps contusion?
Immobilization in 120 degrees of flexion using an ace wrap or hinged knee brace for 24-48 hours.
Frequent use of cold therapy.
Transition to stretching and active ROM exercises after initial flexion period. PWB and crutches often required.
Begin functional rehabilitation and sport-specific activities once full and pain-free ROM achieved.
163
What is the most common exercise induced leg syndrome?
Second?
Medial tibial stress syndrome.
Exercise induced compartment syndrome.
164
What is something found in 40% of individuals with exertional compartment syndrome on decompression?
facial defects. Only 5% of asymptomatic people have facial defects.
Most common location is near the intramuscular septum of the naterior and lateral compartments where the superficial peroneal nerve exits.
165
What values on compartent pressure measurement are consistent with exertional compartment syndrome?
Resting (pre-exercise) pressure \> 15mmHg
Immediate post-exercise \> 30mmHg
Post-exercise pressure \> 20mmHg at 5 minutes
Post-exercise pressure \> 15mmHg at 15 minutes
166
What is the treatment for exertional compartment syndrome?
3 months of anti-inflammatories and activity modification.
Two incision fasciotomy if not succesful.
80% success in anterior compartment.
60& success for deep posterior compartment.
Recurrence is 20% at 2 years.
167
What is the pathophysiology of tibial stress syndrome?
ANTEROLATERAL: traction periostitis of tibialis anterior on tibia nad interosseous membrane.
POSTEROMEDIAL: traction periostitis of tibialis posterior and soleus
168
What are the three phases of a bone scan?
What will it show tibial stress syndrome vs a stress fracture?
**Phase 1** flow phase. **Phase 2** blood pool phase **Phase 3** delayed phase
Tibial stess syndrome will show normal phase 1 and 2. Phase 3 will show increased uptake.
Stress fracture has focal intense hyperperfusion and hyperemia in phase 1 and 2. Fusiform uptake in phase 3.
**Stress syndrome pain is from periosteum where stress fracture is pain from the bone.**
169
What treatment is recommended for a femoral neck stress fracture?
Compression side stress fracture with a fatigue line \<50% of femoral neck width -\> non-weight bearing, crutches, and activity restriction.
Tension side stress fracture -\> ORIF with percutaneous screw fixation.
also treat with ORIF if fatigue line \> 50% or progression of compression side stress fractures.
Use three 6.5 or 7.0mm cannulated screws.
170
Which stress fracture location has the greatest likelihood of delayed healing or developing a nonunion?
Anterior cortex of tibia
consider operative fixation
171
For the following ribs wich athletes most commonly have stress fractures there:
First rib?
Middle ribs?
Posteromedial ribs?
baseball pitching, basketball, weightlifting, and ballet. Occurs anterolaterally. **Anatomic site of weakness is the groove for subclavian artery where there is superiorly directed forces from the scalene muscles and inferiorly directed forces from the serratus anterior and intercostal muscles.**
Competitive rowers. Occurs laterally and anterolaterally
Novice golfers
172
What is the leading cause of sport-related death?
Traumatic brain injury
173
How much does a prior concussion increase the risk of sustaining another concussion?
What are other risk factors?
2-8x higher
Sports with player to player contact
Female
Age \< 18 years
Mood disorders, learning disorders, history of migraines. Also complicates diagnosis and recovery.
174
What are the four categories of symptoms from a concussion?
Somatic symptoms-HA, dizziness, balance, vision etc
Cognitive symptoms- Feeling in a fog, difficulty concentrating, forgetful
Emotional symptoms- Lability, irritability, and sadness
Sleep distrubance- can be insomnia or increased amount of sleep.
175
What are some mandatory sings of concussion?
Be aware that it does differ between sports but in general:
Loss of consciousness
Lying motionless \> 5 seconds
Confusion/disorientation
Clutching the head
amnesia
vacant look
Motor incoordination
Ataxia
176
What are the two parts of the SCAT5?
**Immediate on-field assessment:** Red flags, observable signs, Maddock questions, GCS, and cervical spine assessment.
**Off-field assessment:** Should be done in a private distraction-free area.
Standard Assessment of Concussion test. Evaluates orientation. Memory immediate and delayed. Concentration.
Balance Error Scoring System. Need to perform the following for 10 seconds each. Bipedal stance. Unipedal stance, and tandem stance.
177
What is the Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT).
A computer-based test that assesses verbal and visual memory, processing speed, reaction time, impulse control, and presence of concussive symptoms.
Comparison is made to baseline scores or historical controls.
Useful tool in guiding treatment and return to play decisions.
178
Describe the neurometabilic cascade resulting in the typical signs and symptoms of a concussion?
ABNORMAL NEURONAL IONIC FLUX: Headache, photophobia, phonophobia
ALTERED RELEASE OF NEUROTRANSMITTERS(GLUTAMATE): impaired cognition, amnesion, slowed reaction time
ENERGY DEPLETION: In an effor to correct the above underlying biochemical imbalances. Vulnerable to second injury (second-hit pphenomenon)
179
True or false gender is a risk factor for concussions?
True
180
What is involved in a Standard Assessment of Concusiion (SAC) test?
Orientation- ex what month is it?
Memory both immediate and delayed- Repeating 5 words over 3 trials
Concentration- ex repeating string of 5 numbers backwards
181
What should be done if there are any signs/symptoms that may be concerning for concussion?
Immediate removal from play.
**Same day return to play is NOT indicated.**
Other indications include: no experienced medical providor to evaluate an athlete. heat trauma with history of concussion. Loss of consciousness. Amensia
Positive exertional stress test. Symptoms lasting \> 15 minutes
182
Describe the graduated return to play protocol for concussions?
Each step should take 24 hours so an athlete should take one week to proceed through the full protocol and return to play.
183
What is the mortality rate associated with second impact syndrome?
Second impact syndrome = second head trauma before symptoms of a concussion have resolved.
Catastrophic cerebral edema resulting from loss of autoregulation of the brain blood supply.
up to 50% mortality rate.
184
What is postconcussion syndrome?
persistent symptoms of a concussion
\>10-14 days in adults
\> 4 weeks in children
return to play is contraindicated
Should undergo formal neuropsychiatric evaluation
185
which intracranial hemorrhage has a lucid period before neurologic decline?
Epidural hematoma
186
What will be found on postmortem neuropathologic examination of the brain in a patient with Chronic traumatic encephalopathy (CTE)?
Cerebral atrophy
Enlarged ventricles
Diffuse senile plaques
187
What are the symptoms of chronic traumatic encephalopathy?
BEHAVIOR CHANGES- loss of impulse control, aggression, irritability
MOOD CHANGES- depression, apathy, suicidal ideation
COGNITIVE IMPAIRMENT- difficulty with executive functions (i.e. carrying out tasks), memory loss, dementia
188
Is acetabular retroversion in the setting of FAI more suggestive of a CAM lesion or a Pincer lesion?
Pincer lesion.
189
A score on the Beighton scale of what defines hypermobility?
Score greater than 5/9.
190
Chronic PCL deficiency will lead to degenerative changes in what compartments of the knee?
MEdial and patellofemoral
According to Strobel et all retrospective review.
191
What are the two locations from the trochlear donor site that osteochondral autografts are obtained?
Distal/medial in the trochlea is the site with the lowest contact pressures. It is convex in shape. The other location is the intercondylar notch which has more of a saddle shape.
192
What genes have been shown to be associated with ACL Ruptures?
COL5A1 and COL1A1 are associated with decreased ACL ruptures.
